Center for Health Market Innovations (CHMI)

The Shasthya Sena model seeks to reduce harmful treatment and improve the overall performance of informal providers in Bangladesh by addressing two main challenges: the poor service quality of many informal providers and the lack of accountability and formal links to the healthcare system.

The model aims to harness informal providers and effectively link them to the system by employing a three-pronged approach: training informal providers, establishing an association of informal providers to implement quality control, and involving the Bangladesh Health Watch (a civil society initiative) in monitoring informal provider performance.

The program's main components are:

• Provider training: The program has trained 135 informal allopathic health care providers (known as village doctors) in Chakaria upazila (sub-district) on 11 major diseases. During training, providers are given a booklet that includes clear guidelines on appropriate treatments (DO’s and DON’T’s for managing illnesses and prescribing drugs) and referral practices for serious cases (name, location, mode and cost of transport, estimated cost of treatment, estimated duration, telephone directory of contacts). Refresher trainings are provided every two months, and a 24-hour phone service is also available.

• Provider network: In order to establish accountability and brand identity for village doctors, Shasthya Sena has created a network of the providers it has trained. Network members are expected to adhere to quality standards in safety, appropriateness of treatment, and avoidance of unnecessary costs to patients. The network is governed by members of government, civil society, and formal private practice, who set membership eligibility, which is verified and publicly announced twice a year.

• Provider monitoring: Shasthya Sena has established community Health Watch Groups in villages to monitor the performance of informal providers. The committees include representatives of Shaysthya Sena, local government, and formal health care providers from the public and private sectors. A system of recognition based on an assessment of their knowledge and practices by a committee has been established and a crest was given to the successful ones in public gathering by the assessment committee and local Health Watch group.

Baseline and endline data show that existing Village Doctors are enthusiastic about joining training programmes and are keen to learn and networks like Shasthya Sena can be established to engage with the informal healthcare providers with an aim to improve their quality of service and to utilize this huge workforce in filling the void that is created in the formal healthcare system. However, the intervention package of medical training and monitoring through local watch alone seems to be not enough to bring in the desired level of change in practice pattern of the Village Doctors. Additional incentives need to be built into the system that can significantly improve their practice and ensure quality healthcare for the people in general and the poor in particular.

Additional Information

• ICDDR,B Annual Report (2008)
• Shasthya Sena Case Study: Innovative Pro-Poor Healthcare Financing and Delivery Models
• Future Health Systems Research Brief