PERSPECTIVES

BRAC — learning to reach health for all

Jon E Rohde

James P Grant School of Public Health, BRAC University, 66 Mohakhali, Dhaka 1212, Bangladesh (email: jrohde@msh.org)

Introduction

BRAC (formerly Bangladesh Rural Advancement Committee) was founded in response to the disaster of the 1971 War of Independence that created Bangladesh. Over 10 million people had fled the country seeking safety in India, and millions more had been displaced or killed in their homes. The founders of BRAC initiated relief work in the refugee camps and accompanied the refugees home on the trucks, boats and foot trails that led back to thousands of devastated villages. A new nation had to be built out of the ruins.

From the outset, BRAC was located in rural areas, working with villagers to rebuild homes, and to re-establish farming, fishing and other livelihoods. At the same time, BRAC embarked on efforts to improve the fundamental determinants of well-being including health, nutrition, education and particularly the plight of women in a very traditional society. By concentrating on the most remote rural communities, BRAC was addressing a great unmet need that the new government could not possibly meet with its limited resources and experience. This situation allowed BRAC to develop models of development in collaboration with local communities, free from outside interference or control.

Innovative approaches

Innovation was critical to success in addressing such a range of needs with so few resources. The leadership of BRAC encouraged new approaches while constantly asking for proof of both impact and sustainability. Based on the daily meetings which took place each evening to share the experiences of the day, and the village gatherings in which plans and progress were discussed, BRAC critically examined and then documented its experiences in close collaboration with those it served. The results were in turn shared with those who provided funding for BRAC's efforts, enabling them to measure the impact of their suppport. Fund-raising became a matter of recording and disseminating the lessons of development.

Traditional development models using outside expertise and workers rapidly gave way to close reliance on the efforts and wisdom of villagers themselves — the major and often only resource available. The importance and previous neglect of women in the development process led BRAC to focus increasingly on women and girls. Early efforts at village empowerment were all too often taken over by the village elite, excluding once again the poor and powerless; this fact eventually caused BRAC to focus its programmes exclusively on the landless. BRAC provided a protected space where the energies of people long suppressed by tradition and society could blossom and bear fruit; poor women organized and began to take control of their lives.

Dialogue and receptivity to new ideas and approaches drove the agenda. "Lets try it!" was the response to suggestions. BRAC realized that it was vital to continue learning from the experiences gained by such an approach, the failures as well as the successes, and to find a way to evolve continuously. BRAC became known as a "learning organization", plotting its course by analysing its own actions under close internal scrutiny. Soon, this de facto research and development approach was formalized by the establishment of the Research and Evaluation Division, whose role was to document, measure and assess the elements of each programme. The findings were then fed back to communities and workers to enable them to repair what didn't work, and develop further what had been shown to work well. The development community also profited from BRAC's introspection and documentation which over the years has become one of the hallmarks of BRAC's success.

Health promotion

Ill-health saps the strength of poor communities and retards their development. From the earliest days of its existence, BRAC endeavoured to meet the need for health care expressed by poor villagers while attempting to encourage healthier living through education, behavioural change strategies and the provision of effective preventive meassures. Seeing health as an essential part of development, BRAC wove many health activities into the fabric of its approach to improving the lives of poor women and their families. Until the last 10 years or so or so, BRAC did not even have a health division, per se, but rather made health care, nutrition, preventive actions and freedom for women to control their fertility integral parts of the expanding range of BRAC development activities: women's groups, school curricula, literacy efforts, credit schemes, income-producing projects and cooperative farming. Even in BRAC rural banks, women are routinely encouraged to breastfeed, to immunize their children, to use antenatal care services, to join insurance schemes, and to choose family size.

BRAC has tackled the great health challenges that face the nation: endemic and epidemic diseases, malnutrition, unrestrained fertility, maternal mortality and tuberculosis (TB) – the conditions that victimize poor people everywhere. Embracing the promise of oral rehydration to prevent millions of needless childhood deaths, BRAC trained women in 13 million households throughout the country to use this home therapy — an unprecedented public health effort that was followed by a substantial fall in infant and young child mortality in the following decade. To this BRAC added immunization, then vitamin A supplementation, then more complex efforts to redress malnutrition, therapy for pneumonia — the list continues to expand. BRAC recognized the strong desire of rural women to control their own fertility, and family planning use among BRAC's members now exceeds 40%, when the rest of the country has not reached half that level. Cure rates for TB exceed 90%, among the highest in the world. Disabilities, arsenic contamination of water supplies, malaria — whatever conditions afflict the poor, BRAC is prepared to work with communities to find affordable solutions.

Lessons learned

Along with BRAC colleagues, I have reviewed the history of health activities in BRAC over the past 30 years in a recent book, Learning to reach health for all: thirty years of instructive experience at BRAC.¹ This analysis seeks to reveal the characteristics that are common to all of BRAC's work, and thereby provide some answers to the frequently heard question: "How does BRAC do it?" We believe that these answers will be useful when it comes to designing effective programmes in other countries. It is evident that the health impact of BRAC is intimately related to its approach: its partnership with those it serves, its respect for women, especially poor women, its attention to effective support, management and evaluation, and above all, its inspiring leadership. BRAC's workers and their partners believe that a better life is possible for all, and by their actions aim to realize this belief.

Competing interests: none declared.

References

1. Rohde JE, editor. Learning to reach health for all: thirty years of instructive experience at BRAC. Dhaka: The University Press; 2005.