NOTE NUMBER 235 P U B L I C P O L I C Y F O R T H E privatesector 24543 AUGUST 2001 Educating for Health Sadia Chowdhury Sadia Chowdhury is a Using Incentive-Based Salaries to Teach Oral Rehydration Therapy senior health specialist at the World Bank. Before I n B a n g l a d e s h a n e d u c at i o n p rog r a m a i m e d at t e a c h i n g m o t h e r s h ow joining the Bank in t o p re p a re a n d u s e o r a l re hy d r at i o n s o l u t i o n t o t re at d i a r r h e a re l i e d 1998, she worked as director of the Health o n o u t p u t - b a s e d i n c e n t i ve s t o e n s u re t h at t h e t e a c h i n g wa s e f f e c t i ve . T H E W O R L D B A N K G R O U P PRIVATE SECTOR AND INFRASTRUCTURE NETWORK and Population Division T h e p rog r a m t i e d f i e l d - wo r ke r s ’ p ay t o f a s t - c y c l e f e e d b a c k o n of the Bangladesh Rural Advancement p e r f o r m a n c e a g a i n s t o u t p u t i n d i c at o r s . M o n i t o r i n g re s u l t s s h ow t h at Committee (BRAC), a t h e a p p ro a c h wo r ke d : t h e m o t h e r s l e a r n e d e f f e c t i ve l y. O ve r 1 0 ye a r s nongovernmental development organization t h e p rog r a m re a c h e d 1 2 m i l l i o n h o u s e h o l d s . with an annual budget of Diarrhea was the leading cause of infant mor- was needed was an inexpensive therapy that was US$131 million and tality in Bangladesh during the 1980s. Diarrhea available in the community and easily adminis- more than 25,000 full- leads to the loss of fluids and electrolytes, result- tered by nonprofessionals using no special time staff. Along with ing in mild to severe dehydration and, in some equipment. BRAC saw that the best option was Oxfam, BRAC funded and ran a trial of the cases, death. Because it is the loss of fluids and a fluid that could be given orally, which would oral rehydration program. electrolytes that causes illness and death, it is eliminate the need for sterile equipment. An Bilateral donors funded essential that they be replaced. Intravenous oral rehydration solution was developed in the subsequent rollout of therapy is critical for treating cases of severe Bangladesh, clinically tested, and perfected so BRAC’s large-scale dehydration, but the means are expensive and that it was effective in treating dehydration from program, run in three difficult to transport. A severely dehydrated per- all types of diarrhea in infants and children, phases over 10 years. son would require 5–10 bags of saline. One bag even cases of severe dehydration, as long as the cost 100 taka (Tk) in Bangladeshi villages in children were alert and could drink the fluid. 1983, when the average income was Tk 1,500 a To work, though, the solution needed to be year (Chowdhury and Cash 1996; Shepard, available in the community and used effectively Brenzel, and Kenneth 1985). Moreover, admin- as soon as an episode of diarrhea began. istering this therapy requires sterile fluid, At this stage BRAC weighed several options needles, tubing, and trained professionals. for a diarrhea prevention program: ▪ Having trained personnel provide treatment Choosing the solution at fixed government facilities. Seeking a solution, the Bangladesh Rural ▪ Providing safe water and sanitation. Advancement Committee (BRAC), a non- ▪ Making packets of oral rehydration solution governmental organization, realized that what broadly available through commercial outlets. E D U C A T I N G F O R H E A L T H USING INCENTIVE-BASED SALARIES TO TEACH ORAL REHYDRATION THERAPY ▪ Teaching mothers how to make the solution ▪ To teach at least one woman in each house- at home with commonly available ingredients. hold to prepare the oral rehydration solution. A treatment program relying on trained per- ▪ To raise awareness in the community about sonnel was rejected because there were too few diarrhea prevention. facilities and health workers. An effort focused Using mainly one-on-one and group com- only on improving water and sanitation was also munication techniques, this program taught a rejected, because experience with tubewell pro- 10-point health message, including how to pre- grams to supply safe drinking water showed that pare the solution using local ingredients and a when the wells were broken, people resorted to simple but accurate measuring system (box 1). 2 unsafe sources of water. The solution is prepared from a three-finger Marketing packets of oral rehydration solu- pinch of lobon (common table salt) and one tion had many advantages. The product was eas- fistful of gur (unrefined brown sugar) in half a ily identified, it was a complete mix, and it could seer (467 cubic centimeters) of water. The be easily distributed to all small shops. But it was lobon-gur solution has almost all the essential impossible for Bangladesh to produce the vol- properties: it is simple, cheap, safe, effective, ume needed. Treating all episodes of diarrhea and readily available (BRAC 1980). only in children under five—79 million in 1989 The female health workers teaching women —would require about 200 million packets a how to prepare the solution first had to over- year. The government had the capacity to pro- come some suspicion and confusion. They had duce only about a third of that. Moreover, the to convince villagers that the solution was not annual cost of US$16 million was onerous. harmful. And because the last time health work- Commercial production and marketing of ers had appeared in villages was to teach family packets also appeared impractical, as people planning, they had to overcome an assumption had limited purchasing power and the distribu- that the solution was a contraceptive. tion system was weak. Moreover, the printed In the program’s first phase most health instructions for mixing and administering the workers were from the district where the pro- solution could not be read by the 80 percent or gram was being implemented. This allowed the so of the population who were illiterate. But the health workers access to their families, and it main flaw of a commercial initiative was that it eased communication with mothers, since the would not include efforts to build people’s health workers could talk to them in their own awareness of the deleterious effects of diarrhea dialect. The health workers had to be 20–35 and the effectiveness of oral rehydration solu- years old and have at least 10 years of schooling. tion in combating it—crucial in overcoming Teams consisting of 14–16 health workers social and cultural barriers to the solution’s use. and a team coordinator worked together in a vil- For all these reasons, the option chosen was lage (unless a village was small). They visited all to teach mothers to prepare an oral rehydration the households, with each worker covering an solution and treat their children themselves. So average of 10 a day. Before leaving a household, in 1980 BRAC launched a pilot program sup- they made sure that the mother had understood ported by its own funds and by Oxfam. After the the messages by asking questions about each of pilot the teaching program was rolled out in the 10 points. Most important, they had the three phases over 10 years, with the US$9.3 mil- mother make the solution. The health workers lion cost funded by different donors. The donor reviewed the accuracy of the measurements and funding was disbursed every quarter as a reim- Box What the program taught each mother bursement of expenditures. The cost of teaching each household was estimated at US$0.75. Teaching mothers 1 ▪ What diarrhea is and how it is transmitted. ▪ How to prepare the rehydration solution. ▪ What can go wrong if the quantities are not right The teaching program had three aims: (too much salt, too large a dose). ▪ To reduce diarrhea-related illness and deaths, ▪ When to consult a doctor. particularly among children under five. then asked the woman to repeat the process. If salary increased their incentives to ensure that a health worker was dissatisfied with the the mothers had learned to prepare the solution woman’s level of understanding, she repeated correctly, so the health workers began to ask the the entire session. Each session took about mothers to demonstrate. This also increased the 20–30 minutes. By December 1990 the health mothers’ interest in the teaching session. workers had reached two-thirds of the country’s rural households—around 12 million. Monitoring and evaluating results The program’s results were monitored both Creating incentives through the salary system internally and externally in all phases. 3 There was concern that a normal monthly salary Monitoring costs were estimated at about 4 per- system would make the health workers more task cent of project costs. oriented than results oriented, particularly as the program began to expand. So an incentive Internal monitoring system was developed that linked their earnings The salary system required an effective, built-in to results—mothers’ knowledge of diarrhea and monitoring system. During the pilot phase each their ability to prepare the solution. health worker gave a list of the mothers she had A monitor visited 10 percent of the mothers taught that day to her supervisor, who randomly a health worker had taught over the past month, selected 10 percent of the mothers and assigned asked them questions about the 10-point mes- a monitor to interview them. Men were sage, and had them prepare the solution. To recruited to work as monitors, as the job determine the health worker’s pay, the moth- required extensive travel. ers’ responses were graded from A to D and the In the expanded program the selection of number of mothers receiving each grade was mothers had to be done at a higher level and the multiplied by 10, since only 10 percent were monitors kept separate from the health worker interviewed. For each A the health worker teams to prevent collusion. The lists were sent received Tk 4, and for each D, nothing (table 1). to Dhaka, where monitors were randomly This salary system put the emphasis squarely assigned to visit 5–10 percent of the mothers a on ensuring that mothers learned correctly. month. One technique used to ensure the During the pilot phase health workers received veracity and accuracy of the monitors’ reports Tk 600 a month on average (US$40 at the 1980 was to ask them to record the name of each exchange rate, a good income in rural areas). mother’s youngest child. This information was The range was Tk 400–700. With the minimum then compared with that collected by the health salary set at Tk 250, much of the pay was based worker to confirm that the monitor had visited on performance. (There was no incentive-based the right mother. salary system for male workers, and questions BRAC’s Research and Evaluation Division were raised about gender bias.) played an invaluable role in helping the pro- The incentive system improved teaching gram to continually increase its effectiveness. methods. Before it was introduced, only the An emphasis on evaluation as a means to health workers prepared the solution during a improve results rather than to punish the work- teaching session. But the performance-based ers helped to create a positive attitude. The divi- Table Rate paid for each grade 1 Mother’s performance Remembered all 10 points and prepared the solution correctly Remembered 7–9 points and prepared the solution correctly Grade A B Rate (taka) 4 2 Remembered fewer than 7 points but prepared the solution correctly C 1 Failed to prepare the solution correctly D 0 Note: In 1981 the rates for grades B and C were increased by Tk 1. Source: Chowdhury and Cash 1996; BRAC 1984; Bhatia, Cash, and Cornaz 1983. E D U C A T I N G F O R H E A L T H USING INCENTIVE-BASED SALARIES TO TEACH ORAL REHYDRATION THERAPY sion encouraged field-workers and supervisors may not have. And third, it must be possible to to suggest ways to improve the system, and their dismiss nonperforming employees rather than ideas often led to research that helped to verify reassigning them to other positions, as required field observations. by labor laws in many countries. BRAC has only recently begun to use the technique again—in a External monitoring community-based education program with four viewpoint The monitoring also required an analysis of the clearly defined HIV/AIDS messages. solutions prepared by the mothers. For this pur- is an open forum to pose, the International Center for Diarrheal encourage dissemination of Disease Research helped BRAC set up field labo- public policy innovations for ratories. As a quality control measure, the center References private sector–led and reanalyzed 10 percent of the samples. In addi- Abed, F. H. 1999. “Development Cooperation on market-based solutions for tion, its staff made routine supervisory visits to the the Brink of a New Century: What Role for NGOs?� UvA development. The views field laboratories (Chowdhury and Cash 1996). Development Lecture, Amsterdam Research Institute for published are those of the During periodic visits a technical advisory Global Issues and Development Studies. authors and should not be committee of international experts provided Bhatia, S., R. A. Cash, and I. Cornaz. 1983. attributed to the World valuable technical assistance to the program. “Evaluation of the Oral Therapy Extension Programme Bank or any other affiliated And the donors conducted independent assess- of the Bangladesh Rural Advancement Committee.� organizations. Nor do any of ments of the program at the end of each phase. Swiss Agency for Development and Cooperation, Bern. the conclusions represent BRAC (Bangladesh Rural Advancement official policy of the World Conclusion Committee). 1980. “Oral Therapy Extension Program Bank or of its Executive Monitoring showed that 90 percent of mothers Phase I.� Dhaka. Directors or the countries scored in the A and B categories. Two years later ———. 1984. Report of Phase I of the Oral Therapy they represent. only 65 percent of these mothers scored A or B. Extension Program. Dhaka. To increase retention, follow-up education was Chowdhury, A. M. R. 1986. “Evaluation of a To order additional copies introduced on local radio and television and in Community-Based ORT Program in Rural Bangladesh.� contact Suzanne Smith, schools. Mortality rates fell after the program was Doctoral thesis. University of London. managing editor, Room I9-017, implemented, but it is hard to isolate the effects Chowdhury, A. M. R., and R. A. Cash. 1996. A Simple The World Bank, of the oral therapy from other factors. Solution: Teaching Millions to Treat Diarrhoea at Home. 1818 H Street, NW, Analysis showed that the program had char- Dhaka: University Press. Washington, DC 20433. acteristics that allow scaling up: It dealt with a Shepard, D. S., L. E. Brenzel, and K. T. Kenneth. problem common to all of Bangladesh. The 1985. “Cost-Effectiveness of Oral Rehydration Therapy Telephone: intervention was relatively simple. It was also for Diarrheal Disease.� Harvard School of Public Health, 001 202 458 7281 inexpensive, requiring households to purchase Institute for Health Research, Boston. Fax: only salt and gur. The training and messages 001 202 522 3181 built on existing skills and knowledge, such as Sadia Chowdhury (schowdhury@worldbank.org). Email: cooking and child care, and were culturally ssmith7@worldbank.org acceptable. The health workers’ performance could be measured through the knowledge acquired by mothers. Though the program was Printed on recycled paper large, it was possible to put in place an adminis- trative structure of checks and balances and rig- orous supervision. Finally, the program had a clear goal and specific outcome indicators. BRAC’s experience with the output-based salary system shows that the approach can be suc- cessful in certain circumstances. First, the out- comes sought must be tangible and quantifiable. Second, there must be an independent moni- toring unit, something that many organizations This Note is available online: www.worldbank.org/html/fpd/notes/