Learnings From a Pilot Study to Strengthen Primary Health Care Services: The Community-Clinic-Centered Health Service Model in Barishal District, Bangladesh

The community-clinic-centered health service model piloted in Bangladesh strengthened community and local government engagement, harmonized the work of different community health worker cadres, and improved client satisfaction. The approach has the potential to strengthen the delivery of close-to-community primary health care services and accelerate progress toward achieving universal health coverage.

Background:

Community clinics (CCs) staffed by community health workers (CHWs) represent an effort of the Government of Bangladesh to strengthen the grassroots provision of primary health care services and to accelerate progress in achieving universal health coverage. The Improving Community Health Workers (ICHWs) Project of Save the Children piloted a CC-centered health service (CCHS) model that strengthened community and local government engagement, harmonized the work of different CHW cadres who were working in the same catchment area of each CC, and improved the accountability of CHWs and the CC to the local community.

Methods:

We describe the process for developing and implementing the CCHS model in 6 unions in Barishal District where the model was piloted and provide some early qualitative and quantitative findings pertaining to the model's effectiveness. Data were collected from CCs in the 6 pilot unions and 6 other unions that served as a control. Qualitative data were collected from the intervention area during the pre-pilot (October 2017–September 2018) and pilot phase (October 2018–September 2019). Document review, key informant interviews, and focus group discussions were also conducted. Maternal and child health service utilization data were extracted from the government health information system in both the intervention and control areas.

Results:

Community group meetings ensured engagement with local government authorities and supported resource mobilization. There was greater coordination of work among CHWs and increased motivation of CHWs to better serve their clients. The analysis showed that the increase in maternal health consultations was substantially greater in the intervention area than in the control area, as was the number of referrals for higher-level care.

Conclusion:

The CCHS model as applied in this pilot project is effective in engaging local key stakeholders, increasing CHW capacity, and improving client satisfaction. The model demonstrated that a community health system can be strengthened by a comprehensive approach that engages communities and local government officials and that harmonizes the work of CHWs.

Enteric methane, lactation performances, digestibility, and metabolism of nitrogen and energy of Holsteins and Jerseys fed 2 levels of forage fiber from alfalfa silage or corn silage

Our objective was to determine the effects of replacing alfalfa silage (AS) neutral detergent fiber (NDF) with corn silage (CS) NDF at 2 levels of forage NDF (FNDF) on enteric methane (CH₄), lactation performance, ruminal fluid characteristics, digestibility, and metabolism of N and energy in Holstein and Jersey cows. Twelve Holstein and 12 Jersey cows (all primiparous and mid-lactation) were used in a triplicated split-plot 4 × 4 Latin square experiment, where breed and diet formed the main and subplots, respectively. The 4 iso-nitrogenous and iso-starch dietary treatments were arranged as a 2 × 2 factorial with 2 levels of FNDF [19 (low FNDF, LF) and 24% (high FNDF, HF) of dry matter] and 2 sources of FNDF (70:30 and 30:70 ratio of AS NDF to CS NDF). Soyhull (non-forage NDF) and corn grain were respectively used to keep dietary NDF and starch content similar across diets. Total collection of feces and urine over 3 d was performed on 8 cows (1 Latin square from each breed). The difference in dry matter intake (DMI) between Holsteins and Jerseys was greater when fed AS than CS. Compared with Jerseys, Holstein cows had greater body weight (48%), DMI (34%), fat- and protein-corrected milk (FPCM; 31%) and CH₄ production (22%; 471 vs. 385 g/d). However, breed did not affect CH₄ intensity (g/kg of FPCM) or yield (g/kg of DMI), nutrient digestibility, and N partitioning. Compared with HF, LF-fed cows had greater DMI (10%), N intake (8%), and FPCM (5%), but they were 5% less efficient (both FPCM/DMI and milk N/intake N). Compared with HF, LF-fed cows excreted 11 and 17% less urinary N (g/d and % of N intake, respectively). In spite of lower (2.5%) acetate and higher (10%) propionate (mol/100 mol ruminal volatile fatty acids) LF-fed cows had greater (6%) CH₄ production (g/d) than did HF-fed cows, most likely due to increased DMI, as affected mainly by the soyhulls. Compared with AS, CS-fed cows had greater DMI (7%) and FPCM (4%), but they were less efficient (5%), and CH₄ yield (g/kg of DMI) was reduced by 8%. In addition, per unit of gross energy intake, CS-fed cows lost less urinary energy (15%) and CH energy (11%) than did AS-fed cows. We concluded that, in contrast to level and source of FNDF, breed did not affect digestive and metabolic efficiencies, and, furthermore, neither breed nor dietary treatments affected CH₄ intensity. The tradeoff between CH₄ and N losses may have implications in future studies assessing the environmental effects of milk production when approached from a whole-farm perspective.