>> We're now going to focus on one particular project that BRAC operates now in urban Bangladesh. It's called Manoshi, which is a combination of three Bengali words for mother, newborn, and child. This is an extraordinary project, and it's a massive project, but it's only one small Activity in the health portfolio of BRAC. And of course, health is only one part of the overall organization. But one of the reasons I thought it would be good to review this is because we haven't in this course touched very much on urban health issues. And I think we're all aware of the fact that. All of the population growth in the world now is taking place in urban areas of developing countries and so thinking about how to provide services in this setting is terribly important and how to involve primary health care and community based primary health care in this process is terribly important as well. And I think we have an example here of what could be an important form for addressing these issues and many urban areas of developing countries. Bangladesh used to the most rural country in the world. Back in the early 1900s and prior to that time. And you see here this is a slide that came from my back but the growth of the urban population in Bangladesh really didn't Begin to gather steam until perhaps 1980. You can see now that there's been a mass of growth in the urban population. Dhaka City itself, the capital of Bangladesh, when I was living there in the Late 1990s had about 8 or9 million people, and about 1 3rd of those people were living in slums. And Dhaka is now projected, over the next 20 years, to become, I think, the second or the third largest city in the world. And probably more than 1 3rd of these people will be living in slums. So this is a very important issue. This is a satellite image of one slum in Dhaka. It's actually in a middle class or perhaps even an upper middle class neighborhood. And you can see that this particular slum is a relatively modest proportion of this overall area in the city. It's called Korail, and it just happened to be right across the street from a 15 story building that BRAC has constructed as it's headquarters. This is a typical view of one of the slums in Dhaka. Once you get inside of these they're really not quite as depressing as you might think they would be. They're full of life and vitality, and the sanitation issues in most of these slums are not that, That bad except for the specific areas where people are defecating and so forth. This is the view of the Korail Slum from the office window of BRAC where I was a consultant recently and I took this picture. But you see that people go to this slum on a boat because there's no road that goes out to it. And that's one of the reasons it's a slum because it was not an attractive commercial area or an attractive area for building an apartment building. One of the themes that I really liked about this project was they have embraced CBIO principles. They have numbered every house. And you see here this is the painted number on one of the houses. They have created a census-based approach, in which they've mapped every household, and they've created a system whereby the community health worker visits every home on a regular basis, just like they do in all of their other programs in rural Bangladesh. The woman on the left, her name is Happy. She's a Shasthya Shebika and I was visiting her with one of the supervisors for the program on the right. These are some of the medications that the Shasthya Shebika carries with her when she visits the homes of the people that she's rsponsible for. There are various things in here from birth control pills to condoms to scabies medication to oral re-hydration salts and so forth. There's also pain medicine in here so she sells these as I've mentioned at a below market rate and makes a small profit. When she visits a client's home, she also completes a health information chart that the woman in the home keeps. And this is available for the supervisor to review so the supervisors have a system of visiting a sample of homes and they can tell by visiting that home when the community health worker was there, and what the community health worker actually did. There are many aspects of this program that are important and I can only mention a few here. And let me also say that this project was funded by the Gates Foundation. And over a period of about six years and $25 million of funding, this program is being scaled up to reach eight million people. So this is a very large activity that. Is going to be an important pilot program for the future. Once pregnant women are identified through home visitation, then they enter into a process of various standardized activities that the Shasta Subhikas carry out when they visit the homes. And then, once a pregnant woman is identified a higher level person also visits that woman. And checks her, and provides, essentially, prenatal care in the home. One of the things they do is they strongly encourage these women to develop a small savings account that they put into this little container, so that if they do develop an emergency, they'll have enough money to be able to get to the hospital for emergency care. When a woman is ready to give birth and goes into labor she goes within the slum to a, what they call a birth hut, which is a small little house. It's simply a place with a bed in it where there's always a woman called an urban birth attendant, who actually used to be a traditional midwife who's had some special training that brac provides. And the urban birth attendant attends to the delivery of the woman there in the birth hut. There are no supplies and equipment. There is water, there is a toilet there and there's a bed on the floor, and that's it. And these women are well trained to recognize complications. And there is a system developed so that if a woman develops any signs of complications, a rapid referral process is in place to enable that woman to get to a referral hospital. Hospital where brac has established relations. And there's a woman there who works for brac at the hospital who was ready to receive that woman to make sure that she gets into the system. And gets adequate and appropriate care. After the baby is born, there's a whole system in place with the Shasthya Shebika and the supervisory personnel to visit that baby at home using the most current recommendations arising from pioneering research at Gadchiroli by the banks which we have discussed in other parts of this course. But this is revolutionizing the world of global health in developing countries. By reducing neonatal mortality through home visitation by local level people. And so this is being developed and implemented by BRAC, and their urban program here. So, as I have said before this whole program is built around CBIO principles and they have a very sophisticated, computerized health information system that guides daily work and in particular, the work of the supervisors and as the Shasthya Shebikas identify pregnant woman for instance, then all automatic set of activities become generated by high levels of supervision. There's a strong engagement of the community, the community leadership in setting priority activities and working with a program and building it's work. And the Shasthya Shebikas, like in other parts of Bangladesh, they generate a small amount of money from provision of services. And the development of referral chain is a critical part of all this as well. This particular acvtivity is one of the few examples of application of the state of the art knowledge for materrnal neonatal and child health at scale of the urban slums and I think that's one of the reasons this is so important. The project will be completing its initial stage in the near future. And so, there will be evidence coming out about the mortality impact of this. And once that evidence comes forth, there'll be a lot more to learn from this as we think about the future. So in summary, looking back over the entire lecture, I think we can all agree that Bangladesh and BRAC are both a positive deviance in their own ways in their own area in health and development. And understanding what it was that made this possible has been a fascinating question for me, and I have thought about it quite a bit. I've asked many people about it I think one of the fundamental elements that made all this possible was the fact that after the war for independence there was a new playing field in essence for the country. The traditional forms of economic, political and religious power were no longer there because they had supported the losing side of This war, and a whole new spirit of freedom and innovation was there and sensed that people were going to come together to rebuild this country in a way that would eliminated the injustice and poverty of the past. And while this did not occur at the speed that people hoped that it would, nevertheless, enormous progress was made. And still it's continuing to be made and that's why Bangladesh is a psoitive deviant compared to so many other developing countries that are very poor. Interestingly enough for me, after I lived in Bangladesh from 1995 to 1999 I moved to Haiti. And I lived there for four years and so I had a chance to really have an on the ground feel for these two different countries. And after being in Haiti for several years I suddenly found myself saying that, Haiti makes Bangladesh look like a picnic in Paris because Bangladesh had a number of features as a country that Haiti didn't have. Bangladesh had a democratic government that Haiti really didn't have. Bangladesh had a civil society that Haiti didn't really have. Bangladesh had a system of law and order that Haiti didn't have. Bangladesh had a functioning infrastructure that Haiti didn't really have. And by that, I mean roads and electricity and postal service and so forth. And then finally, and very powerfully, I think, Bangladesh has a sense of people working together for the common good to improve their future. And that just did not happen in Haiti. I didn't see very much evidence of that. So, the contrast between these two countries is very interesting. So, we can also see from what I presented here that there is a long history of strong vertical programming in health that have been very successful. But at the same time there has been a strong history of grass roots integrated programming as well. And BRAC has been a real master at linking these together in a complementary fashion. Not a competitive fashion. And so I think the whole focus on the community and community based programming is one the reasons why Bangladesh and BRAC have been so successful. And this whole notion focusing on priority diseases priority conditions, working with the community is so critical to the success as well. So, this has been fun sharing these important ideas with you, and I hope you have found this lecture to be engaging, and of educational value. And I hope you'll continue to explore the very interesting history that is Bangladesh's, as we think about how to apply these principles in other places.