Community-Led Health in Bangladesh

(1) Ultimate outcome: This project aimed to improve the health of 3 communities comprising 3 Union Parishads (UPs), especially for mothers, adolescents, children, and infants, as measured by 4 indicators of Neonatal Mortality Rate (NMR), Infant Mortality Rate (IMR), Under-5 year Crude Mortality Rate (CMR) and Maternal Mortality Rates (MMR).

(2) Intermediate outcomes: This project aimed to improve both health service delivery, particularly for mothers; and improved behaviour in reproductive health, basic health care, and community sanitation in target communities, particularly for mothers and adolescents.

(3) Immediate outcomes: This project aimed to increase accessibility of local health facilities and services, capacity of local health providers and project personnel, accountability of local health service and systems and providers, and awareness in the communities for prevention of treatment of health problems.

Results achieved through this project include: (1) three satellite health clinics were built and are providing health services to 13,210women, men, and children; (2) about 15,285 patients, largely women and children, have received quality care from the three rural health clinics and community-based health workers; (3) 598 live births were assisted by skilled health personnel; and (4) 911 women have received antenatal care by skilled health personnel.

Other accomplishments include: (1) 6,667 women and girls (100% of those living in the target areas) are now able to access health care when travel is involved; (2) 82% of beneficiaries now feel that the local health system and health service providers are more accountable; (3) 60% of the citizens who are engaging with their local government representatives to discuss community health issues are women (representing 446 women); (4) 2,056 (58%) of women living in target areas report feeling more empowered to make financial decisions about their own health care needs; (5) 28 adolescent girls and boys groups are now working to empower youth and have held a total of 868 health education sessions on issues such as health, nutrition, hygiene, early marriage, family planning and pregnancy; (6) 3,145 (85%) of eligible couples between the ages of 15 and 49 are using contraception; (7) 1,864 (67%) of targeted households are now aware of the benefits of natal, antenatal and postnatal care; and (8) 3004 women (85% of those living in the target areas) have received health services in their community from a trained community-based health care worker or certified birthing attendant.

These results are contributing to: (1) improving the health of people, especially women and children, living in the under-served rural villages of Golachipa, Charmontaj, and Rangabali in southern Bangladesh; and (2) strengthening the local health care system by facilitating collaboration and coordination between the local government and targeted communities.

Specifically related to expected outcomes:

(1) Ultimate outcome: NMR and IMR rates have decreased significantly within the target group to 19 and 26 respectively; they have exceeded the targets and are now reportedly below the national average. This is likely to be due to an increase in health awareness and access to services through the project, as well as increased government coverage in the area. CMR and MMR rates have reduced to 53 and 299 respectively, from 61 and 346 before the project began. Comparisons to national mortality rates are made cautiously, as the calculation of rates (both baseline and final) has been based on limited data collection at the field level, and cannot be compared to the much more rigorously calculated national statistics. Improvements only apply to the population directly targeted by this project, and cannot be said to apply to any indirect beneficiaries. While also recognizing that this data is limited and can be used only to provide a snapshot, rather than a comprehensive assessment, of impact, the trends suggested by the data are encouraging.

(2) Intermediate outcomes: Indicators reveal that mothers are receiving greater “in-time” treatment (the indicator is 30% above the target). They also reveal that more beneficiaries are receiving antenatal care and care at the time of a delivery. Additionally, contraception rates have increased significantly and women are more in control of their finances in regards to healthcare. Healthy practices of beneficiaries have increased. Although uptake of nutritional practices taught through training was chosen as the primary indicator to assess whether or not families were using techniques and knowledge learned through the project at the immediate level, and contraception use and women’s empowerment were used as indicators at the intermediate level, other indications of knowledge application are just as, if not more, compelling in terms of demonstrating the effectiveness and usefulness of training sessions in improving health-seeking behaviours of the population. Beneficiaries reported implementing changes that they have learned about, which included behaviours ranging from hand-washing, to nutrition, to use of latrines, to use of contraception.

(3) Immediate outcomes:

There has been a considerable increase in accessibility to basic health services (treatment and advice for the management of certain illnesses, antenatal, and postnatal care). 100% of women and girls participating in the project (a total of 6,667 women, adolescent girls, and girl children) were able to access healthcare when travel is involved, compared to a baseline of 20%. Over the course of the project, the three clinics (as well as community health outreach satellite clinics and Community Health Workers) provided healthcare and referral services to 15,285 patients, of which 18% were men, 55% were women, 8% were adolescents, and 19% were children. Beneficiaries have expressed a high degree of satisfaction with services. The increase in accessibility to services is due to the establishment of the clinics, running of monthly satellite clinics, and provision of health workers. In total, there are 28 health professionals and administrative personnel working across the 3 clinics. The clinics are further supported by 22 Community Health Workers and 22 Community Birth Attendants (one for each village), all of whom have been trained to provide community-based services on a volunteer basis. In terms of increased capacity, the field staff and local volunteers are all well trained on a range of health issues as planned. At the end of the project, 100% of staff express feeling confident in their ability to provide quality healthcare.

The output and outcome indicators demonstrate that there is accountability of the project health services. Dialogues with local government and local service providers proved an effective first step in increasing accountability. Given the generally dysfunctional state of existing healthcare services available in project areas in December 2011, it is unsurprising that only 20% of beneficiaries initially believed that their healthcare providers and systems were accountable and prioritized providing quality care. As the project progressed and beneficiaries interacted with project infrastructure and with government officials through dialogues and meetings, this percentage gradually increased to 82% at the end of the project, exceeding the target of 75%. The focus on empowering community members, men and women alike, to voice concerns with existing systems and to request services where these are lacking helped increase both perceptions of and actual performance of accountability. A large measure of this success can be attributed to the work of community organizations. Project staff were encouraged by the level of meaningful participation by government officials in this project. The positivity demonstrated by government officials and their willingness to participate in dialogue is a major reason that project targets related to perceptions of accountability have been met.

A range of trainings and sessions on health and social issues provided to staff and community members has increased awareness in the community, eventually resulting in better nutrition within households and better health practices. At the beginning of the project, over one third of households reported that their children were malnourished. Indeed, the health status of children in general was not good: two-thirds of children frequently had fevers, and almost one in five children suffered from diarrhea, typhoid, scabies, and/or pneumonia. Training for low-cost balanced nutrition as well as training support for home gardening was a focus of this project. As a result of these trainings, parents gradually demonstrated improved nutrition awareness and ability to ensure nutrition in their homes. By the end of the project, 93% of households report that their children are better nourished. The majority of families surveyed at the end of the project are now eating healthy foods. Awareness of the benefits of antenatal, natal, and postnatal care for women and children also increased substantially through the project. By the end of the project, 4.5 times more people understood the benefits of care during pregnancy. Both men and women responded similarly, indicating that there is no gender divide with regard to attitudes towards the importance of care for women during pregnancy.