The details of the participants’ characteristics are presented in Table 1. Of total 14 health facilities included in this study, five were from the urban setting, six from rural and three from the central level health facilities.
a. NCDs related health services delivered by CHWs in Bangladesh:
Community Clinics (CCs) are the grassroots level public sector health facilities in Bangladesh. The services are provided by the Community Health Workers, including CHCP along with FWA and HA. The common NCD and related services provided by these CHWs include a screening of common NCDs such as diabetes and hypertension. However, the services for the detection of other NCDs such as COPD and cancer are not yet available. Basic medication for diabetes and hypertension is also available at the community clinic level. However, for further investigation and confirmatory diagnosis of NCDs and appropriate management, the patients are referred to upper-level health facilities, such as Upazila health complex (sub-district level health facility) or district level health facility, where specialized health services are available. The FGD members reflected this opinion during the FGD.
“When the patients with the possible non-communicable disease come to our community clinic, we tell them about the risk factors of NCDs, but we realize more awareness and health education needs to motivate the community. We offer BP measurement, Blood sugar test using a glucometer, minor treatment of RTA and some basic biochemical test.” – IDI 1-Medical Officer, Urban Primary Healthcare Centre, Dhaka
Notably, CHWs said that they usually provide necessary advice and counselling for common NCDs to the people who come to see them. The CHWs provide advice related to dietary habits, the importance of physical activity, health education and healthy behaviour to prevent NCDs when anyone come to consult them. Most of the CCs have limited laboratory facilities available, and the CHWs diagnose hypertension but no other NCDs because of lack of resources and training. Some of those CCs, which have glucometers available to test blood sugar, are most of the time, out of order or the supplies such as glucometer strips or batteries ran out. One participant said:
“BP machine and glucometer, along with other measuring tools, are available in our CCs. But the problem is we don’t have enough strips here at the CCs, right now because of the shortages of glucometer strips, so I can’t check the blood glucose level using the glucometer.” – FGD1-Health Assistant-Community Clinic, Sylhet district
In general, CHCPs received 12-weeks basic training, mostly focused on maternal and child health and HCPs and AHI/HI received one-day training on NCD prevention and management. The NCD training included a general screening of NCDs, health education, counselling and basic care for common NCDs. One CHCP expressed:
“We don’t have any extensive training on the management of common NCDs, i.e. diabetes, hypertension but these are the very common finding in our regular activity and identified patient wants to get their treatment at the community level” - IDI2 Health Supervisor, Urban PH Clinic, Lalbagh, Dhaka
To date, there is no systematic approach in place for a referral and follow up of a patient. These are up to the patient to choose the health facility they want to go for further investigation and management. Suspected patients are referred to UHCs for further investigation, diagnosis and necessary management of NCDs.
To provide medication, the NCD related drugs are supplied within the regular drug supply schedule, which in general takes longer time, even up to four months once the requisition is made. Also, the uncertainties exist in terms of discrepancy between requisition and actual supply. One of the KIIs shared that:
“to date, over 29 different types of medicines are supplied to community clinics from the government. They are mostly antibiotic, vitamins, eye ointments, salbutamol, anti-helminths, oral saline and acetaminophen product. These drugs also have more demand for community people. The anti-hypertensive and diabetic drug is not yet available at community clinic though community people are regularly demanding supply for those from CHCP”. KII1 Line Director, (NCD), Director General of Health Service
In terms of recording and reporting, participants noted that there is no separate registration for NCDs conditions or related risk factors. The information regarding the patients with NCDs conditions is recorded and reported along with patients of other health conditions.
b. Barriers and challenges to engaging CHWs in the NCD prevention and control services:
This study identified several challenges and obstacles to engaging CHWs for NCD prevention and control in Bangladesh. The challenges are mainly related to workload, inadequate training, poor system-level support, inadequate remuneration, delivery of services and the availability of resources. The challenging factors are structured in the following key sub-themes:
(i) Lack of trained human resources for health:
At present, the CHWs job description primarily involves providing services for communicable diseases, MNCH care, nutrition, immunization and health education and counselling services. Participants opined that, to date, no clear job description had been given, which would involve NCD services too. However, in recent years, the health facilities have initiated providing essential preventive and care services for those with NCDs conditions. The CHWs are currently multi-tasking and responsible for both the administrative and technical tasks. One KII opined that:
“Our jobs have so far given mainly focused on providing services for communicable, maternal and child health and related services. We still do not have a clear job description on NCD services, however, we know somehow about preventive aspects and also basic NCD services, such as medication for diabetes and hypertension”- KII2, Line Director, Community Based Health Care, Director General of Health Service
Further, the CHWs are not yet trained on NCDs screening and providing basic NCD care which hinders them providing NCD services. This may require providing focused training on NCDs and making necessary supplies (i.e. medical equipment and medicines) available. Inadequate number of health workers at the health facilities often resulted in increased workload on the existing staffs, thus affecting the effective health services delivery, including NCDs services. One health worker expressed that:
“There are no trained CHCPs, AHI/HI at this CC. Even still now, I have not received any training on NCD. We all received maternal and child health-related training. - FGD2, Community Clinic, Uttar Matlob, Chandpur
Another participant also added that there had been a shortage of health care providers too:
“…. but the problem is the staffs need to be involved with their regular activities, and we have staff shortage, especially paramedics. So due to support staff shortage, there is no one to support the dedicatedly NCD patients at the Community Clinic.” – KII3, Principal Scientific Officer, Institute of Epidemiology Disease Control and Research, Director General of Health Service
(ii) Lack of regular supply of logistics and medicine:
CHWs reported frequent delays in the delivery of medication supplies for common NCDs (i.e. hypertension and diabetes) at the community clinic from the sub-district hospitals. This has hampered their service delivery to the community members and raised dissatisfaction among the public. One participant opined:
“Yes, we have received glucometer, BP machine, weight and height machine for the CC. But now the problem is, there is a shortage of battery and strips for the glucometer for which we can’t use the glucometers.” - - FGD3 Health inspector, Rakhal Gonj Community Clinic, South Surma, Sylhet
Another participant in the FGD expressed that, once a year, the CCs provide a requisition for medicine. The medicine comes at the CS office, and from where the CCs take what is being allotted for them. The NCD related medicines come with the regular medicine supply, but the supply schedule is uncertain. Also, the amount and types of medicine sent for treating NCD patient is not adequate.
“For the outpatients, the type of medicines dispensed depends on the available medicines and supply. We always try to provide whatever medicines are available at the CCs. But for the inpatients, we have medicines required to treat the NCD patients at Upazila level.” – KII4 Upazilla Health and Family Planning Officer South Surma, Sylhet.
Further, the health facilities, in particularly the CCs, are facing other logistics-related challenges, such as shortages of adequate space, lack of furniture, and inadequate necessary instruments to deliver NCD related services. One FGD participant said:
“The CCs are facing many problems. There is a lack of proper instrumental support. At my CC, we received only a BP measurement set. We are waiting for other equipment to arrive. We have no glucometer for screening NCD cases as most of the required blood tests we now advised them to go UHC, but we need available immediate screening and measurement tools.” – FGD4 Zohirbad Nadamodi Community Clinic Uttar Matlab, Chandpur
Coupled with above-described challenges, the participants also identified other key challenges including: inadequate health systems priority and lack of standard operating procedure to NCDs prevention and care, no specific policy documents prioritizing NCDs care and services as core activities of the health facilities, and lack of awareness on NCDs risk factors, NCDs symptoms and delay in seeking care by the patients at the community level.
c. Facilitating and enabling factors in engaging CHWs in NCD prevention and control:
Participants identified following facilitating factors to support engagement of CHWs in NCDs prevention and control.
(i) Supportive policy initiatives to NCDs prevention and control: Over the past several years, the government of Bangladesh has initiated several NCD prevention and management related initiatives. Policies and guidelines to NCDs prevention and control at the systems level have been developed, an NCD control program at the DG health services has been created - to primarily looking after the NCD issues. To this end, the NCD corners at the sub-district level health facilities (UHCs) has been introduced, and several efforts to increase NCDs prevention and control measures at the community level have been initiated. One participant opined that:
“The government of Bangladesh has given priority for NCDs prevention and control. The government also has established over 300 NCD corners in the country, and we have been able to somehow implement NCD services through these NCD corners in the country” – KII5 Divisional Director, Sylhet Division, Director General of Health Service.
Further, in recent years few necessary NCD drugs have been added into the essential drug list and made these essential services drugs (ESDs) freely available at the community health facilities.
ii) Recruitment and fulfilling the vacant positions in health facilities: The CHWs believed that the initiatives taken by the Directorate General of Health Services, Bangladesh, to fulfil the vacant positions in the health facilities will ensure delivery of quality health services in the community level, including NCDs services. They also thought that the retention of health workers is another important aspect of delivering NCD and related services. This is one of the keys facilitating factors the CHWs identified in this study. One participant said:
“Government of Bangladesh has taken a good initiative to recruit new positions and fulfil the vacant positions in all health facilities. Retention of health workers to the assigned health facility, in particular, the rural areas is equally important as recruitment and deployment” – KII6, Head of the Department of Epidemiology, National Institute of Preventive and Social Medicine.
iii) Job satisfaction: Despite several challenges the CHWs are facing, they shared that they have a good level of personal satisfaction to the services they are providing. CHWs said that serving people in the community reciprocate the respect and recognition from the community members. One of the participants shared:
“I feel great that I have got the opportunity to work at the health facility in my community, and I am serving people in my area. When people tell me that I have done a good job, I feel very proud and happy, and that makes me more responsible” – IDI-4, CHCP, Rakhal Gonj Community Clinic, South Surma, Sylhet.
iv) CHWs as key drivers to NCDs prevention and control: Most of the KIIs, IDIs and the participants of the stakeholder consultation meeting viewed that the CHWs have been playing a vital role for NCDs prevention and management services. One KII emphasized:
“Traditionally, the CHWs have been trained and given tasks to deliver communicable diseases and related services. However, the situation in Bangladesh has changed where we are dealing with NCDs rather than communicable diseases. The CHWs have been well recognized to play vital roles in the prevention and management of NCDs. Of course, the CHWs need a range of policy and systems support and guidance, which they have been provided by the government of Bangladesh. KII-7, Manager, Directorate General of Drug Administration
v) Collective efforts to NCDs prevention and control: The policy level participants (health managers, researchers, academicians and clinicians) stated that the Ministry of Health and Family Welfare, Bangladesh has given priority to NCDs prevention and control in Bangladesh. There has been a government level commitment. However, there is a need for working together and collaborating with other ministries and non-state sector to optimize the efforts for NCDs prevention and control in Bangladesh. Participants also shared that the non-state sector, in particular, the NGOs and private sector have also taken several initiatives. They also provide NCDs prevention and care services, including screening, early detection, diagnosis, treatment, referral, and health education and counselling services in Bangladesh. One participant highlighted:
“The government of Bangladesh have developed a range of NCD related policies and guidelines. We have a dedicated department (housed within the DG Health services) to look after NCD related programs in the country. However, there is a need for working together with other ministries, NGOs and private sector” KII-1, Line Director, Community Based Health Care, Director General of Health Service