“The health care providers at the Upazila Health Complex (UHC) cannot speak or understand our local language. How can we expect to receive quality services if they are unable to interact with us?” asked one of the local residents in Teknaf.
Brac James P Grant School of Public Health, Brac University interviewed about 985 Community Health Workers (CHW) working at community, union and upazila levels from four selected sub-districts in Bangladesh (Teknaf, Tetulia, Chowgacha, Sulla)—Government CHWs included Community Health Care Providers (CHCPs), Health Assistants (HAs), Family Welfare Assistants (FWAs), Family Welfare Visitors (FWVs), etc.
On the other hand, Brac Shasthya Shebika (SS) and Shasthya Kormi (SK) and community volunteers were notable among the non-government CHWs.
Unsurprisingly, almost two third of them (65%) reported being unhappy with their current employment. Inadequate compensation and allowance, heavy workload due to human resource shortage, a lack of career progress opportunity, and unmet training needs made their life difficult. However, despite all the hurdles, they continued to serve the community.
“Our monthly compensation is less than Tk5,000. Nobody would respect us if they knew our income,” recounted one of the non-govt CHWs in Tetulia.
Ironically, almost 33% of the CHWs earned less than Tk5,000 monthly, and only 28% expressed satisfaction with their current remuneration. Multipurpose health volunteers (MHVs) were mostly compensated every six months to one-year intervals.
The study also demonstrated the compensation disparities between the government and non-government CHWs. Notably, 80% of non-government CHWs earned less than or equal to Tk15,000, compared to 51% of the government CHWs.
CourtesyIn addition to their monthly salary, the CHWs expressed the dire need for some supplementary allowances and benefits, such as an adequate travel allowance and mobile phone bill, festival bonus, low-interest loan, paid maternity leave, and the ability to take leave when necessary.
Almost two-thirds of the CHWs (64%) highlighted the necessity for these incentives in addition to their salary considering the inflation rate and current living expenses in Bangladesh.
A large proportion of the CHWs considered the opportunity for career growth (84%) to be the most significant motivator, alongside financial compensation and other advantages.
“Almost 12 years have passed since I joined here. I haven't received any promotion yet and I don't think I will receive a promotion even in the next 12 years,” said a government CHW from Chowgacha.
A little over half of the CHWs (55%) noted that there is limited opportunity for promotion in their current position. Either it took years for the govt. CHWs earn a promotion, or they never achieved it in their lifetime. Similarly, the non-government CHWs indicated not having a clear career path for them.
The CHWs who were happy with their job attributed it primarily to the opportunity to serve their local community (69%).
The local community also facilitated the seamless delivery of health services in the community clinics (CCs) through the community groups (CGs) and community support groups (CSGs) of the community clinics.
However, several CGs and CSGs were not functioning effectively because many members had low commitment levels and were unaware of their roles and responsibilities as part of these support groups.
“The CCs are more disciplined, have available funds, and deliver quality care, when the CSGs are powerful and have strong ownership over the CCs,” recounted a respondent from the central level. The Community-Based Health Care (CBHC) Programme has already started training the support groups on their roles and responsibilities in certain locations of Bangladesh.
The CHWs reported receiving training in various subject areas. Nevertheless, the duration of training varied between government and non-govenment CHWs.
The initial training period ranged from 21 days to six months for the government employed CHWs and from 5 to 18 days for the non-govt. CHWs. Furthermore, the introduction of electronic devices for reporting posed a challenge for several senior and elderly CHWs who required training, including refresher training, on using electronic devices. However, the refresher training they received was considered insufficient.
“We need more refresher training on the most common and prevalent diseases in the community such as Covid-19,” mentioned one of the government CHWs from Tetulia. The lack of training and guidelines impacted service delivery during Covid-19 as well.
As stated by the CHWs, a large number of sanctioned positions were empty, which resulted in an overwhelming workload, particularly for the government CHWs, further intensified during the Covid-19 pandemic.
“We travelled 45 kilometres twice every week, spending out of our own pocket to screen the individuals coming from other countries at the Banglabandha border during Covid-19. We were assigned responsibilities whenever and wherever necessary but were not compensated, even with a travel allowance,” expressed a government CHW from Tetulia.
Many of them also reported a shortage of personal protective equipment amidst the pandemic.
“We have submitted written applications, participated in a human chain protest, worn a black badge, and notified government officials of anyone who visits the facility. We have made every effort to inform them of our difficulties,” shared a government CHW from Tetulia.
The situation faced by CHWs described above raises several critical questions.
Can we realistically reduce out-of-pocket (OOP) expenditures for the individual seeking healthcare if our primary healthcare (PHC) system is not strong?
Is it possible to establish an efficient PHC system without addressing the needs of CHWs? How can we ensure universal health coverage (UHC) and achieve sustainable development goals (SDG) without a strong PHC system? Will our decision-makers take a few moments to ponder these issues and come up with a feasible solution?
Zarin Tasnim is a research associate at Brac James P Grant School of Public Health of Brac University
