Learnings From a Pilot Study to Strengthen Primary Health Care Services: The Community-Clinic-Centered Health Service Model in Barishal District, Bangladesh

Abstract

Background: Community clinics (CCs) staffed by community health workers (CHWs) represent an effort of the Government of Bangladesh to strengthen the grassroots provision of primary health care services and to accelerate progress in achieving universal health coverage. The Improving Community Health Workers (ICHWs) Project of Save the Children piloted a CC-centered health service (CCHS) model that strengthened community and local government engagement, harmonized the work of different CHW cadres who were working in the same catchment area of each CC, and improved the accountability of CHWs and the CC to the local community.

Methods: We describe the process for developing and implementing the CCHS model in 6 unions in Barishal District where the model was piloted and provide some early qualitative and quantitative findings pertaining to the model's effectiveness. Data were collected from CCs in the 6 pilot unions and 6 other unions that served as a control. Qualitative data were collected from the intervention area during the pre-pilot (October 2017-September 2018) and pilot phase (October 2018-September 2019). Document review, key informant interviews, and focus group discussions were also conducted. Maternal and child health service utilization data were extracted from the government health information system in both the intervention and control areas.

Results: Community group meetings ensured engagement with local government authorities and supported resource mobilization. There was greater coordination of work among CHWs and increased motivation of CHWs to better serve their clients. The analysis showed that the increase in maternal health consultations was substantially greater in the intervention area than in the control area, as was the number of referrals for higher-level care.

Conclusion: The CCHS model as applied in this pilot project is effective in engaging local key stakeholders, increasing CHW capacity, and improving client satisfaction. The model demonstrated that a community health system can be strengthened by a comprehensive approach that engages communities and local government officials and that harmonizes the work of CHWs.

FIGURE 1

Components of the Community-Clinic-Centered Health Service Model Piloted in Bangladesh

FIGURE 2

Social Map Showing Typical Distribution of Community Group and Community Support Group Members Before and After Reformation of Group Membership^{a a} Each dot refers to the residence location of a group member.

FIGURE 3

Organizational Hierarchy and Relationship Between Local Government and Rural Community Health Service Delivery System, Bangladesh Abbreviation: CSG, community support group.

FIGURE 4

Difference in Maternal and Child Health Community Clinic Services Utilization Between the Pre-pilot Period (October 2017–September 2018) and the Community-Clinic-Centered Health Service Model Pilot Period (October 2018–September 2019), Barishal District, Bangladesh Abbreviations: ANC, antenatal care; PNC, postnatal care.

FIGURE 5

Difference in Antenatal Care Visits at Community Clinics (%) Between the Pre-pilot Period (October 2017–September 2018) and the Community-Clinic-Centered Health Service Model Pilot Period (October 2018–September 2019), Barishal District, Bangladesh

FIGURE 6

Difference in Referral Cases From Community Clinics Between the Pre-pilot Period (October 2017–September 2018) and the Community-Clinic-Centered Health Service Model Pilot Period (October 2018–September 2019), Barishal District, Bangladesh