MCSP Community Health Contributions

Series: Bangladesh
July 2019 www.mcsprogram.org

Background
The US Agency for International Development
(USAID)’s flagship Maternal and Child Survival
Program (MCSP) operated globally and within
32 countries with the ultimate goal of preventing
maternal and child deaths. To support community
health structures in countries, MCSP advocated for
institutionalizing community health as part of
national health systems, strengthening the capacity
of community health workers (CHWs), and
supporting community infrastructure in
partnership with country governments and civil
society organizations. This brief is one of an
eight-part series developed by MCSP to review
and understand the processes of community An expectant mother from a remote village in Bangladesh
engagement in MCSP-supported countries and travels to the nearest union health and family welfare center to
identify how the community health approaches deliver her baby. In intervention upazilas of the MaMoni HSS
implemented by the project have contributed to project, community action groups established emergency
changes in health service uptake and behavioral transport systems for maternal and newborn care within their
communities. Photo Credit: GMB Akash/ Save the Children
outcomes.

In Bangladesh, MCSP supported the MaMoni Health Systems Strengthening (HSS) project, which was a
five-year (2013–2018) associate award under MCSP’s predecessor project, the USAID Maternal and Child
Health Integrated Program (MCHIP). MaMoni HSS’s overall goal was to increase utilization of integrated
maternal, newborn, and child health, family planning, and nutrition (MNCH/FP/N) services, through
improved service readiness, strengthened national and district health systems, and reduction in barriers to
accessing health services. MCSP undertook this review of the MaMoni HSS project to understand the process
and outcomes of community engagement in Bangladesh.

Community Health Focused on MNCH/FP/N

To strengthen community health, MaMoni HSS provided support and assistance to the Bangladesh Ministry
of Health and Family Welfare (MOHFW) at the national, district, and sub-district levels to increase quality
public sector service delivery and significantly streamline its approach to community mobilization. Through
strengthening the existing union education, health, and FP standing committees, the project sought to engage
communities to mobilize resources and strengthen community response for MNCH/FP/N issues.
Community health activities covered four high-intensity project districts (i.e., Habiganj, Lakshmipur,
Jhalokathi, and Noakhali).

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MaMoni HSS used a multi-pronged strategy to enhance community engagement around MNCH/FP. 1
MCSP’s global community health strategy combined community service delivery with community
capacity-strengthening and community social and behavior change. In Bangladesh, this strategy was used to
reduce barriers and increase demand for and use of MNCH/FP/N services. Table 1 outlines the activities
the project undertook to enhance community engagement. Overall, the project institutionalized community
microplanning monthly meetings (cMPMs) and leveraged the involvement of local governments to address
barriers to service utilization. Additionally, the project worked with union parishads (union councils) to
understand a range of responsibilities, at facility and community levels, as outlined by the Government of
Bangladesh. 2 MaMoni HSS also ensured that union council members were aware of the range of community
health-related activities that were within their scope and successfully advocated for union council funds to be
allocated to address local health needs. The project also trained and supported community volunteers to
facilitate community action groups (CAGs), to promote healthy behaviors and care-seeking within their
communities, and to liaise with frontline MOHFW health workers (family welfare assistants [FWAs] and
health assistants [Has]) during the cMPMs.

Table 1: Three Pillars of the MaMoni HSS Project’s Community Health Approaches
Service Delivery Capacity Strengthening Social and Behavior Change
• Helped establish local governance • Trained and provided follow-up • Staged community theater shows
and oversight by union councils. support to build capacity of local to support positive changes in
• Supported routine and emergency government institutions to health knowledge and behavior,
referral. actively contribute to as well as social norms, related
• Strengthened civil registration and MNCH/FP/N services. to MNCH/FP/N.
vital statistics through improved • Recruited, trained, and supported • Used mHealth to increase
coordination between the unpaid community volunteers to awareness on MNCH/FP/N
MOHFW and the Ministry of initiate and lead CAGs within through messages sent via a
Local Government, Rural their catchment area (of 250–300 mobile phone to pregnant and
Development, and Cooperatives. people). lactating mothers during
• Supported community volunteers • Strengthened outreach workers’ pregnancy and the postpartum
and health workers to maintain a knowledge and skills for home period. 3
register for their catchment areas visits. • Developed various support
with an updated list of pregnant • Facilitated bi-monthly union materials in conjunction with the
women, childbirths, emergency education health and FP standing social and behavior change
referrals, and maternal and committee meetings. activities.
newborn deaths. • Collaborated with the MOHFW
• Provided direct project financial to mobilize community volunteers
support for various elements of and field-level health providers to
service delivery preparedness. promote community awareness
about FP/postpartum FP services
and methods.

Achievements
Overall, the community health approaches described here contributed to the project’s efforts to identify and
reduce barriers to accessing health services and contributed to changes in MNCH/FP/N. These approaches
showed that it is possible to mobilize local assets and increase transparency, as well as increase accountability
around use of local resources. Engagement of local government in health service delivery in high-intensity
project districts and the activation of existing management committees was a major achievement of the
project. Local government actors gained knowledge on their roles and responsibilities for service delivery and
became important sources of advocacy and resources in project areas.

1
MaMoni HSS nutrition interventions focused on increasing demand for facility-based nutrition services (i.e., severe acute malnutrition
screening and facility-based case management).
2
1) Hold service providers in their union accountable and ensure they are not charging for services; 2) help popularize the clinics and promote
service utilization within their union; and 3) mobilize resources to address MNCH/FP/N needs within their communities.
3
Aponjon Pregnancy (Aponjon Shogorbha in Bangla) is a locally branded version of Mobile Alliance for Maternal Action (MAMA) initiative, a
global public-private partnership between USAID, Johnson and Johnson, Inc., Baby Center, mHealth Alliance, and the United Nations
Foundation. Aponjon delivered health information to pregnant women and new mothers using mobile phone technology. Over the life of the
project, a cumulative total of 2,070,014 women subscribed to the project and received messages.

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Resource mobilization
In total, the project worked with 211 union councils to support and allocate funds for MNCH/FP/N
services in the sub-districts. Union councils collectively mobilized BDT 28,547,505 (approximately USD
335,000) in funds for constructing, repairing, and maintaining facilities; purchasing emergency medicine
during stock-outs and small medical and non-medical equipment; repairing roads to enable easier access to
facilities, and providing temporary support staff when needed (e.g., staff for crowd control during peak hours,
cleaners, etc.). In four out of five districts, 83% of CAGs (or, 20,299 of 24,355 possible groups) collectively
set up an emergency transport system for maternal and newborn health care within their communities and set
aside approximately BDT 1 million for emergency funds to help women access care when they could not
afford it.

Community action groups

MaMoni HSS worked with 22,304 active community volunteers in the project’s 23 high-intensity sub-districts,
called upazilas. Community volunteers’ facilitated 958,719 monthly CAG meetings over the life of the project
in MaMoni HSS areas to coordinate, implement, and follow up on community action plans and support
health education and dialogue. CAGs also collected vital event data to share during cMPMs.

Community microplanning meetings

The project established cMPMs so that community volunteers could interface with FWAs and HAs and
provide a link between CAGs and the formal health system. During these meetings, health workers and
community volunteers addressed discrepancies in their counts of new eligible couples, pregnancies, births,
deaths, and other vital information. The meetings also enabled participants to identify follow-up actions for
the health workers and community volunteers. Initially, MaMoni HSS staff facilitated the cMPMs as well as
union follow-up meetings, but the FWAs and HAs eventually took on the facilitation and provided their
cMPM reports directly to the sub-district health complexes. A total of 18,452 FWAs and HAs served as
facilitators and recorders for 85% of the cMPMs in the project areas. The members of the cMPMs were also
linked with members of the community support groups and community health care providers at the
community clinics to ensure improved coordination and sustainability.

Sustainability
The Government of Bangladesh has made moves to commit to ensuring universal health coverage for its
population over the next few decades and has acknowledged MaMoni HSS’s unique contribution toward this
aim. The MOHFW has taken up the MaMoni HSS model in two divisions of Bangladesh (covering 1,200
unions), where they are now providing targeted advocacy and sensitization meetings on the role local
government can play in the health sector. The MOHFW provided forums for union council chairmen—who
were champions of this cause under MaMoni HSS—to share their experiences and successes within their
sub-districts so that additional unions may learn from their examples. As a result, these government actors
will continue to play an ongoing role in strengthening service delivery and monitoring progress in improving
the quality of care in their own communities. Moreover, community-based assets (i.e., community volunteers,
CAGs, cMPMs, and transport networks for referrals) will continue to function and provide benefits to
mothers, newborns, and children in the community.

Improvements in MNCH and FP

Population outcomes and service delivery data indicate that the MaMoni HSS community health approaches
contributed to the government’s effort to improve MNCH/FP/N services and service utilization in
implementation areas. For example, household survey data collected by the project showed that in the four
high-intensity districts, facility deliveries increased by 19% during project implementation, from 25% in
2014 to 40% in 2016. MaMoni HSS-supported districts also fared better in coverage of facility deliveries
when compared with the trends in their respective divisions. For example, project household surveys showed
that Noakhali (a MaMoni HSS-supported district in the Chattogram division) experienced a 24% increase in
facility deliveries from 2014–2016. Similarly, the percentage of women that received at least one
antenatal care visit from a medically trained provider increased by 31% in MaMoni HSS districts,

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from 51% in 2014 to 82% in 2016. Major contributors to the increase in antenatal care attendance and facility
deliveries include the project’s significant efforts to strengthen union health and family welfare centers in
project areas to provide 24/7 delivery care, as well as project activities to raise awareness at the community
level on the importance and availability of health services. Additionally, MaMoni HSS improved demand for
long-acting reversible contraception. Utilization of postpartum intrauterine contraceptive device more
than doubled from pre-intervention numbers from 695 in 2015 to 1,682 in 2017.

Conclusion
The MaMoni HSS Project supported
Bangladesh in its journey to self-reliance
by effectively engaging local government
and mobilizing communities to increase
utilization of their resources for health
purposes. This approach proved to be an
effective method to support local
governments in removing barriers to
service utilization, generating local
resources, and strengthening public
health facilities. Additionally, the
approach ensured participation of
community members at scale and helped
institutionalize local problem-solving. It
also showed that it is possible to increase
transparency and accountability around
local resource use. The experience in Actors in a community theater show engage with the audience to involve
Bangladesh highlights the critical them in the experience. Photo credit: MCSP
importance of meaningfully engaging
community leaders in interventions to improve health care. Local government can play a vital role for
sustainable changes in the union health and family welfare centers, as well as to increase utilization of health
services. Moving forward, it will be necessary to focus not only on how local governments can be leveraged to
support community service delivery, but also on the role they may play in shifting social norms and helping to
create supportive environments for sustainable behavior change within households and in their communities.

This brief is made possible by the generous support of the American people through the United States Agency for
International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents
are the responsibility of the Maternal and Child Survival Project and do not necessarily reflect the views of USAID or the
United States Government.

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