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IncentivizingCHWs:BRACExperienceSharminSharif

ProgramManager,HealthBRACUgandaMarch30,2017

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BRACHistoricalContextOrigin of BRAC:- Tied to the birth of Bangladesh

after liberation war; 1971- BRAC was born in1972;

rehabilitation support to refugees

- Quick realization rehabilitation is not solution but development

- 1973, 10% mark-up on sales

“Poor people are poor because they are powerless.We must organize people for

power.”-Sir Fazle Hasan Abed,

Founder and Chair, BRAC

BRACisadevelopmentorganizationdedicatedtoalleviatepovertybyempoweringthepoor,andhelpingthemtobringaboutpositive

changesintheirlivesbycreatingopportunitiesforthepoor

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Mission:Toempowerpeopleandcommunitiesinsituationsofpoverty,illiteracy,diseaseandsocialinjustice

Goal:Tocontributetoeliminationofpovertyandempowermentofmarginalizedpeople,especiallywomen

HealthcareinterventionshavebeenanintegralaspectincludingCHWs.Startedin1973

BRACMissionandGoal

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Health

Financial Inclusion

Education

Legal Aid

Community Empowerment

Environmental Sustainability

Agriculture& Food Security

Our Comprehensive Approach

ELA

OUR APPROACHOur approach is providing preventive, promotive, curative and rehabilitativecare driven by the organization's overall mission, vision and values with aholistic approach to poverty reduction and empowerment of the poor

OUR AIMOur aim is to improve reproductive, maternal, neonatal and child health andnutritional status, reduce vulnerability to communicable diseases, combat non-communicable diseases, and enhance the quality of life.

OUR SCALEWe are operating in all 64 districts of Bangladesh reaching 120 million people,particularly serving the hard to reach, marginalized population.

BRAC Health Nutrition and Population Programme

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ShasthyaShebika/C

HW

ShasthyaKormi

Behavior and

practices

Empower communit

y

Women-friendly,

culturally-appropria

te services

Continuum of care

Prompt diagnosis

and referral of

complication

COMMUNITY HUMAN RESOURCE

Agent of Change

•Selected from community BRAC staff •At least SSC degree•Willing to work •Age 25-35 years • Nominal honorarium•Serve 4000-5000 HHs

•Selected from community preferably BRAC VO•Age 25-40 years• Preferable education Grade 8 •Willingness to work•Socially acceptable •Voluntary service•Serve around 400-500 HHs

•Training•Continuing education•Supportive supervision•Frequent contact withcommunity•Incentives•Quality of care•Trust of the community

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Incentives in Bangladesh

• Social : Community trust and acceptability and respect from BRAC

• Financial incentives a) Revolving fund (interest free loan)b) Selling Over the counter essential medicine and health

commoditiesc) Performance based incentives: Pregnancy identification

and referral of complications; Infant young child feeding, maternal nutrition and MNP compliance; TB treatment compliance

d) Selling services: DM and hypertension screening

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BRACCHWModelsinAfricanContinents

i. Uganda:4,075ii. SouthSudan:120CHP,200CBDiii. Liberia– 599CHPsiv. SierraLeone– 406CHPs

• EssenceoftheBRACCHPmodelwasintactandbestpracticeswereincorporated,

a)CHPsprovidingbasichealthcarewithinthecommunity,andb)salesofhealthproducts- thebuilt-inentrepreneurialmodelforsustainability,c)stronggovt.linkages,d)refreshers,supportivesupervision,e)monitoring/evaluation,f)reports- easilymeasurableKPIs,targetvs.achievements

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BRACCHPsinUganda:OverviewandAchievements

• CurrentHealthProgrami. Since2008,BRACEHC,SSmodelwithCHPsii. Maternalandchildhealthfocusiii. Currentcoverage:3.6Million,4,075CHPs,iv. 273healthstaff,139branchesacross72districts

• ImpactAchievementsi. RCTconductedbyStockholmUniversityshowed21%mortalityreduction

amongunder5childrenii. RCT studiesshowedaspillovereffectonthemarketpriceofACTsand

loweredcounterfeitdrugsiii. Anotherstudy showedBRACCHPsincreaseddemandandserviceuptake

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Scale and Innovations• Scale(outandup)i. Scaleout- Expansionoftheprogramin2016from2808CHPsto4075CHPs

– 45%growthii. Scaleup- Scopeofactivitiesenhancement– fullICCM,m-RDTs,FP,

nutrition,m-health

• Innovationsi. Built-inentrepreneurialmodel- SSii. Technologyincorporation- mobileapplicationsandHMISiii. Incentiveschemestesting,CHPinputsupplyloanthroughMFiv. Supportivesupervisionwithcertification,re-certification,knowledgetestsv. Enhancednutritionandfamilyplanning

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IncentivesExperiencea.Monetaryincentives:i.Salesofproducts– supplementaryincomeii.Performancebasedphase1:componentsspecific

b.Socialincentives:i.Communityrecognitionandrespect-CHPsas‘musawo’ii.CHPawardsandrecognitionceremony,i.e.CHPAppreciationDay;iii.certification/recertificationiv.Technologicalinclusion– mobilephoneforscreeningandreporting

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ChallengesandSuccessesChallenges(Monetaryincentive):-Shiftoffocusonspecificcomponents-Overreportingissues;monitoring– cumbersome;Operationalfeasibility-Demotivatedoncefundforincentivesrunsout-Donorfocusdifferences/shiftsbringschallengesforacomprehensivemechanism-Policyenvironment:mobilizationtobringCHWsunderpayscale,CHEW,VHTs

ChallengesonSocialincentives:-Fundingrequired,hascostimplications-Built-inentrepreneurialsystemissuccessful,butrequiresbusinessskillsdevelopmentSuccesses:-Improvedperformancesonspecificcomponentsselectedformonetaryincentives-treatments,pregnancy;-Eventhoughshort-term,CHWsseemtoappreciate/motivated,lowattritionrate-Revolvingfund– ensures100%costrecoveryofinputsupplyofCHWsinUganda

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LessonsLearned- Accountabilityandtransparencywithstrongcheckand

balance- Advocacy- waystoalsoaddressbottlenecksonCHWsscope

ofworkwithinthepoliciesandguidelinesbasedonevidenceandregulation/compliance

- Innovationsandflexibilities,learningbydoing- Expectationmanagementatalllevel,CHWs,communities,

staff,government- MorerobustfullPHCcoveragethroughCHWsmakesCHPs

moresustainable- Entrepreneurialmodelrequiresinvestmentsonmarketing,

outreaches,businessskills,

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Upcomingincentivestesting• Phase2: comprehensivescoringsystembasedonperformance- Overallperformanceisconsideredandcomponentsare

incorporated/weigthedintoascoringsystem- Probabilisticmodelwiththreetreatmentarmstofindoutwhich

oneenhanceCHPperformancesmost• Inputsupplyloan– testingthisyearformechanismtoscaleout- CHPswhoarenotpartoftheMF,providethemwithainput

supplyloan/smallloanforthemtostart/overcomebarriersontheircapitalswithshorterrecoverysystem

• Salesofservices– sayanapress,depoproveratrainingwithenhancedFPmethodmixandscreeningtraining

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Thankyouforlistening!

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ThoughtsonHIVST- TestingHIVSTthroughBRACCHPs,AHPs,ELA,combinations–

incorporateintotheCHPproductbasket- Incentives(forproductssalesand/orservice)andits’

mechanismaroundself-testing- Demandcreationandsupplychain