Centre for Equity and Health Systems, ICDDR,B, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
BMC Health Serv Res. 2012 Aug 17;12:260. doi: 10.1186/1472-6963-12-260.
The model of volunteer community health workers (CHWs) is a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, has been using 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 would help to reduce dropout and increase program sustainability. The main objective of the study was to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, we estimated cost of possible strategies to reduce dropout and compared whether these costs were more or less than the costs borne by BRAC and the community.
We used the 'ingredient approach' to estimate the cost of recruiting and training of CHWs and the so-called 'friction cost approach' to estimate the cost of replacement of CHWs after adapting. Finally, we estimated forgone services in the community due to CHW dropout applying the concept of the friction period.
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 performance in the community meant 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 could save another US$ 60 invested an ad-hoc CHW plus forgone services in the community.
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 can improve the sustainability of the program.
志愿者社区卫生工作者（CHWs）模式是为发展中国家贫困社区提供服务的常用方法。BRAC 是孟加拉国的一个大型非政府组织，是该领域的先驱，自 1977 年以来，一直将女性 CHWs 作为其社区为基础的卫生方案的核心工作人员。在农村地区实施 CHW 模式 25 年后，BRAC 已开始通过社区为基础的孕产妇保健干预措施在城市贫民窟使用女性 CHWs。然而，BRAC 发现 CHWs 的流失率很高，这表明需要更好地了解其流失的影响，这将有助于降低流失率并提高计划的可持续性。本研究的主要目的是从 BRAC 和社区两个角度估计志愿者 CHWs 流失的影响。此外，我们还估算了减少流失的可能策略的成本，并比较了这些成本是否高于 BRAC 和社区承担的成本。
我们使用“成分法”来估算招募和培训 CHWs 的成本，以及使用所谓的“摩擦成本法”来估算适应后更换 CHWs 的成本。最后，我们应用摩擦期的概念来估算由于 CHW 流失而导致社区服务中断的情况。
2009 年，每一位常规 CHW 的平均成本为 59.28 美元，如果一名 CHW 参加为期三周的基础培训、一天的复习培训、一天的激励日并在招募后在社区工作一个月，则需要 60.04 美元。一名 CHW 在社区中一个月缺勤，其标准服务会大幅中断，如健康教育、产前检查、分娩、复杂病例转诊以及药物和卫生用品的分发。然而，BRAC 每年只需额外投资 121 美元/CHW，就可以节省 60 美元用于聘请一名临时 CHW 并弥补社区中流失的服务。
尽管在达卡的城市贫民窟中，CHWs 是作为志愿者工作的，但他们的流失对财务和错失的服务都有巨大影响。较高的流失成本使该计划的可持续性降低。然而，简单且具有成本竞争力的策略可以提高该计划的可持续性。
