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In the lead up to the UN General Assembly, the Skoll World Forum partnered with Johnson & Johnson, the United Nations Foundation and the Bill and Melinda Gates Foundation to produce an online debate focused on the last 850 days before the MDGs expire in 2015. We asked some of the world's leading experts what is one thing we must do differently or better to achieve MDGs 4, 5 and/or 6--all focused on improving public health--by the deadline? View the full series here.
“If you want anything said ask a man, if you want anything done ask a woman.”
Whether or not you agree with the politics of Margaret Thatcher, there is wisdom in her words. In my experience in Bangladesh, first as a scientist in the 1980s and now as executive director of icddr,b, an international research organization working with government and civil society to improve the health of people around the world, I have been impressed with the role of female community health workers as a cornerstone of Bangladesh’s strategy for achieving Millennium Development Goals (MDGs) 4 and 5. With fewer than three years to go, Bangladesh is one of only a handful of countries on track to meet those targets.
The contribution of female community health workers to improving maternal and child health followed a decision by the Government of Bangladesh and the non-governmental sector to place great emphasis on the delivery of both primary healthcare and family planning services, and to invest in women to serve on the frontline for delivering these services. This approach was first developed and tested by icddr,b in the 1970s in its maternal and child health program at Matlab, a rural subdistrict of 142 villages and 220,000 residents some 30 miles southeast of Dhaka. Initially, working with the village dais (illiterate, female elders who traditionally attended births), contraceptive use rates failed to rise appreciably. Pursuing an alternative—and at the time novel—approach, researchers reached out to young, educated, married women who lived in the villages and could counsel their neighbors about contraception and family planning with credibility.
These young women were trained to deliver simple, effective interventions inexpensively. By drawing on and sharing their own experiences with their contemporaries, the female community health workers successfully created demand for maternal and child health and family planning services, and over time also became the frontline agents for a broader range of primary care interventions, including those to treat diarrhea, respiratory infections, and other infectious diseases, as well as immunizations and nutrition counseling. The community health workers in Matlab were taught to keep accurate records of their visits and services—information vital for monitoring and assessing impact, and improving service delivery—and as such helped establish Matlab as a leading site of continual health and demographic surveillance. The lessons from this seminal experiment provided the basis for the later countrywide roll out of female community health workers, both by government and non-governmental sectors, as the principal deliverers of family planning services and primary health care to the country.
Today in Matlab about 80 percent of pregnant women deliver in facilities, in large part due to demand creation by icddr,b’s community health workers and to community-friendly obstetric facilities. While the national average for the rate of facility-based deliveries is lower, around 30 percent, it has more than tripled since 2001. In addition, the emphasis on family planning has reduced total fertility rates in Bangladesh from over 6 births per woman in 1970 to 2.3 births per woman in 2011, which has not only greatly slowed population growth, but also synergized with direct interventions to reduce maternal and child deaths. Child deaths have decreased by two thirds since 1990, representing an early achievement of MDG 4. These results are remarkable considering the poverty and relatively weak healthcare system in Bangladesh.
The work of female community health workers necessarily engaged men in the communities, improved literacy about health and family planning, and helped improve the status of all women in the villages. Investing in women and training female community health workers in every community, even villages at the “end of the road,” have also helped to address the lack of health resources in many rural communities. Unlike doctors and nurses, who tend to be attracted to work in urban settings, the community health workers remain in their communities enjoying the income, prestige, and respect conferred by their roles.
Today at Matlab, and in many other rural communities that I visit in Bangladesh, I meet empowered female community health workers who are proud to talk with me about the training they receive, the education they provide to other women and mothers, the health records they maintain, and the lives they help save.
There are many developing countries that have not emulated this successful Bangladesh strategy. So is this a single “magic bullet” that will enable other countries to achieve MDGs 4 and 5? The short answer is “unlikely”, without concomitant facilitators. The Bangladesh success story could not have happened without the commitment of and collaboration between researchers, governmental and non-governmental agencies, the private sector, and international donors; a government committed to equity for its population, willing to provide a major role for civil society to partner in delivering primary health care and family planning services; a focus on scalable and targeted interventions; and a willingness on the part of all parties to introduce new interventions and to proceed on the basis of evidence. However, there are remarkable lessons to be learned from the synergies of primary healthcare and family planning delivered at the community level by well trained, female community health workers. Supporting and investing in a women-centered approach to service delivery embodies the equity focus that needs to be central to any country’s plan for achieving the MDGs— and indeed for ensuring the long-term sustainability of gains in child and maternal health.
John D. Clemens MD is the executive director of the International Centre for Diarrhoeal Disease Research, Bangladesh.