Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh

Introduction: Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the perfor-mance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. Methods: This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. Results: Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. Discussion: Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to en-able systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without ad-equate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.