Author: Tahmina Ferdousy, Kamrun Naher Ahmed, Mohammad Omar Faruque, Hayalnesh Tarekegn, and Rashed Shah from Save the Children’s Bangladesh Sponsorship Team and the Urban Hub Team at Save the Children.

Community health workers (CHWs) in Bangladesh’s slums are improving healthcare access for children by addressing malnutrition, preventable diseases, adolescent sexual and reproductive health and maternal health. Organisations like BRAC and Save the Children are enhancing CHWs’ impact through training, mentoring and policy support, ensuring that the most at-risk children receive essential care. 

The UN Convention on the Rights of the Child and the Sustainable Development Goals, both endorsed by most countries, affirm that every child has the right to a healthy start in life. Yet for many growing up in urban slums, where formal healthcare services are scarce or unaffordable, this right is far from guaranteed. Community health workers (CHWs) play a vital role in improving children’s health in these environments, where overcrowding, poor sanitation, lack of safety, and limited services put them at greater risk. 

Health and nutrition disparities faced by children in slums 

Children in urban slums face high risks of diarrhoea, pneumonia, and malnutrition, alongside low vaccination coverage. [i] For example, while global child nutrition has improved and stunting among under-fives has dropped from 32% in 2000 to 23% in 2022, [ii]  rates remain alarmingly high in some urban slums, reaching 40–50%.[iii]

Adolescents in slums also lack access to information and services. Rising rates of unwanted teenage pregnancies and sexually transmitted infections, put young people, especially girls, at risk of lifelong health and social consequences. 

Without affordable, accessible care, preventable illnesses go untreated, and the combined effects of poor nutrition, infectious disease, and adolescent health risks reinforce cycles of poverty and inequality. 

CHWs bring services directly into these underserved neighbourhoods.  

Role of community health workers

As trusted members of their communities, CHWs bridge the gap between families and health systems by providing essential services such as health education, basic treatment, immunisation outreach, hygiene promotion, and referrals to clinics or hospitals. They are often the first point of contact for caregivers, ensuring that children receive timely care for common but potentially deadly illnesses like diarrhoea, pneumonia, and malnutrition. Beyond addressing immediate health needs, CHWs promote preventive practices such as hygiene, nutrition, adolescent reproductive health and maternal health services, which build the foundation for healthier childhoods. 

Helping vulnerable women gives CHWs the drive to keep going. In an article on factors affecting the motivation of CHWs delivering sexual and reproductive health services in urban slums in Bangladesh, a 44-year-old worker says:

“Well, a helpless girl, who cannot tell anyone that she has got pregnant, feels happy when she sees us. I feel good doing these types of work. I mean she cannot tell anyone but feels good to see us. These are the secrets [of my motivation].”[iv]

Two maternal health and child nutrition programs in Bangladesh’s urban slums engaging community health workers

Bangladesh is widely recognised as home to some of the world’s most long-standing and robust community health worker programmes, which have significantly contributed to improved maternal and child health outcomes and inspired similar initiatives globally. There are close to 185,000 CHWs in the country, with 70,000 employed by the government. As government CHWs are not present in urban slums, non-government organisations like BRAC and Save the Children Bangladesh bridge the gap by developing local cadres of CHWs. [v]

Manoshi by BRAC

BRAC’s Manoshi programme, launched in 2007, was developed to reduce maternal and newborn deaths in Bangladesh’s rapidly growing urban slums, Central to the programme are two levels of trained community health workers.  

• Shasthya Shebikas are volunteer community health workers with basic literacy, each serving 150–200 households. They visit families at least once a month to provide education on family planning, hygiene, immunisation, nutrition, and water and sanitation. They also identify pregnancies, treat minor illnesses, distribute and sell essential items such as oral rehydration salts, vitamins, and delivery kits, and refer cases needing advanced care. They earn small incentives (about USD 1–2) for identifying pregnant women and accompanying them to delivery or referral centres, along with modest profits from selling commodities. 

• Shasthya Kormis are salaried and supervisory CHWs with secondary education or higher. Each Shasthya Kormi oversees about 10 Shasthya Shebikas (roughly 2,000 households). They conduct household register updates, organise and provide antenatal/postnatal care, assist deliveries, manage newborn care, counsel on reproductive and adolescent health, and oversee treatment programs (e.g., for TB, acute malnutrition). 

Community health workers in the Manoshi programme operate in challenging conditions, navigating crowded settlements and inadequate infrastructure. Yet their constant presence in these communities builds trust with families and makes them a reliable source of care and support serving as a vital bridge between underserved families and the formal health system.  

The results are clear: as evidenced in the table below, in areas where Manoshi is active, child health and survival are improving, and more mothers and newborns are getting the care they need. Despite the many challenges they face, these health workers remain the backbone of Manoshi’s success, showing how locally rooted, community-driven care can transform health outcomes in even the most vulnerable urban neighbourhoods. 

Save the Children Bangladesh’s Sponsorship Programme

Since 2014, Save the Children Bangladesh’s Sponsorship Program has been working in the Rayer Bazar slums of Dhaka to improve health for children and families. The program employs 15 CHWs, each covering about 100 households every month, with support from 50 Adult Health Volunteers.

CHWs play a vital role in delivering essential health services. They visit homes to support pregnant women with basic antenatal care, educate families on health, nutrition, and safe childbirth, and run Growth Monitoring Promotion sessions to detect malnutrition in young children. CHWs collaborate with Traditional Birth Attendants to promote better maternal health practices and work with local leaders to identify suitable spaces for health education in overcrowded slums. They also adapt their schedules to meet families at times that work best for them.

To build CHWs’ capacity and effectiveness, Save the Children provides:

• Training on maternal and child health, nutrition, and disease prevention.
• Mobile health (mHealth) tools for tracking patients, diagnosing illnesses early, and making referrals.
• Education on climate-related health risks, such as heat stress and waterborne diseases.
• Support to Adult Health Volunteers to expand outreach and strengthen community connections with CHWs

The programme has had a significant impact. Baseline data from 2016 and survey results from 2023 show that the percentage of fully immunised children increased from 11% to 89%, while the proportion of newborns who were breastfed rose from 48% to 97%.

Challenges faced by Community Health Workers

CHWs in urban areas often operate within fragmented systems, characterised by limited coordination, unclear roles, and minimal recognition. Many are left to navigate complex community dynamics, unsafe environments, high caseloads and highly mobile populations, all with limited training, meagre pay and resources.

For many CHWs in urban slums, low pay is one of the toughest challenges. As one 28-year-old CHW in Bangladesh put it:

“I like this work; hence I am doing this. . . But our financial incentives are not justifiable considering our workload. . .If someone asks us about our financial benefits, we feel ashamed. They ask us “why you are doing this work with such a low salary.” [iv]

Safety is also a concern, especially for women CHWs.

“Moreover, working alone is risky for women. In some areas, people are not good. Sometimes/some places, where a man can enter, a woman cannot. In this case, if someone accompanies me, I feel secure, and it also helps to do my work better.” (Community Health Service Promoter, 22-year-old, Bangladesh)[iv]

CHWs are seldom integrated into official health systems, making it harder for them to deliver consistent care or build community trust.[vi]

Female CHWs face additional pressures, juggling household and childcare duties while trying to reach families, often in unsafe or hard-to-access areas. Social norms can restrict their mobility, and many are in lower-paid or volunteer roles with few opportunities to advance.

And while the structural issues are daunting, the emotional toll is just as severe.

CHWs frequently face burnout, anxiety, and emotional exhaustion, especially when responding to trauma, violence, or overwhelming need with few tools or support. Additionally, the mental health of CHWs themselves is often overlooked, even though it’s crucial for sustainable community care. [vi] If we want stronger, more equitable health systems in cities, we have to start by supporting those on the front lines.

How Governments and NGOs Can Empower Community Health workers

To improve CHWs’ effectiveness and ensure sustainable urban health programs, governments and NGOs should:

• Build trust within communities by working with local leaders to formally acknowledge and support CHWs and provide visible, safe and dedicated spaces for community-based health services.
• Integrate CHWs into formal health systems by formally recognising their role, budgeting for fair salaries, and ensuring they are part of the urban health planning and delivery continuum.
• Compensate CHWs fairly through stipends, incentive-based remuneration, travel allowances, and fair wages, considering high living costs in cities.
• Strengthen CHWs’ skills and capacity through regular training on healthcare guidelines, communication, community outreach, and climate-related health risks.
• Leverage technology to improve reach and quality by expanding mobile health (mHealth) programs, training CHWs to use digital tools, and developing digital health records to track families who move frequently.
• Expand community-level health promotion by equipping CHWs and volunteers to deliver health education, promote sanitation, and make timely healthcare referrals.
• Build collaborative partnerships among governments, NGOs, local leaders, and communities to sustain and scale equitable healthcare services in urban slums.

Community health workers play a crucial role in ensuring that children in urban slums have the healthy start in life they are entitled to, while also helping to build more resilient and equitable cities. They reduce child mortality and boost immunisation in dense settlements, create trusted community health access points where formal systems fall short, and build resilience to climate-related health risks through education and outreach. By offering flexible services for mobile urban populations, they ensure no child is left behind.

If you are aware of other urban health programs that work with community health workers in sustainable ways to enhance child health and nutrition in urban slums, please share them with us at info@cities4children.org.

About the Author

This blog was written by Tahmina Ferdousy, Kamrun Naher Ahmed, Mohammad Omar Faruque, Hayalnesh Tarekegn, and Rashed Shah from Save the Children’s Bangladesh Sponsorship Team and the Urban Hub Team at Save the Children.

We would like to thank Sheridan Bartlett, Ana Ortigoza (Pan American Health Organization) and Margaret Caffrey (Global Health Partnerships) for reviewing earlier drafts of this blog and providing valuable insights and suggestions which helped strengthen the blog.

Endnotes

[i] Unger A. Children’s health in slum settings. Arch Dis Child. 2013 Oct;98(10):799-805. doi: 10.1136/archdischild-2011-301621. Epub 2013 Jul 30. PMID: 23899920

[ii] Malnutrition in Children. (n.d.). Retrieved July 20, 2025, from UNICEF DATA website: https://data.unicef.org/topic/nutrition/malnutrition/

[iii] Ahsan, K. Z., Arifeen, S. E., Al-Mamun, Md. A., Khan, S. H., & Chakraborty, N. (2017). Effects of individual, household and community characteristics on child nutritional status in the slums of urban Bangladesh. Archives of Public Health, 75, 9. https://doi.org/10.1186/s13690-017-0176-x

Das, S., Chanani, S., Shah More, N., Osrin, D., Pantvaidya, S., & Jayaraman, A. (2020). Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: Evidence from a household census. Journal of Health, Population and Nutrition, 39(1), 1–13. https://doi.org/10.1186/s41043-020-00222-x

[iv] Mahmud, I., Siddiqua, S., Akhter, I., Sarker, M., Theobald, S., & Rashid, S. F. (2023). Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study. PloS one, 18(1), e0279110. (Quotes from pg 7, 8)

[v] https://evaluationreports.unicef.org/GetDocument?documentID=18456&fileID=45144

[vi] Ludwick, T., Morgan, A., Kane, S., Kelaher, M., & McPake, B. (2020). The distinctive roles of urban community health workers in low- and middle-income countries: A scoping review of the literature. Health Policy and Planning, 35(8), 1039–1052. https://doi.org/10.1093/heapol/czaa049

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