Non-communicable diseases (NCDs) commonly occurring amongst the people of 35 years and above, require a large quantum of health and social care, irrespective of socio-economic status. Most NCDs are chronic debilitating disease associated with a range of severe complications. Bangladesh has a large number of people living with NCDs. BRAC is going to undertake NCD pilot initiatives in 3 sub-districts of two districts (Narayanganj and Narsingdi) under EHC and 8 sub-districts of 5 districts under Leeds University COMDIS study project. Initially there will be screening, referral and follow up of hypertension and diabetes patients in the community.
To reduce the burden of chronic NCDs by promoting healthy lifestyles and reducing the prevalence of common risk factors through community based health care approach.
To provide an easy access for diagnostic, preventive and curative services of chronic diseases (especially diabetes, hypertension, chronic respiratory illness and cancer) by an integrated evidence-based suspicion with a referral backup support.
The frontline community health workers (CSWs) –shasthyashebikas and shasthyakormis will perform screening of hypertension and diabetes in the community. They will refer the patients with high blood pressure and high sugar to the hospital for confirmation of diagnosis and treatment; and perform post-treatment follow-up.
The CSWs will inform and educate people through door-to-door health education. They will also educate about healthy ageing, nutritional requirements, and lifestyle and behaviour changes during their regular household visit and follow-up.
Vision Bangladesh Project (VBP) is a joint venture of Ministry of Health and Family Welfare (MoH&FW) of Bangladesh, BRAC and Sightsavers to eliminate the cataract backlog from Sylhet division by 2013.
Elimination of avoidable blindness from Bangladesh by the year 2020.
Elimination of the backlog of cataract blindness from Sylhet Division by the year 2013.
• Increase demand for eye care services particularly for cataract in the community
• Increase accessibility to quality eye care services especially cataract particularly for the poor
• Develop efficient HR of service providing eye care facilities
• Manage programme efficiently and effectively
This project is undertaken in close partnership with the government health sectors under the leadership of the Civil Surgeon. All BRAC staffs are trained in prevention of blindness at the intervention areas. The activities include dissemination of eye health message, patient detection, referral to eye care facilities and follow-up of the patients. BRAC staff mobilise the community people through different forums to attend patient screening programme (PSP) for eye care services. The community health workers are trained to identify suspected cataract patient and carry out the activities by visiting houses. They refer suspected patients to the PSP for screening. The diagnosed cataract patients are referred to specially selected eye hospitals. The operated patients are followed up at home. If any complications occur, respective eye care hospitals are immediately informed for appropriate management of the patients. Local government stakeholders are also involved in the programme.
Reading Glasses for Improved Livelihoods
In Bangladesh, about 20 percent people suffer from presbyopia which deprives them of contributing to household activities and in the national economy as well; and so it has become a major public health problem.
This project aims to combat presbyopia - a chronic eye problem, which results difficulty in near vision and reduces productivity of adults over the age of 35 years. It has been implemented in partnership between BRAC and VisionSpring which is a non-profit organisation based in the USA.
The mission of VisionSpring is to reduce poverty and generate opportunity in the developing world through the sale of affordable eyeglasses, and it is consistent with the mission of BRAC, which is to bring positive changes in the quality of life of people who are poor.
The activities on reading glasses have been incorporated in the normal work schedule of the Shasthya Shebika (SS). Before conducting vision screening in the community, the SS mobilises people who suffer from eye problems, using forums like village organisation (VO) meetings, group health education meetings, etc. For a broader coverage of the programme, camps are also held in different project areas. After testing the subject groups’ visions, the SS offers reading glasses of proper magnification to the presbyopic clients at affordable costs. Patients with other eye complaints are referred to district eye hospitals. The Shasthya Kormis and programme organisers support the SS in screening and referral. Upazila Manager and other supervisors provide periodic supervision and follow-up.
Vision Bangladesh Project: Phase II
The Vision Bangladesh Project (VBP) is a joint venture of National Eye Care-DGHS (under the Ministry of Health & Family Welfare (MoH&FW) of Bangladesh), and BRAC to eliminate the backlog of cataract sufferers from slums in the cities of Bangladesh by the year 2015. In addition, the project seeks to address the incidental cataract cases and to reach the unreached. The project will also work in the Sylhet Division until 2015.
The elimination of avoidable blindness in Bangladesh by 2020.
Purpose of the Project:
To eliminate the backlog of cataract blindness in the slums of Bangladesh by 2015.
1. To Increase knowledge and awareness of eye care services within slum communities
2. To build capacity for and institutionalise eye care within the Bangladesh healthcare system; thereby enabling access to quality, affordable treatment for disadvantaged people affected by cataract blindness.
3. To strengthen the capacity of eye care facilities’ service through collaboration between the partners, in a manner that is suitable for Bangladesh’s social, cultural, and economic context.
• Prepare action plan for patient screening programme
(PSP) with hospital partners
• Develop plan for community mobilisation activities
• Orientation of staffs on primary eye care
• Dissemination of eye health messages, patient detection, referral to eye care facilities and follow-up treatment
• Follow-up of operated patients and referral of complicated cases to partner hospitals for appropriate treatment
Malnutrition is a major public health concern in Bangladesh. To address this problem, BRAC’s nutrition programme has been working at household and community level for creating awareness on nutrition. BRAC’s shasthya shebika and nutrition promoters visit households in their communities and provide counselling, coaching and demonstration. Moreover, they offer community-based management of acute malnutrition (CMAM) service to mother and child of 6 to 59 months who are affected by moderate accurate malnutrition by providing supplementary food. Nutrition programme creates awareness about adolescent girls’ nutrition and encourages mothers and family members about many issues like intake of healthy and various types of food, early initiation of breast feeding, exclusive breast feeding till 6 months, breast feeding for at least two years and initiation of complementary feeding after six months. Moreover, to prevent child malnutrition and anaemia, micro-nutrient powder sachets are distributed under maternal, infant and young child nutrition(MIYCN) home fortification programme. It helps to prevent anaemia of 6 to 59 months old child by providing required iron, vitamin and minerals
More information can be found by following the links below.
Bangladesh Maternal Infant and Young Child Nutrition (MIYCN)- Home Fortification Programme
Improving Maternal and Child Nutrition (IMCN)
BRAC USI (Universal Salt Iodisation) RTK (Rapid Test kit) Project: A new initiative
Bangladesh Sprinkles Programme
Malaria is a major public health problem in some parts of Bangladesh, particularly in 13 districts in the north-east & south-east areas which border India and Myanmar. Among them are the Chittagong hill tracts (CHT) districts which highly endemic and Cox’s Bazar which is moderately endemic. The other districts are categorised as low endemic areas as fewer numbers of cases have been reported there. Sporadic incidences occur in other parts of the country.
The National Malaria Control Programme (NMCP) established an effective partnership with a consortium of 21 NGOs led by BRAC. This partnership has leveraged the programme and increased the access to malaria treatment, prevention and awareness raising activities within communities, including the hard-to-reach areas.
In partnership with the National Malaria Control Programme (NMCP), BRAC successfully secured a grant from the GFATM to strengthen and expand national malaria control activities to all endemic districts working directly and through other NGOs. BRAC is directly implementing malaria control activities in all sub districts of CHT, two sub districts of Moulvibazar, and through 20 partner NGOs in other districts which are monitored and supervised by BRAC.
To reduce the overall burden of malaria (morbidity and mortality) by 60 percent from baseline year 2008 in 10.9 million populations in 13 high endemic districts of Bangladesh by 2015.
To reduce the overall burden of malaria (morbidity and mortality) in the 13 high endemic districts of Bangladesh by 60 percent, by the year 2015.
• To expand the use of Long Lasting Insecticidal bed Nets (LLIN)( two nets per household), to achieve 100 percent coverage in the three malaria endemic districts and to maintain 80 percent coverage with Insecticide Treated bed Nets (ITN)/LLIN in the remaining districts.
• To expand and improve the quality of diagnosis and treatment of malaria cases to 90 percent.
• To further strengthen programme management and partnership coordination surrounding malaria control.
BRAC’s community based model has been applied in malaria programmes to promote health education, empowerment and home based services. BRAC’s shasthyashebikas and shasthyakormis diagnose malaria patients using a Rapid Diagnostic Test (RDT) kit, therefore providing treatment at a household level They also refer patients to the nearest government health facilities in case of pregnant women, children under five kilograms of weight and severe malaria cases. In addition, 121 laboratories and sub-centres have been established in remote areas to strengthen early diagnosis and prompt treatment (EDPT). LLINs are distributed in the community free of cost as one of the most important methods of preventing the transmission of malaria.
Various sensitisation and advocacy meetings are conducted among the different stakeholders of the community to make them aware of malaria symptoms and to engage them in the effort to identify patients, increase utilisation of LLIN and to create early care seeking behaviour. The stakeholders include local figures, religious leaders, headmen, karbaris, teachers, village doctors, pharmacists, private practitioners and hotel owners/ managers.
Since May 2007 to June 2014, a total of 3,067,663 cases of fever were examined nationally by RDT and/or microscopy, of which BRAC and its partner NGOs performed 1,822,086. Out of 318,649 confirmed malaria cases, 228,233 (72%) were treated at the community level in the same period. In addition, death due to malaria was reduced by 90 percent (15) in 2013 in comparison with the baseline year 2008 (154). Since the beginning of the programme, a total of 3,735,905 LLINs have been distributed among the beneficiaries in the malaria endemic areas.
Tuberculosis (TB) has been a major public health concern for Bangladesh for decades. According to the World Health Organization (WHO), Bangladesh ranksseventhamong the 22 highest TB-burdened countries. BRAC initiated the tuberculosis control programme in 1984 in one district as a pilot. In 1994, BRAC became the first NGO in the country to sign a memorandum of understanding with the government to expand directly observed treatment short course (DOTS) services across the country. BRAC also became a principle recipient (PR) of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), along with the government. The aim of the programmeis to reduce the morbidity, mortality and transmission of TB until it is no longer a public health problem.
BRAC's shasthyashebikas(frontline community health worker) play a pivotal role inconnecting individuals with TB control services during household visits and health forums. They disseminate TB-specific messages to the community, identify presumptive TB patients and refer them, for sputum examination, to the governmen tsub-district health complex or peripheral laboratories of BRAC. The frontline health workers also ensure regular intake of medicine for identified TB patients through DOTS. They refer complicated TB patients to health facilities for further treatment and for proper management of side effects and other complications during TB treatment.
BRAC's approach towards the diagnosis and treatment of TB focuses on community level education and engagement. The programme conducts orientation with different stakeholders of the community to engage them in efforts to identify TB patients, ensure treatment adherence, and reduce stigma surrounding TB. The stakeholders include cured TB patients, local religious leaders, school going children, girls' guides and scouts, other NGO workers, formal and non-formal care providers like graduate private practitioners, village doctors and pharmacists.
Currently, BRAC covers 297 sub-districts from 42 districts, 7 city corporations with a population of 92.9 million people including 31 academic institutes, 41 prisons, 405 peripheral laboratories and 26 external quality assessment centres. BRAC is leading a group of 42 local NGOs who are the sub -recipients (SRs) of the GFATM under the same umbrella of NTP. BRAC supervises, monitors, guides and provides technical assistance to the SRs,to ensure that the quality of the service delivered is uncompromised.
In Bangladesh, about one-third of the population lives in urban areas with worse health situation in slums and squatters in cities. To improve the health status of the slum population, particularly women and children, BRAC started Manoshi, a community based healthcare programme, in 2007 at urban slums of nine city corporations around Bangladesh through development and delivery of an integrated, community-based package of essential health services.
To decrease illness and death in mothers, newborns, and children in urban slums of Bangladesh
• Increase knowledge of individuals, households and community
• Increase skills and motivation of human resources to offer services at household and community levels
• Improve and strengthen referral system for management of complications
• Strengthen and sustain linkage with government, NGO and private health facilities
• Develop a supportive network to support communities and individual households to sustain services
• Facilitate scaling up of successful approaches
Manoshi envisages improvement in the health status of poor urban mothers, newborns and children by bringing healthcare services to their doorstep through our frontline Community Health Workers (CHWs). The shasthya shebikas and shasthyakormis provide antenatal and postnatal care, essential newborn care (ENC) and child health care. Through behaviour change communication interventions they motivate, educate and prepare expectant mothers for childbirth, highlighting an array of health issues including maternal and neonatal danger signs, maternal and neonatal nutrition and so on. BRAC Delivery Centres are established within slums to provide intra-natal care to mothers and immediate care to newborns. Emergency obstetric, neonatal and child health complications are referred to the hospital through an established referral system.The community is connected to health facilities via an innovative mobile phone based referral system. Manoshi is currently being implemented in eleven city corporations.
m-Health (Mobile Health)
Currently piloted in the urban slums as Manoshi (MNCH Urban) Programme, the initiative intends to digitise the health services by collecting, recordingandpreserving household information.Thusit createsa real time virtual database. The database helps to speed up service delivery process to the target population.
Read the book on Manoshi approach
Improving maternal, neonatal and child survival (IMNCS) project is a comprehensive community based health intervention focusing on preventive and curative care with a group of trained community health workers under structured supervision and monitoring system. This comprehensive undertaking is uniquely designed to address the bottlenecks of demand and supply side for ensuring continuum of care from home to hospital. We are reaching around 25 million people living in rural areas of 14 districts (Nilphamari, Rangpur, Gaibandha, Mymensingh, Kurigarm, Lalmonirhat, Faridpur, Rajbari, Madaripur, Magura, Pirojpur, Joypurhat, Shaerpur and Shariatpur) with maternal, neonatal and child health (MNCH) services.
To reduce maternal, neonatal and child mortality, particularly among the poor and socially excluded populations
• Increase knowledge of and practices related to maternal, neonatal and child health
• Improve provision of quality maternal, neonatal and child health services at household and community levels
• Increase availability and access to a quality supplyof maternal, neonatal and child healthcare
• Increase participation, accountability and responsiveness to the voice of communities in maternal, neonatal and child health services
Community Health Workers (CHW): namely, shasthyashebika, Newborn Health Worker, shasthyakormi and Community Skilled Birth Attendant (CSBA) are the frontline workers catering to family planning, pregnancy related care, childcare of newborns and children under fivein the household.. A change in behaviour towards healthy practices in terms of reproductive health, nutrition, hygiene and sanitation is the strategy to preventive and promotive care. CHWs offer basic care eg, antenatal care, delivery care, postnatal care, newborn care and management of birth asphyxia, diarrhoea, ARI and some common ailments. CSBA attends home deliveries to ensure safe maternal and neonatal outcome at birth. By bridging gaps between community and facility during emergencies,a well structured referral system is put in place to reduce delays in accessing health care UNICEF is working with the government at hospitals and health facilities to improve health care. In essence, a continuum of care is provided to mothers, neonates and children under-five.
The programme intervention started in 2005 as a pilot initiative in Nilphamari district. The intervention is mainly aimed at providing basic primary healthcare at the community level, working with village health committees to motivate behaviour change in the committee by addressing issues of pregnancy, newborn and child health, and facilitating access to obstetric and newborn care at public and private facilities.
Aligned with the growth of the programme, the MNCH Programme has been divided into two components: ‘Manoshi’, MNCH (Urban), which currently works in city slums of nine city corportations and IMNCS (MNCH Rural) which currently works in 14 defined districts.
Essential health care (EHC) is the foundation of BRAC's health programme, combining promotive, preventive and basic curative services. EHC has revolutionised the primary healthcare approach in Bangladesh, reaching millions with low cost basic health services through BRAC's frontline community health workers.
EHC aims to improve reproductive, maternal, neonatal and child health along with the nutritional status of women and children. The programme further aims to reduce vulnerability to infectious, communicable diseases and non-communicable diseases. The programme provides primary healthcare services including maternal and child healthcare, basic treatment for acute respiratory infections (ARIs) and promotes family planning methods and safe delivery practices. Use of proper sanitation, safe drinking water, hygiene-specific messages are also disseminated among communities.
The EHC programme has partnered with different government agencies under the Ministry of Health and Family Welfare to observe national health-specific days and events of instruction across the country. Collaboration with the government to promote family planning, immunisation of children and distribution of vitamin A capsules within communities are a few of the many successes of the programme.
Currently the programme is operating in all 64 districts of the country and delivering healthcare services to over 120 million people, in turn serving as a platform for other health interventions.
Essential Health Care Programme for CFPR-TUP
In Bangladesh, 8 per cent of the population is suffering from extreme poverty. Their health status lags far behind that of the general population. Essential Health Care (EHC) services for the ultra-poor under Challenging the frontiers of poverty reduction – Targeting the ultra poor programme (CFPR-TUP) is specially designed to meet the needs of extremely poor households unable to access or benefit from traditional development interventions.
The goal of the programme is to reduce the vulnerability of the poor and ultra-poor to sudden health problems and to prevent them from sliding back into the vicious cycle of extreme poverty
The programme aims to increase access to health services, through demand-based strategies and by providing a package of basic health services which meets the needs of the ultra-poor.
The ffinancial constraint of the ultra pooris a major impediment in accessing available health services. To address this problem BRAC has introduced the provision of financial assistance to the ultra-poor so that they can access medical care from government or other health facilities.
Community participation is ensured in the programme through community forums (Gram Daridro Bimochon Committee) which form an organised network for the improvement of health and the social status of the rural poor in each village. Committee members actively provide motivation and financial support to the ultra-poor for accessing different health services.
Bangladesh has made remarkable strides in healthcare in the four decades since independence. Since the 1990's maternal mortality has dropped from 574 to 194 deaths per 100,000 live births, and child mortality from 133 to less than 32 per 1,000 live births. Over four decades, the contraceptive prevalence rate has gone up seven to eightfold. In the 1980's, when immunisation coverage was two per cent, the shared roles and activities of BRAC and the government improved the status to 70 per cent within the last four years. The current status of fully immunised children is at 86 per cent. Despite the achievements, Bangladesh still suffers a high burden of deaths and diseases. Over 70 per cent of people seek care from informal health care providers and 62 per cent of those health providers practicing modern medicine have little or no formal schooling. One thirds of births take place at home, mostly assisted by unsupervised, untrained birth attendants. Recognising these problems, we have created a pool of frontline community health workers, the shasthya shebikas and shasthya kormis, who strive to address the crisis of human resources in the health sector by playing a substantial role in providing accessible and affordable services to the majority of the population.
Initiated in 1991, Essential Health Care (EHC) has revolutionised the primary healthcare approach in Bangladesh reaching millions with low cost basic promotive, preventive and curative services through our cadre of frontline community health workers. The goal of EHC is to improve access to essential health services through delivering community care and organising a bridging network with public healthcare system. Shashtyashebikas and shasthyakormis are mainly part of Essential Health Care (EHC) Programme. In fact, EHC is the basic platform of Health, Nutrition and Population Programme. All health interventions of BRAC are fundamentally based on the platform of EHC programme. To provide these services to the doorstep of millions of people would have required huge investment in the traditional system because of the large number of employees involved in the system. However, EHC developed a very innovative entrepreneurship model where the primary service deliverer (shasthyashebika) provides voluntary service. Although they do not receive any salary or monthly stipend, they are provided with financial incentives on the sale of basic medicines and selected health commodities to their community. This low cost innovative service delivery strategy has attracted various donors and partners in BRAC’s health programme because BRAC can deliver the service very effectively with a much lower cost.
We have started maternal, neonatal and child health (MNCH) programmes in 2005 as a pilot project and has been scaled up to 11 city corporations and14 rural districts in partnership with the government, UKAID and Australian High Commission. We have demonstrated that with limited resources, it is possible to change behaviour and practices to lower the incidences of maternal and neonatal deaths within a short period. With the active engagement of community health workers and birth attendants, we ensure high coverage of antenatal and postnatal care while supporting skilled birth attendance. More importantly, an innovative referral system is developed which facilitates transfer of acute emergency cases to hospitals. Within three to four years, we have observed a decline in maternal and neonatal deaths in both urban slums and rural districts.
Bangladesh has made a remarkable progress toward tuberculosis control since the inception of the Directly Observed Treatment Short- course (DOTS) strategy in 1993. In 1994, BRAC became the first NGO in the country to sign a memorandum of understanding with the government and expanded DOTS services across the country through its diversified partners. The national TB control programme in Bangladesh has established effective partnership with the consortium of 43 NGOs led by BRAC to implement the programme throughout the countries. BRAC has been working in 297 sub-districts of 42 districts with the coverage of 93 million population. In BRAC supported areas, all forms of TB case notification rate has increased from 105 to 129 /100,000 population per year. From 2004 to 2013, more than 1.5 million TB patients have been treated; yielding present treatment success rate 93 per cent in BRAC supported areas which has exceeded the national target (85 per cent) and is the second highest treatment success rate in the world Bangladesh has also improved case notification for child TB, smear negative TB, extra-pulmonary TB and drug resistant TB. The contribution of shasthya shebika in detecting presumptive TB cases, collecting sputum for lab diagnosis and DOTS for TB is tremendous. The Global Fund plays important role to control TB programme in Bangladesh. Growing challenges like TB/HIV co-infection, TB/diabetes are also being prioritised. More initiatives will be taken to address vulnerable communities including people with high risk behaviour and marginalised socially excluded people for TB care services. Urban TB programme is also given special attention for further strengthening of the programme.
The malaria control programme is on track in terms of MDG targets and has shown considerable success among the people at risk from malaria. The National Malaria Control Programme (NMCP) established an effective partnership with the consortium of 21 NGOs led by BRAC to implement the programme in 70 sub-districts of 13 endemic districts. Through the funding of The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and Health, Population and Nutrition Sector Development Program (HPNSDP) of government of Bangladesh, the malaria control activities were scaled up and the quality of preventive, diagnostic and treatment services have been improved. BRAC is directly implementing the programme in high endemic three Chittagong hill tracts districts and in 2 sub-districts of Moulvibazar. BRAC’s community based models applied in malaria programme using a large workforce of local shasthya shebikas and shasthya kormis in managing malaria patients at doorstep, raising awareness on malaria prevention and health service utilisation. Malaria cases were reduced by 68per cent in 2013 comparing to baseline year 2008 and whereas death was reduced by 90 per cent at the same time. A total of 3,735,905 long lasting insecticidal nets (LLIN) were distributed and 4,231,689 ordinary bed nets were treated with insecticide in the same period. Recent malaria prevalence survey conducted in 2013, documented the decreasing of point prevalence of malaria from 4 in 2007 to 1.41 in 2013 per 1,000 populations based on RDT in malaria endemic districts. A good utilisation rate (>85 percent) of insecticidal bed net was observed among pregnant women and children under 5 years of age.
Malnutrition among children is one of the major problems of our country. To mitigate this problem, BRAC’s nutrition programme has been working at household and community level for creating awareness on nutrition. BRAC’s shasthya shebika and nutrition promoters visit households in their communities and provide counselling, coaching and demonstration. Moreover, they offer community-based management of acute malnutrition (CMAM) service to mother and child of 6 to 59 months who are affected by moderate accurate malnutrition by providing supplementary food. Nutrition programme creates awareness about adolescent girls’ nutrition and encourages mothers and family members about many issues like intake of healthy and various types of food, early initiation of breast feeding, exclusive breast feeding till 6 months, breast feeding for at least two years and initiation of complementary feeding after six months. Moreover, to prevent child malnutrition and anaemia, micro-nutrient powder sachets are distributed under maternal, infant and young child nutrition (MIYCN)home fortification programme. It helps to prevent anaemia of 6 to 59 months old child by providing required iron, vitamin and minerals.
In Bangladesh, around seven hundred thousand people suffer from cataract blindness. Moreover, around one fifty thousand people are becoming blind every year. BRAC started ‘Vision Bangladesh’ project with the aim to remove the backlog of cataract blindness. In this programme, cataracts are identified through local eye camp and patients are sent to various government and private hospitals for operation. Community health workers visit household in their community and aware people about eye problems. And if there is any complex case, they send the patients to nearby hospitals or health centres. Moreover, BRAC’s ‘Reading Glass for Improved Living’ project has been providing reading glasses to the people whose vision has become blurred due to age.