Background:
Volunteer Community Health Workers (CHWs) are a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, uses female CHWs as core workers in its community-based health programs since 1977. After 25 years of implementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through a community-based maternal health intervention. However, BRAC experiences high dropout rates among CHWs suggesting a need to better understand the impact of their dropout which will help to reduce dropout and increase program sustainability. The main objective of the study is to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, it estimates cost of possible strategies to reduce dropout and compares whether they are more or less than the cost borne by BRAC and the community.
Methods:
The study uses ‘ingredient approach’ to estimate the cost of recruiting and training of CHWs and so-called ‘friction cost approach’ to estimate the cost of replacement of CHWs after adapting. Finally, forgone services in the community due to CHW dropout are estimated applying the concept of friction period.
Results:
In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if a CHW participated, a three-week basic training, a one-day refresher training, one incentive day and worked for a month in the community after recruitment. One month absence of a CHW with standard average performance in the community means substantial forgone health services like health education, antenatal visits, deliveries, referrals of complicated cases, and distribution of drugs and health commodities. However, with an additional investment of US$ 121 yearly per CHW BRAC can save another US$ 60 invested for ad-hoc CHWs plus forgone services in the community.
Conclusion:
Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immense both in financial term and forgone services. High cost of dropout makes the program less sustainable. However, simple and financially competitive strategies could improve the sustainability of the program.