Strengthening Community Health Systems through CHW Harmonization in Bangladesh

CHWs operating in interprofessional primary care teams are critical partners in healthcare delivery. However, inconsistent support of CHWs and failure to integrate them into the health system can impede the full realization of their potential contribution in the context of primary health care. The concept of harmonization in community health programs can mean a variety of things, from harmonization of job functions among public and NGO CHWs to harmonization of reporting between different siloed reporting channels. For the purpose of this brief, harmonization means a focus on developing a more coherent and organized approach to CHW programs. The Community Clinic (CC) Centered Health Service Model, which incorporated harmonization as an approach to provide organization and increase the quality of care provided by the community health system, was piloted in Bangladesh. The CC Centered Health Service Model includes a multi-component intervention, consisting of team-building and harmonization of CHW roles and responsibilities, engagement of local government officials and the community, development of action plans based on consultation, data collection and analysis, and enhanced supervision and monitoring. The model aims to provide a more coherent and organized approach to CHW programs leading to increased coverage, improved care seeking, and increased referrals to higher levels of care. A twelve-month pilot was conducted by the ICHW project in six unions with a total of 25 community clinics, and six other unions serving as controls. Using a curriculum developed by NIPORT to emphasize team building, joint planning and local government and community engagement, 609 CHWs in the six intervention districts were trained. The project worked closely with three categories of MOHFW CHWs affiliated with community clinics—HA, FWA, and CHCP. Qualitative and quantitative methods were used in baseline and endline surveys with CHWs, supervisors and local government representatives. Focus group discussions were conducted with members of Community Groups (CGs) and Community Support Groups (CSGs). The pilot study found that visits to CCs in pilot unions increased by 50%. Linking CCs to higher-level facilities is critical to reduce morbidity and mortality for conditions that cannot be managed locally. The project emphasized strengthening referral systems to CHWs, CCs and the community at large, and especially the need to follow up with patients referred. The percentage of referred mothers and newborns who actually attended at a higher-level facility increased from 23% at baseline to 78% at endline. There were 4,455 referrals from the CC to higher-level health facilities for services not available at the CC. A random check of 639 patients found that 50% of those patients had actually visited the higher-level facilities after follow-up by the CHW. The project also strengthened community engagement and accountability. CGs and CSGs had been developed to support CCs and CHWs but had lapsed. To improve representation in the catchment area, ICHW, through the District Coordination Committee (DCC), reformulated the CG and CSG membership. Utilizing social mapping tools these groups were reformulated and became more functional and more representative. Representation of the catchment area improved from 19% and 16% respectively at baseline to 100% of both groups at endline, and 100% conducted regular meetings. The communities demonstrated increased ownership and awareness of CC services, and thus contributed to improve service delivery of the CCs.