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Scaling-Up and Sustainability of Community-Based Primary Health Care: The BRAC Experience

Section B

With the assistance of Faruque Ahmed, Director BRAC Health Program

BRAC at a Glance

  At work since 1972 -  Bangladesh Rural Advancement Committee is now Building

Resources Across Communities   Reaching beyond Bangladesh to Afghanistan, Sri Lanka, Pakistan,

Tanzania, Uganda, Southern Sudan   Annual budget in 2007: US$ 495 million -  77% self-generated

  Reaching 110 million people in all 64 districts in Bangladesh   More than 95,000 staff and 3,350 offices in Bangladesh   Largest NGO in world in terms of beneficiaries and staff   Core programs -  Economic development (including micro-finance) -  Education -  Health -  Social development -  Human rights

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www.brac.net

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BRAC Vision

  Our vision is of a just, enlightened, healthy, and democratic world free from hunger, poverty, environmental degradation and all forms of exploitation

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Learning from Early Mistakes

  “Capture” of programs by local elites   Failure of doctors and paramedics to function effectively in the

villages   Doctor-run clinics were expensive and had little outreach   Refashioning of programs to serve the neediest people

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Village Organizations

  Village organizations are pathways to BRAC’s community work -  Micro-finance:

backbone for VOs -  Village organizations:

needed to support Shasthya Shebikas

-  Shasthya Shebikas: provide essential health care

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Micro-finance

Village organizations

Shasthya Shebikas

Essential health care

Community Health Volunteers: Shasthya Shebikas

  BRAC VO member -  Married -  Over 25 years of age

  Delivers door-to-door preventive and basic curative health

  Average coverage: 250 households   Fills in the critical health human

resource gap

8 Shasthya Shebikas

Photo: Henry Perry

BRAC Village Organization

9 Photo: Henry Perry

Responsibilities of Shasthya Shebikas

  Routine systematic home visitation

  Promote of health, nutrition, and hygiene

  Treat 10 common diseases and sell essential drugs

  Implement DOTS   Sell iodized salt, delivery

kits, condoms, pills, soap, etc.

  Social mobilization for NID and vitamin A campaigns

  Collect health information and ensure timely referrals

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Shasthya Shebika providing DOTS

Photo: Henry Perry

Heath For All in Bangladesh

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Activities of Shasthya Shebikas with 150–200 Families

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Activities of Shasthya Shebikas with 150–200 Families

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Shasthya Shebika Scale-Up

14 Chart: Henry Perry. Data Source: BRAC.

An Overview of BRAC’s Global Operations

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Country Total number of beneficiaries

Year program established

Number of program staff

Full-time Part-time/non-salaried staff

Total

Bangladesh 110,000,000 1982 56,740 126,607 183,347

Afghanistan 335,838 2002 3,808 0 3,808

Sri Lanka 40,701 2004 550 0 550

Tanzania 64,444 2006 355 0 355

Uganda 48,405 2006 399 0 399 Southern Sudan

4,772 2006 44 0 44

Pakistan 4,772 2007 198 0 198

Indonesia na 2008 na na na

Data Source: BRAC.

Oral Therapy Extension Program

  13 million homes visited

  “Perhaps the largest house-to-house” public health effort ever undertaken (Jon Rohde)

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Measurable Impacts of Shasthya Shebikas in TB Control

  Tuberculosis (TB) control -  Treatment completion rate over 90% -  TB prevalence in BRAC areas half the rate in other areas -  Reference: Chowdhury et al., Lancet, 1997

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Collection and Analysis of Sputum

18 Photos: Henry Perry

Shasthya Shebikas Link Vertical, Horizontal Approaches

  The BRAC experience suggests that perhaps vertical and horizontal approaches can be synergistic if there is a unifying agent at the community level with appropriate: -  Training -  Supervision -  Logistical support -  Incentives to carry out her work

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Getting the Right Balance of Responsibilities Is Critical

  How to further improve and expand programs without overloading such a community worker is now a key issue for BRAC

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Emergence of PHC Systems

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“The emphasis has to shift from showing immediate results from single interventions to creating integrated, long-term, sustainable health systems, which can be built from a more selective primary health-care start.”

—Walley et al., (2008). Lancet.

BRAC’s Contributions to PHC

  BRAC is leading the way in this shift   BRAC is the world’s best example of implementation of the

principles of Alma Ata at scale

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Impacts of Shasthya Shebikas in Child Health

  BRAC’s programs reach two-thirds of the Bangladesh population   Universal child immunization achieved only in the BRAC areas in

1990s   Oral rehydration therapy: highest utilization rate in the world   Under-five mortality: Bangladesh one of only 19 of 68 high-mortality

countries on track to reach MDG 4

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Sources: Chowdhury. (1995). Near Miracle in Bangladesh. Chowdhury and Cash. (1996). A Simple Solution: Teaching Millions to Treat Diarrhea at Home UNICEF, Countdown to 2015: Tracking Progress in Maternal, Newborn & Child Health, the 2008 Report.

Ingredients for Scale-Up

  Logistical support   Supervision   Government cooperation   Remuneration strategy

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Other Elements for Scale-Up and Sustainability

  Vision   Leadership   Learning from mistakes/fostering “learning organization: mentality   Strong M&E system -  5% of budget goes to research activities designed to improve

programs   Interdependence with, not dependence on, donors -  And willingness to detach from donors

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F. H. Abed, President and Founder of BRAC

26 Photo Source: http://en.wikipedia.org/wiki/File:F-H-Abed-shadow.jpg. Creative Commons BY.

Other Elements for Scale-Up and Sustainability

  Vision   Leadership   Learning from mistakes/fostering “learning organization: mentality   Strong M&E system -  5% of budget goes to research activities designed to improve

programs   Interdependence with, not dependence on, donors -  And willingness to detach from donors

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Critical Elements

  Primacy of village-level workers -  Recruited from among their own community -  Compensated through resources mobilized in the community -  Responsible to that community and its members

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Critical Elements

  Orderly, objective, incremental training focused on the most common problems

  Training provided by more experienced community-level workers who become the regular supervisors of the first-line workers

  Continuing of training and ongoing supervision and continuous learning

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Critical Elements

  Rapid and effective referral   Backed-up by well-trained health professionals   Assures quality of both the technical content of training and

supervision and confidence in entire system based on the demonstrated competency of the professional team when faced with emergencies or complicated cases

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Critical Elements

  Team must build from the bottom up, not from the top down   Professionals function largely as teachers, problem solvers and

facilitators -  Their technical competence in the demanding cases establishes

trust, respect, and credibility of the entire system

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Approaches to Training

  Use few didactic materials   Rely on observation and questioning, habits that are reinforced

through regular meetings and reinforcement by supervisors   Residential training centers (Training and Resource Centers—TARCs)

for: -  Health -  Poultry raising -  Rural banking -  Teachers in rural schools, etc.

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Other Keys to Success

  “Organic” existence of program (not dependent on external funding)

  Develop of simple implementation models

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