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Chowdhury champions constant learning, evaluation and innovation in research
13 Oct 2010
TropIKA.net team
Source: TropIKA.net
Dr Mushtaque Chowdhury.
A three-finger pinch of salt, a fistful of gur – a sort of unrefined sugar or molasses – in half a litre of water; this simple concoction revolutionized the treatment of diarrhoea
in Bangladeshi children in the 1980s.
Oral rehydration therapy (ORT), in its various guises, has since become a major tool in the armoury against the second leading cause of death among children under five globally. It has been described as potentially the most important medical advance of the 20th century [1].
That Bangladesh successfully introduced home-based ORT on such a large scale is in no small part down to research carried out by a modest, softly-spoken researcher called Dr Mushtaque Chowdhury. Nudged to acknowledge his achievements he says: “I am very proud that Bangladesh has the highest ORT use in the world. The research contribution in that is enormous”.
In 1977 he began working for the Bangladesh Rural Advancement Committee (BRAC), the world’s largest NGO, which had embarked on a major programme to teach mothers to create a sugar–salt solution at home and had experimented on the measurements of local ingredients to get the right solution to enable them to treat their children effectively. The project, interestingly, went ahead despite some consternation within the international community that mothers might make up incorrect solutions, which could be extremely dangerous.
“There was a lot of controversy: whether BRAC should be allowed to promote home-made ORT at all, whether illiterate mothers would be able to make solution correctly and whether BRAC should do this training all over the country,” Chowdhury says. “Many, including some of the influential international organizations, tried to block it but BRAC was resolute and firm and carried it out against all odds and opposition.” (The international community only distributed sachets of oral rehydration salts, containing ingredients in the correct quantities.)
During the 1980s, BRAC taught over 12 million mothers how to prepare a home-based solution for ORT. [Credit: BRAC.]
BRAC’s experiments were inspired by work to establish ORT as a more effective and cheaper alternative to costlier intravenous saline methods, by Bangladesh’s International Centre for Diarrhoeal Disease Research ICCDR, B (then called the Pakistan–SEATO Cholera Research Laboratory). ICCDR,B carried out the first successful clinical trials of ORT, together with the Johns Hopkins Center for Medical Research and Training in what was then Calcutta. The beneficial effects of oral rehydration were famously proven in Bangladeshi refugee camps after IV supplies ran out during the liberation war of 1971 [2].
Why the low uptake?
Chowdhury, who had joined BRAC as a trained statistician, was appointed the evaluation manager to measure the impact of the BRAC ORT programme on mortality six months on. But there was no point looking at mortality, he found, because despite BRAC’s best efforts to teach women how to create the solution, just 10% of women were using it. “That was a very frustrating thing because we thought that ORT would make sense [to mothers],” he says.
It seemed perverse that women should not want to help their own children, so Chowdhury turned away from statistics and looked for other ways to study what was happening. His research threw up some interesting results. “At the early stage we overlooked the behavioural aspects,” he says. “We found a number of things which meant we had to change the programme strategy to improve the rate.”
Firstly, when health workers instructed mothers, they neglected to include their husbands. That led to misunderstandings. Husbands assumed ORT was an imposition from government, and perhaps a ploy to introduce family planning (a very unpopular concept at the time) by the back-door.
Chowdhury also found that Bangladeshi women have more complex terminology for different kinds of diarrhoea than public health officials [3]. They were only administering ORT to infants with certain types of diarrhoea and not others. Dud-haga, which is associated with breastfeeding, was not considered to be diarrhoea by Bangladeshi mothers, nor was another form called ajima. In contrast, daeria (severe watery diarrhoea associated with cholera) and amasha (dysentery) were regarded as diarrhoea. “[BRAC] changed their strategy and the message after the research,” says Chowdhury.
The research transformed the project. It also underlined the importance of including a research component within implementation projects, says Chowdhury. He set about establishing a permanent arm dedicated to monitoring and evaluating projects carried out by the NGO.
Building the evidence base
“The evidence base for any decision is so critical for its success. BRAC was huge and doing really good work but if it included research into its work, its performance would be increased many fold,” he says. “I spent most of my time developing the research and evaluation.”
The new division started looking at a range of research projects and modified designs for existing ones. For instance, Chowdhury initiated studies to find the causes of low ORT uptake. In this project, a BRAC health worker’s salary was based on a mother’s ability to retain the salt–sugar recipe. In other words, the health worker would only be paid if, a few days after teaching the recipe to a mother, an independent assessment established that the mother was able to make up solution that complied with the WHO formula (verified by laboratory testing). Monitoring the ability of mothers to prepare ‘safe and effective’ solutions was continually assessed too.
The concept of incentive was extended to other BRAC projects, including a TB detection and treatment programme in which patients were given an incentive to finish their treatment. The patients offered free TB treatment on one condition – a deposit of Taka 100 (then worth around US$2), as a bond with the community health worker. When they completed the course of treatment, the deposit would be returned.
“Incentive should be a very important part of any health delivery programme,” he says. “We have seen in Bangladesh that if you really can build an incentive into the system you can achieve a lot.”
“A huge impact”
Professor Lincoln Chen of the China Health Board, who studied cholera physiology and epidemiology in Bangladesh at the Cholera Research Laboratory, was appointed to an international technical advisory committee to advise BRAC on the ORT programme and its evaluations. He says these evaluation and incentive schemes were viewed as creative by the research community. “Mushtaque has had the responsibility to craft research approaches to community-wide and large-scale health actions,” he says. “These types of health interventions have exerted a huge impact on the field, and have the promise of transforming the nature of health interventions of many kinds.”
Today, the dedicated research arm that Chowdhury set up at BRAC is now around 100-strong and has become core to BRAC’s work. Over the years, Chowdhury and colleagues have looked at HIV/AIDS, immunization and prevention programmes in sexual and reproductive health. He has also published on the role of women in community-based health care, nutrition, primary education and poverty alleviation.
He has used qualitative methods to understand the taboos and beliefs about immunization in rural societies, and simple quantitative tools, such as the so-called 30-cluster survey method that is employed for estimating immunization coverage, which he describes as having revolutionised the monitoring of immunization in Bangladesh. Researchers should not have to choose between either quantitative or qualitative research says Chowdhury. As he puts it, “The challenge today for a researcher is integrating the two into research”.
The work done by BRAC’s research arm has been diverse. It has had to acquire expertise in new disciplines in order to embark on different types of research. To evaluate primary education projects, for instance, it was necessary to build capacity in education research. And to look at the impact of women-based micro-credit schemes on income – and ultimately, health outcomes – the division had to develop capacity in economics.
Career path
The process by which BRAC absorbed new learning in order to conduct new types of research is not unlike Chowdhury’s own career path. A statistician specializing in population demography, Chowdhury quickly realized the importance of both qualitative and quantitative research during the ORT project. That experience led him to re-evaluate his skills. “I discovered the limitations of statistics quite early in my life,” he says. “It’s only a tool or provides only some information, not everything that a programme needs. For example you may know the use-rate of ORT, but statistics will not tell you why people do not use it. That is why I moved into more qualitative research and public health.”
BRAC ended up sending Chowdhury away to study. He was awarded a PhD in qualitative research after two years’ study at the London School of Hygiene & Tropical Medicine, having turned down a longer course at Harvard [4].
BRAC set up its own university and Chowdhury was appointed the first dean of the new school of public health (named the James P Grant School after the UNICEF boss who championed immunization). That school now runs courses taught by international, as well as Bangladeshi experts, including Dr Richard Cash of Harvard University, who originally investigated ORT’s efficacy against cholera during the sixties. Chowdhury continued the focus on research, heading the school’s Centre for Health Systems Studies (CHSS), which was set up to research ways to improve Bangladesh’s health systems.
Now working for the Rockefeller Foundation in Asia, Chowdhury wants to broaden the use of many principles he learned from working at BRAC.
A global perspective
Today, he has a global perspective on projects taking place in many countries. He is, for example, helping to sustain and expand a disease surveillance network by transforming it into a legal entity involving the six Mekong countries. He is also working in Vietnam and Bangladesh to promote financial protection in universal health system coverage.
There is a dearth of operational research, he has concluded: “In most places it is not happening, unfortunately”.
In places where research does happen, it has produced great results, says Chowdhury. He lives in Thailand now and points to the country’s International Health Policy Programme (IHPP). The institution has been instrumental in research that has helped enable universal health coverage, he says.
One answer may be to help civil society organizations acquire the ability to carry out research, says Chowdhury. In Bangladesh, an NGO called Health Watch produces a report every year that takes a critical and influential look at the state of health in Bangladesh. “It’s important for someone working in an NGO to develop capacity, particularly in research,” he says. “I am trying to export that to other countries.” (Health Watch was one of the projects supported by Chowdhury when he headed up the health systems research arm at BRAC’s school of public health.)
It is this extensive research background that has led Chowdhury to work on the Global Report on R&D into infectious diseases of poverty, initiated by the Special Programme for Research and Training in Tropical Diseases (TDR).
Immunization is likely to be a major part of the focus on health systems for universal coverage, a chapter of the report. Of course, immunization has been amazingly successful. Measles has seen a drop of over 90% in some African countries since large-scale immunization campaigns were introduced. However, several problems remain and prevent equity. “The issue is whether all the groups in the populations are being equally reached,” he explains. “If you reach 80% of one country, it doesn’t mean that all of the groups are equally covered.”
Chowdhury believes far more attention needs to be focussed on groups that are not being reached. It’s not always a supply-side problem, it is a question of demand too, he says.
There remain pockets around the world where immunization does not occur. Many of the reasons are down to religious beliefs or a distrust of the government. These are areas that need serious attention says Chowdhury.
Slum dwellers are another group that is often missed too. “Many of these populations are very mobile, so having them return to a health centre several times is an issue,” he says. “It has been shown in many other countries that even in a mobile population you can provide the clinicians if your health system is working well.”
What is needed now, says Chowdhury, is more operational research in countries facing problems in reaching these populations to better understand the dynamics there and to develop programmes that are more suitable.
Crucially, however, the success of immunization projects, and health systems, is down to national commitment says Chowdhury. In the 1980s, immunization coverage in Bangladesh was a paltry 2% but pressure from the international community and a growing focus on the importance of immunization from UNICEF’s James Grant had a palpable effect on the then military government. Immunization rates rose to 70% in five years says Chowdhury. “That was possible because of the commitment of the government at the time with the support of many other stakeholders, NGOs, civil society,” he says. “But commitment still remains a problem in many countries.”
BIOBOX
2009
Associate Director, the Rockefeller Foundation.
2004
Dean of BRAC University’s James P Grant School of Public Health in Bangladesh. Director of the recently established Centre for Health Systems Studies (CheSS) at the BRAC School of Public Health in Dhaka, Bangladesh.
2002
Visiting Professor of Population and Family Health at the Mailman School of Public Health of Columbia University in New York.
2000
Deputy Executive Director of BRAC.
1989
Short Course in Medical Anthropology, London School of Hygiene & Tropical Medicine, London, UK.
1986
PhD, London School of Hygiene & Tropical Medicine, London, UK. (Thesis theme: Evaluation of a large nation-wide health education programme).
1977
Founding Director of BRAC’s Research and Evaluation Division (RED).
1979
MSc in Demography, London School of Economics and Political Science.
1976
BA Hons in Statistics, university of Dhaka, Bangladesh.
Further information about the history and achievements of BRAC may be found in a book [4] published last year.
References
1. [No authors listed] (1978). Water with sugar and salt. Lancet; 2(8084):300-301. Available from: http://www.ncbi.nlm.nih.gov/pubmed/79090
2. Fontaine O, Garner P, Bhan MK (2007). Oral rehydration therapy: the simple solution for saving lives. BMJ; 334 Suppl 1:s14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17204754
3. Chowdhury AM, Karim F, Sarkar SK, Cash RA, Bhuiya A (1997). The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used? Health Policy Plan; 12(1):58-66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10166103
4. Smillie I (2009). Freedom From Want: The Remarkable Success Story of BRAC, the Global Grassroots Organization That’s Winning the Fight Against Poverty. Sterling VA, Kumarian Press. Available from: http://books.google.com.br
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