BACKGROUND: 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.
METHODS: 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.
RESULTS: 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.
CONCLUSION: 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.