Current State of the Model Shasthya Shebikas of BRAC: A Quick Exploration of the ‘Pilot Project for SS Sustainability’

By - Antora Mahmud Khan and Syed Masud Ahmed

Inspired by the Primary Health Care (PHC) concept of Alma-Ata and the bare-foot doctors of Mao’s China, the Essential Health Care (EHC) services of BRAC evolved over time from its experiences of working with the poor for improving their health and well-being (Hadi and Ahmed 2005, Karim et al. 1994, Islam et al. 1991). It provides the building blocks with which the larger BRAC Health Programme (BHP) is built, and contributes to the mitigation of income-erosion effect of illness and vulnerability of the poor households. For sustainability, the EHC programme is embedded in BRAC’s microfinance programme.The nucleus of BRAC’s EHC is the Shasthya Shebika (SS) who are the front-line workers of BHP (Ahmed 2008).

They provide a cost-effective bridge between the community they serve and the PHC level facilities of formal health systems, though they are not part of it. They receive basic training on PHC (with additional, need-based programme-specific training for DOTS, community-based ARI or MNCH as and when necessary)2 and backed by regular monthly refresher training. During household visits, they disseminate health and nutrition messages including family planning and immunization, motivate for installing tubewells and sanitary latrines, provide pregnancy-related care and treatment for some common illnesses, identify TB suspects and sells health commodities. The SS supposedly works on voluntary basis but earns some income from sale of health commodities and medicine (around Tk. 300-500 per month depending on activity). Currently, BHP has about 80,000 SS actively providing service to >90 million people. The success of micro-credit programme as a health intervention tool is extensively documented. The continuing need of this kind of generic Community Health Workers (CHW) that BRAC propagates is emphasized in the literature, in the context of shortage of human resources for health (HRH) in low income countries (LICs) (Standing and Chowdhury 2008). In the eighties and the nineties, when the EHC/SS model was being developed, the scenario in the rural areas was quite different compared to the beginning of the 21st century. In the 1980s, the economy was only beginning to gain momentum after the liberation war and natural disasters, and mobility and opportunities for rural women were limited. Besides involvement in the family planning programme of the government, large-scale employment of women in income-earning activities at the grassroots level was virtually absent. To work as a community health provider and earn a modest sum of money was quite rewarding for rural women at that time besides social recognition, prestige, etc. However, the scenario has changed over time and income-earning opportunities have increased for rural women in different sectors (ready-made garments RMG, poultry, non-agricultural activities sponsored by the nongovernmental organizations, etc.). The opportunity cost of being involved in low-return activity like SSs, has also increased. Demographic and its associated health transition with emergence of new conditions such as non-communicable diseases, and consumer preference for qualified doctor, are making the traditional model irrelevant. Besides, improved literacy and mobility have widened the horizon for these women. These have led to a system loss of around 15-20% of the Shebikas dropout annually despite adherence of recruitment criteria, introducing performance-based incentives, and diversifying the product basket. So, the challenge now is how can BRAC/BHP maintain her motivation and retention in an era of increasing opportunities for poor women? BRAC has been actively engaged in addressing this issue and craft out a model of next generation SSs in recent times (Special meeting report 20 Dec. 2010).

Related information

  • Writer Name: Antora Mahmud Khan Syed Masud Ahmed
  • Published Date: Monday, 12 December 2011
  • Country: Bangladesh