The digital transformation of thousands of community health workers in Bangladesh has dramatically enhanced their work, while enabling the creation and tracking of a healthcare database covering 64 million people. The resulting model holds remarkable promise for the health of the world, especially in the context of evolving pandemics.
Amid the COVID-19 pandemic, BRAC digitalised the work of our 4,100 shasthya kormi, specially trained community health workers, in Bangladesh. Shasthya kormi are women experienced in health education, antenatal and postnatal checkups, non-communicable disease prevention, reproductive health and nutrition. The digital transformation of their work created benefits on a remarkable number of levels, underscored the vast potential for further scaling, and yielded insights directly relevant to increasing the quality of healthcare globally.
Each shasthya kormi was given an Android tablet and trained in its use. That enabled immediate time saving in myriad ways: faster and more accurate record-keeping; reports conveyed online rather than in person; training conducted online and at convenient times rather than only at designated times in person; and related administrative travel and costs avoided. The time saved can exceed a full day every two weeks. The digital devices also enabled us to save approximately USD3.8 million per year in monitoring costs.
But that is just the beginning of the benefits. The digital tablets enhance the prestige of shasthya kormi, as they now have access to vital information at their fingertips. They can screen for diseases and conditions, confirm diagnoses, have complete confidence in describing required treatment and management, and arrange video chats with doctors and specialists. Their decision-making is quicker and more accurate, improving their quality of care and giving them more time to spend with patients.
Electronic reporting enabled the creation of a database that we expect will grow to cover 76 million people. That database can now be tracked and analysed for trends – in the incidence of disease or other conditions, in the delivery of services, and in outcomes. Those trends can be analysed and addressed in real time – locally and nationally, as BRAC’s shasthya kormi cover 61 of Bangladesh’s 64 districts.
For COVID-19, for instance, reports of symptoms and test results can be tracked, as can vaccinations and outcomes. Recognizing the incidence of positive test results in Bangladesh’s border regions is especially valuable to understanding how trends evolve across regions.
For tuberculosis, 1.4 million samples have been collected and tracked. Similarly, non-communicable diseases like hypertension and diabetes, for both of which the incidences are rising in Bangladesh, can be tracked and addressed. If anyone has high blood pressure, a shasthya kormi can precisely record it. A blood glucose test administered by a shasthya kormi can detect abnormal blood sugar levels indicating possible diabetes. The database can track the percentage of pregnant women who are at high risk.
The overall database – with its 150 data points so far – also enables cross-tabulation of facility-specific and community-specific data. It makes it possible to merge BRAC’s trend analyses with data from government and other institutions. It responds to internal migration, with each individual’s medical records linked to their government-issued national identification card – so each person’s health record moves with them.
When these benefits are combined with the cost-effective nature of this digital approach, the potential for scaling increases dramatically. Each digital tablet costs about $100, so 4,100 shasthya kormi can be equipped for less than half a million dollars. In addition, they save money through the efficiencies described above. Patients also save – out-of-pocket expenditure makes up 63% of medical expenses in Bangladesh, and tests conducted by shasthya kormi often cost one tenth what they would in a private clinic. This in turn also takes pressure off health facilities.
The initiative has enormous potential to scale further – within Bangladesh and around the world. Shasthya kormi can be recruited locally and trained in a matter of weeks. They can be equipped digitally without great expense. The quality of their work can be monitored digitally, and everyone benefits from the enhanced access to health care that results.
Key to scaling are several insights that emerged as we orchestrated this digital transformation.
First, it was critical to track data input closely from the start, to identify anyone struggling with the transformation. One of the first clues was a lot of data being entered after 5:00 pm. It was not because people did not know how to enter it, but because they were nervous about using the devices in public, and did not want to make errors in front of the people who trust them.
Once we saw this in the data and figured out the reason behind it, we could easily work with each person to overcome it. Early on, we created a team of 40 technical officers who provided additional training and support for anyone struggling. The help was provided in some cases over the phone, but otherwise in person. Initially most people needed it, but now only about 10% of people need assistance.
Second, the digital tablets enabled constant, on-demand professional development. Needs, equipment and trends change regularly in the health sector, and these changes can occur rapidly. Shasthya kormi could assess their skills at any time convenient to them using tests available on the tablet, and the module would identify weaknesses and suggest further training to address it. Managers could also track their supervisee’s progress. This enhanced the expertise of the network broadly.
Third, we observed a tendency to skip entering critical but more difficult to obtain inputs, like National Identity numbers and birth registration numbers. Fortunately, we can often fill gaps by cross-tabulating with our mobile-based cash transfer system. We also noticed that counselling information was not recorded as seriously as service data. Iterative training has gradually solved these challenges.
Fourth, the digital transformation addressed a decades-old challenge – prestige. Shasthya kormi are often taken for granted, and they are sometimes welcomed, sometimes not. In order to establish the rapport they need to do their work, however, which is often of a sensitive nature, particularly in conservative communities, it is crucial that they are accepted into every household. Digitalisation has elevated the level of respect they receive in the community, particularly among men.
The success of this digital transformation, if scaled, could change community health globally. The result would be superior primary health care service delivery, operational efficiency and establishment of an infrastructure for real time health trend analysis, in a time when we have never struggled more with quality and accessibility of health care around the world.
Morseda Chowdhury is Director of the Health, Nutrition, and Population Programme at BRAC in Bangladesh.
