Abstract
Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the performance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to enable systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without adequate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.
Highlights
Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care
community health care practitioners (CHCP) were not included in the study due to their role in primarily supporting the CCs; this study focused on CHWs working within the community and making home visits
Our study identifies several challenges that are unique to and have direct implications for the health care sector in Bangladesh
Summary
Bangladesh has made great strides toward improving population health outcomes and meeting the Sustainable Development Goals, as evidenced by improvements in life expectancy at birth and under[5] mortality.[1]. In alignment with recommendations of prior research, Bangladesh’s recent National Strategy for Community Health Workers report outlined the provision of monetary and nonmonetary incentives to better recognize and support CHWs.[3] This represents a significant and crucial first step toward better working conditions for CHWs and aligns with the recent Astana Declaration, which underscored the importance of CHWs in advancing universal health coverage.[15] Given the immense value of CHWs and the role they play in promoting and improving health outcomes in Bangladesh, it is necessary to identify ways to better motivate them and improve their working conditions through the provision of realistic and desirable incentives at the www.ghspjournal.org policy level. This study provides a stronger understanding of the current CHW context in Bangladesh and their preferences for incentives, as well as the disincentives that increase dissatisfaction with their role
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