POLICY BRIEF
Key messages

• The training was effective in increasing the knowledge of community health care providers (CHCPs)
• CHCPs applied the knowledge gained and provided good quality care.
• Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide.
• There are substantial benefits to healthcare provision if countries develop tailored materials and training packages for lower-level health workers.

Recommendations for policy and practice

1. Regular, rather than periodic refresher training and awareness sessions are needed to minimise errors in diagnosing cough, cold and pneumonia
2. The government should continue using the adapted integrated management of childhood illness guide for training CHCPs, with regular reviews of World Health Organization and other guidelines
3. Additional communication workshops are needed to improve the communication skill for better service and popularity of community clinics

The quality of healthcare for children in Bangladesh
Globally, the mortality rate for children aged under 5 years has halved since 1990,[1] with similar reduction in South Asia. In Bangladesh, the mortality rate for under 5s remains high, at 46/1000,[2,3] half of which is due to acute respiratory infections, serious infection and diarrhoea. The first point of contact with health services for sick children is usually primary care. However, in low-income countries, the quality of primary care is often poor. Effective case management through trained healthcare providers could prevent many of these deaths.[4]
Commitment from the government of Bangladesh to improve healthcare provision
To improve the access, utilisation and equity of care, the Ministry of Health and Family Welfare (MOHFW) initiated the Revitalisation of Community Health Care Initiatives in Bangladesh (RCHCIB) project, which aims to provide an Essential Service Package for women, children and the poor. This is delivered by rural community clinics (CCs) with catchments of approximately 6000 people. So far, about 13,309 CCs have been built.
The importance of community healthcare providers
CCs are staffed by community health care providers (CHCPs) who are responsible for providing health education, health promotion, treatment for minor ailments, and identifying and referring severe cases to hospital. They also offer essential medicines (4 simple antibiotics & rest OTC products) & temporary contraceptives to the clients. Millions of patients all over the country visit CC and receive care from them. A huge number of complicated cases are referred to higher facilities by the CHCPs for proper management as well.
The CHCPs are supported and supervised by the Sub-Assistant Community Medical Officer (SACMO) of the upazilla (sub district) in which the CC is located. SACMOs are trained medical professionals who provide healthcare services at the larger upazilla health complexes (UHCs).
Our research
In response to government concerns about the poor quality of care at CCs, we conducted a programme review which indicated that although the CHCPs received 12 weeks of basic training (6 weeks of theory in the classroom, followed by 6 weeks observing doctors at work), they still lacked practical consultation and communication skills. We conducted a rapid pre-intervention study at 5 CCs, which showed that only 29% of the children seen had received proper diagnosis and care, confirming the raised concerns. We also estimated that 90% of children who did not need antibiotics nevertheless received them.
Objectives

• To determine the knowledge and consultation behaviour of the CHCPs after training; and
• To determine the proportion of under-five patients seen by CHCPs who received the correct diagnosis, correct treatment (including rational use of antibiotics) and appropriate referral when necessary.

Designing and pre-testing training material

• To address these issues, we developed, pre-tested and revised a diagnostic and case management job aid adapted from the Integrated Management of Childhood Illness (IMCI) guidelines,[5] and a communication guideline.
• We then trained all CHCPs in the study sites and assessed changes in their knowledge immediately before and after training.
• To assess the diagnosis, treatment and referral of the CHCPs post-intervention, every child aged under 5 years was re-assessed at exit by a SACMO sitting in a separate room within the CC.
• To assess the communication of the CHCPs with the patients and carers, a social researcher observed the consultations on the final day of the assessment, and completed a checklist.

New components to the training package

• A job aid [6] and user guidelines based on IMCI guidelines to help effectively manage 6 common illnesses, including the appropriate use of antibiotics
• Training on ‘how to diagnose and treat’ and how to communicate with the child and the caregivers
• Case studies and role-play exercises

Results

• 99.5% received a correct referral decision by the CHCPs.
• 91% of the children were correctly diagnosed.
• 89% of consultations resulted in the correct use of antibiotics.
• About 11% of children were prescribed antibiotics when they should not have been—less than half the rate found in the pre-intervention study. This is significant given global concerns about antibiotic resistance.
• There were still some errors in diagnosis (9%) and in treatment (14%), especially among children with respiratory symptoms, which can be addressed with on-the-job training.
• An important innovation in this study is the adaptation of the IMCI job aid and training to the Bangladesh context, in line with updated World Health Organization (WHO) guidance. The resulting six-page job aid is easy to use and easily replicable and scalable.
• The pre/post-training evaluation showed a highly significant and clinically meaningful increase in knowledge based on the content of job aid. These findings indicate that the knowledge CHCPs gained in training was applied in clinical practice which justify the decision of the MOHFW to roll out the refresher training countrywide.

Scale-up

• The Ministry of Health and Family Welfare has introduced distance learning and the programme managers have begun to fill the remaining gaps identified in the performance of the community health care providers through electronic distance learning modules.
• The intervention contributed to a change in national policy and practice, with about 14,000 community health care providers nationwide given the job aid and trained.
• In the next health sector programme, there are plans to arrange 6-day refresher training courses for all the community health care providers in 2017.

ARK Foundation is a partner of COMDIS-HSD, a Research Programme Consortium funded by UK aid. COMDIS-HSD carries out research and provides evidence to policymakers to help them improve the way they deliver health services to their populations.
For more information email: info@arkfoundationbd.org or visit www.arkfoundationbd.org
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References

1. Liu L, Johnson H, Cousens S, et al. (2012) Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. The Lancet. 379(9832): 2151-2161. doi.org/10.1016/S0140-6736(12)60560-1
2. You D, Hug L, Ejdemyr S, et al. (2015) Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. The Lancet. 386(10010): 2275-2286. doi.org/10.1016/S0140-6736(15)00120-8
3. Bangladesh Ministry of Health and Family Welfare. (2014) Bangladesh demographic and health survey 2014: key indicators. Dhaka, MOHFW
4. Jones G, Steketee R, Black R, Bhutta Z, Morris S. (2003) How many child deaths can we prevent this year? The Lancet. 362(9377): 65-71. doi.org/10.1016/S0140-6736(03)13811-1
5. World Health Organization. Integrated management of child-hood illness (IMCI). Geneva, WHO
6. Bangladesh Ministry of Health and Family Welfare and ARK Foundation. Integrated management of childhood illness (IMCI): age 2 months up to 5 years – job aid. Dhaka, MOHFW

This brief has been informed by:
Huque R, Ahmed F, King R, Walley J, Hicks J, Elsey H, et al. (2016) Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh. Public Health Action. 6(2): 77-82. doi.org/10.5588/pha.16.0004