Taking healthcare where the community is: The story of the Shasthya Sebikas of BRAC

1. Taking healthcare where the community is: The story of the Shasthya Sebikas of BRAC |Syed Masud Ahmed MBBS, MPH, PhD| | Research & Evaluation Division | | BRAC | http://www.brac.net http://www.brac.net/research

2. Background: BRAC Health Programme (BHP) coverage at a glance Committed to poverty alleviation and empowering the poor

3. Shasthya Sebika: the community health volunteer of BRAC • Nucleus of BHP (FLW, Foot-soldier) • Selected from among the village-based credit and development group (Village Organisation, VO) members of BRAC • Age: not less than 25 years • Married with last child >2 years of age • Preferably 3-4 years of schooling • Good community acceptance • Willingness to provide voluntary services • Each SS is responsible for overseeing 250 HHs • Visits 15 HHs per day (two hours a day, six days a week) Committed to poverty alleviation and empowering the poor

4. A Shasthya Sebika in action Committed to poverty alleviation and empowering the poor

5. A day in the life of a SS • 8am – 10am:From her own courtyard: I) Observes DOTS patients and provides services e.g., supervises intake of drugs II) Sells health commodities e.g., soap, iodized salt, sanitary napkin etc. • 10am – 12pm:Visits 15 households in her catchments area to___ I) disseminates health and nutrition education messages II) motivate for FP, EPI and installation of tube-well/sanitary latrine as relevant III) provide basic curative treatment for ten common illness IV) identify suspect TB cases (>3 weeks cough) and motivate for sputum exam. and treatment-seeking V) Identify and register pregnant mothers, and provides ANC and PNC education; present at the time of delivery to provide essential neonatal care • VI) Follow-up of referral cases • Miscellaneous: helps organizing Health Forum conducted by her supervisor; attends Refresher once a month • Work time: six days a week, two hours a day • Source: BHP Manual for the SS Committed to poverty alleviation and empowering the poor

6. Making of a SS… • Selection and recruitment • Name proposed by the VO members • Ratified by local office • Undergo interview at regional office before final selection • Training • Three weeks residential training in Reg. Office on basic healthcare services • Programme specific training • Refreshers • Once a month at local office conducted by PO (Health) • Supportive Supervision • Field visit by supervisor (CHW/paramedic) 3 days a week • Trouble shooting • Capacity building • Keep motivated Committed to poverty alleviation and empowering the poor

7. Incentives…notonly volunteerism • The SSs are not paid workers of BRAC; however, volunteerism is not the only motivation • Main motivation • Supplementary income for family • Gaining health knowledge; access to medicine for self and family • Social prestige and mobility • Eligible to receive a concurrent second loan • Earns from • Sales of health commodities • Sales of medicines for common illnesses • Service charges (from motivating to install tube-well, sanitary latrine, pregnancy identification, DOTS) Committed to poverty alleviation and empowering the poor

8. Determinants of success/ Lessons learned… • Should be deeply grounded in the community and culture they serve; acceptable and accessible • Meticulous selection, training and supervision • Poor women are very unlikely to get involved in anything that does not contribute to their livelihood strategies; thus, some opportunity cost for SSs’ work is needed • Incentives based on performance (as practiced by BRAC) may create a win-win situation for both the programme and the CHWs • The model has become sustainable as it is integrated with (credit-based) development interventions Committed to poverty alleviation and empowering the poor

9. Challenges… • Sustainability issues : minimizing drop-outs • Incentives: monetary and non-monetary • Content and form of training • Supportive Supervision • Linking community with PHC in the formal sector • Recognition of their importance by public sector and measures to develop their capacity in a planned way so as to ensure a minimum acceptable level of care for the poor in the short-term Committed to poverty alleviation and empowering the poor

10. X-tra slides

11. Two Illustrative Quotes: “…we, the illiterate women, perform a doctor’s job and provide medicine to the villagers. This increases our prestige and honour. Even the rich people come to consult us. (Mahbub 2000, p24) “BRAC will not be able to take what we have learnt from BRAC’s training. We will use our learning…if we do not get further support from BRAC, we will be able to buy medicine on our own and sell them to the villagers…” (Mahbub 2000, p26) Committed to poverty alleviation and empowering the poor

12. Power (to fight exploitation) Entitlement to food & “safety net” Institutional mechanism for savings and credit “Minimum” income and employment Access to health care Access to appropriate technology Entitlement to assets (such as land) Access to housing Gender equity Human rights and their enforcement Investible surplus Access to education Institutions of the poor Enabling environment Background: BRAC’s holistic approach to poverty alleviation Committed to poverty alleviation and empowering the poor

13. Background: BRAC at a glance (end of 2006) • Full-time staff 42,693 • Villages with BRAC Programmes 69,421 (81%) • Participants in Credit Programmes 5.31 million (one person from one household; 99.5% women) • Loans disbursed (cummulative) US$ 3,721 million • Average loan size US$ 120 • Savings by BRAC members US$ 156 million • Jobs created 6,484,267 • BRAC schools (NFPE) 52,168 • Students currently enrolled 1.52 million • Part-time teachers (96% women) 53,205 • BRAC Health Centres 37 • Essential Health Care Coverage 31 million • Shasthya Sebika (100% women) 68,000 Committed to poverty alleviation and empowering the poor

14. Becoming empowered… • Initial disapproval gives way to appreciation as the tangible economic benefits emerge • Community acceptance increases over time • Status within family improves; participates in family decision-making, especially related to health • Certain level of economic independence • Credibility in the informal credit market • Confident about sustaining activities in future even if BRAC support is withdrawn Committed to poverty alleviation and empowering the poor

15. Proposal for regional action • Given the shortage of supply of qualified health care providers in this region as well as various demand-side barriers faced by the poor to reach formal health system, the importance of these health workers should be recognized by the public sector. • Measures should be undertaken to develop their capacity in a planned way so as to ensure a minimum acceptable level of care for the poor in the short-term. • BRAC’s Shasthya Sebika model can be instructive in this regard Committed to poverty alleviation and empowering the poor