Individual level.

Perception about working as an SS influenced performance. The active and better-performing SS perceived her work as an opportunity to have a formally recognised identity in the community and to work with the most disadvantaged population in the community. Before joining BRAC as a SS, most were housewives with no paid employment (Table 3). They were mainly recruited from lower socio-economic families and did not have any other identity in their community other than housewife. Working as a SS gave them an affiliation with BRAC, a well-known organisation not only in Bangladesh but also globally. We did not observe such positive perceptions among all the SS in the study, particularly those who were inactive or irregular in working as SS or were a lower-performing SS.

Age and education of SS were important predictors, but not always. One of the major selection criteria of SS was their age, which was 20–35 years. However, there were a number of SS who were above 50 years of age because, in the BRAC’s model, there was no procedure for terminating an SS from her work (Table 3). Recently recruited SS had to have at least 8 years of schooling (formal education). Earlier, SS had been recruited without considering their educational level. Consequently, many non-literate women or women with below primary-level education had been selected as SS. These categories of SS faced several challenges; they could not effectively receive the training as they were unable to read and write. They also faced difficulties in performing their regular activities, could not maintain their daily registration and the simple calculations that they needed for their work. Although age and education helped SS perform better, we observed there were some SS in this study who were non-literate and aged but performed better than young educated SS. According to the BRAC staff members, these types of SS were naturally talented women; they mostly had learned how to face challenges and how to convince others (Table 3).

Self-efficacy refers to an individual's belief in his or her capability to perform behaviours related to produce specific performance attainments [27]. In the BRAC home-fortification programme, the self-efficacy of an SS has been identified as an important factor associated with her performance. Some SS, irrespective of their age and educational levels, were not keen to visit all households; rather they visited selected households. The SS reported a number of reasons for this which denoted low self-efficacy to overcome the challenges in the communities. For example, SS avoided visiting households where household members belonged to a different religion (Table 3), or where they thought they might not get access. The SS avoided the households with older people who were likely to ask more questions and did not allow them to spend time with caregivers. They also avoided households with educated caregivers who asked more critical questions which they were unable to answer. However, SS felt comfortable to visit households containing a relative and even the caregivers also felt comfortable to discuss any health problem with a SS who is their relative (Table 3).

Work-related knowledge helped SS to better perform in the communities. SS with adequate knowledge about the services were able to deliver them effectively. In the home-fortification programme, there were several tasks, such as counselling mothers about home-fortification of foods with MNP, demonstrating how to mix the MNP with food, explaining the benefits and side-effects of MNP, and responding to the caregivers queries. We observed that the SS who had very clear understanding about home-fortification could clearly explain it and demonstrate it to the caregivers without any hesitation (Table 3). However, their knowledge was influenced by various circumstances, including whether they had received basic training and regular refresher training, or whether they had asked questions or sought help from the trainers and the supervisors while working at the communities. Some SS who participated in the study rarely asked any questions to their supervisors and left difficult tasks for their supervisors. The Shasthya Kormis of those SS needed to spend more time and effort with them to achieve their work-related targets.

Career prospects–working as a SS was a point of entry to future betterment. Although the SS perform voluntary jobs and receive minimal financial incentives, the SS felt that this work may create an opportunity for getting a better job in future. The experiences gained by working as an SS may be valuable in terms of increasing self-confidence and life-skills. The SS reported that, when they were at home, they did not have opportunity to mix with people other than their family members. During community visits, they communicated with many people; they counselled them about healthy behaviours; they sold their products to the caregivers of children, and they maintained a business by themselves. Through their work, the SS become familiar to the community. Several SS were elected members of the local council based on their popularity. The experience of working as an SS was considered an important achievement that they could use when applying for other jobs relating to community-based functions. Some SS also used this experience to run a business (Table 3).

Community level.

Community members had mixed perceptions about SS. As the SS sell health products and provide advice on health issues in the communities, they are recognised as a local doctor; people called them dakterni (female doctor) (Table 3). The SS reported that they appreciated this identity. However, sometimes community members did not accept the SS, as most of them were recruited from socially and economically-disadvantaged families. When their socio-economic status was lower than that of the visited households, household members refused her services. A SS is often ignored (Table 3) if their educational level is lower than that of the caregiver of the child.

Social norms, religious issues, family support, influenced the functions of SS. In Bangladesh, religious beliefs influence the social environment while individual lifestyles also determine the roles of men and women in the community. In some communities, religious leaders consider NGOs’ activities to be non-Islamic and associate them with Christianity. They deter community members from being involved with NGO services (Table 3). Several participants from rural areas said that most of the people in the rural areas practised Islam and they were very sensitive about religious norms. They believed that Islam does not permit a woman to work outside the family. Due to these norms, some community members ignored the SS and discouraged other family members from receiving their services.

Community demand for services from SS critical to their performance. Our analysis revealed that when people in a community knew about the functions of the SS, they requested their services. In such a situation, the SS were comfortable with their work. Interviews with caregivers revealed that many were not aware of SS services until they received a home visit from them. There was very limited advertising by BRAC to raise community awareness about the SS’s functions. However, in sub-districts where BRAC also used community mobilisation activities, including an informational meeting with community leaders about home-fortification of the MNP programme, caregivers had better understanding about Pushtikona (e.g., BRAC’s MNP product) and the performance of the SS was better. Some caregivers were concerned about the side effects of Pushtikona and stopped using it if they saw their child having problems (Table 3).

Geospatial distance was important: the further households were from the SS’s house, the fewer SS visits. In Bangladesh, many households were far away or hard-to-reach for an SS especially during the rainy season and bad weather (Table 3). We observed that BRAC allocated communities to SS without considering the locations of their homes. If the home of an SS was in the middle of the community, it was easier for the SS to reach all households. When the home of an SS was situated on the outer border of a community, it because difficult for the SS to reach households situated on the other side. Distant households were relatively unknown to the SS. In that case, the SS were less confident about whether they would be welcomed by the household head to provide services or to sell their products. The SS also reported that they sometimes required local transport such as a rickshaw or a boat to reach some households but were not reimbursed for this cost by BRAC, and could not afford to spend their own money to visit these households.

SS are struggling to compete with other service providers in the communities. There were a number of other service providers, including village doctors, quack doctors, pharmacists, private practitioners, and CHWs of the Ministry of Health and other NGOs, providing health and nutrition services to the community and creating competition. A local dispensary is very common in Bangladesh along with a village doctor who is usually well trusted. Community members often prefer getting medicine or nutritional products from them rather than an SS (Table 3). In a community, if a village doctor sells MNP, the SS in that community is not able to achieve her MNP sale target.

Organisational level.

Appropriate recruitment of SS is critical to their performance. BRAC recently changed the recruitment criteria of the SS by considering a new organisational strategy and the sustainability of the SS model. In the new recruitment criteria, BRAC considered two critical factors: age and education of the SS. BRAC’s staff members at the sub-district level reported that they were struggling to recruit SS who had all the recommended criteria. Since socio-economic conditions of rural Bangladeshi people have improved during the last two decades, the availability of paid work has made it more difficult for the BRAC’s local office to find volunteer workers. This has led BRAC personnel to compromise on the recruitment criteria (Table 3) and recruit SS who are not eligible to perform assigned tasks.

Workload and uneven distribution of households created concerns for SS. The allocation of households to an SS depended on several factors. At the very beginning of SS service delivery model, an SS was assigned for 250 to 300 households in rural areas; however, this number has changed over time to synchronise with new and upcoming programme needs. In urban areas, BRAC allocated 150 households to each SS. Since the SS dropout rate was high and recruiting an appropriate SS became difficult, the local BRAC office asked SS in nearby communities to provide services to those households who had lost their SS. This led remaining SS becoming overburdened with double the number of households. In addition, BRAC recently reduced their paid staff positions due to programmatic changes and financial constraints (Table 3) which resulted in an increased workload and targets for remaining staff that eventually impacted on their performance.

Inadequate income-generation guidance for SS influenced motivation. The overall philosophy of BRAC SS model was that it was based on voluntary work. The SS did not receive payment for their work. However, to motivate them, BRAC eventually introduced several earning mechanisms, including cash incentives for some services and allowed them make a profit selling BRAC’s products. A strongly motivated skilled SS can earn BDT 2,500 to 5,000 in a month (1 BDT = 0.012 USD) but many others could not. Apart from basic training and a monthly refresher training, BRAC did not provide guidance to the SS about financial security. Furthermore, most SS reported that they had to provide a free sample to caregiver to try before buying. Since most caregivers were female and housewives (not a main earner in the household), they depended on their husband or the other main earner in the household to buy anything. In such a situation, a caregiver always asked the SS to sell the product on loan/credit to be repaid once she got money from her husband. According to the SS, distribution of free samples and sales on credit created financial pressures which demotivated them.

In several evaluations, concerns were raised about SS retention, dropouts and irregular home-visits. Considering these, BRAC shifted from a volunteer SS model to a business model to enable SS become involved in income generation. In this business model, BRAC provided support to SS to develop business skills (Table 3). They started with recruitment of quality SS who received training in the new model and how to apply these skills in real-field settings. Our interviews showed that SS had a limited understanding of their clients or records keeping. According to managerial staff, BRAC is planning to address income-generation for SS.

Regular monitoring and supportive supervision are critical to performance of SS. BRAC has a cascade system of monitoring and supervision with Shasthya Kormis, to Field Organizers and Programme Organizers who are paid to monitor and supervised the SS through regular field visits (Table 3). Supervisors played an important role in motivating the SS by providing advice on excellent service and on how to counsel mothers while visiting the field. The supervisors also identified who performed well and who did not; this was done by investigating targeted households. We observed a high turnover or dropout among the supervisory-level staff, particularly among Field Organizers and Programme Organizers due to a low and uneven salary structure for BRAC staff members at the sub-district level compared to other NGOs working in the regions (Table 3). Unavailability of supervisory-level staff members created a huge constraint on providing regular monitoring of and supportive supervision to SS.

Collaboration and coordination with other BRAC programmes influenced SS performance. BRAC has many programmes running in an area at one time. Staff members of one programme were often unaware of other programmes. This resulted in negative impressions at the community level among the caregivers. Previously, BRAC did not organise coordination meetings but after receiving evidence from previous evaluations, BRAC started coordination meetings across all ongoing programmes. BRAC established internal coordination among the MIYCN staff and other programme officials. These coordination meetings helped in building an effective promotion of MNP (Table 3).

Programme level.

A top-down supply chain was responsible for shortages of BRAC supplies at the SS level. Initially, demand-notes and requisition of commodities had been prepared at the sub-district to the district level, then to the national level. In this process, community-level staff members were not consulted. Often, these requisitions did not reflect the actual demand and resulted in shortfalls in products which created challenges for the performance of SS at the community level. If the SS did not have adequate supplies of products for providing their services, they lose clients’ trust who then refused products or services from the SS. During our initial qualitative data collection, we found supplies of MNP did not match community demand (Table 3). There were also issues at the manufacturer level; they could not always meet increased demand for products.

Low and uneven incentives demotivated SS. The performance of non-paid SS was reliant on incentives; without them, they became demotivated and inactive. The incentives have been reduced for many activities performed by the SS. Earlier, if an SS identified a pregnant woman from the community, she received 50 BDT; if she attended a delivery and early helped initiate breastfeeding, she received BDT 150. At present, the SS receives 20 BDT for identifying a pregnant woman; if she attends a delivery, she receives 10 BDT only. Due to such reductions, many SS do not want to perform the activity.

The SS received higher incentives from a nutrition programme which was phased out recently. However, other ongoing programmes were not interested continuing with these high incentives so that the SS became less interested in performing nutrition-related activities. As SS were used to receiving higher incentives over the past 4–5 years, they did not want to do the same work for no incentives. During the initial period of the MIYCN Programme, there was no incentive included in the home-fortification intervention; for that reason, the SS were reluctant to provide services or sell product (Table 3). Later, BRAC introduced incentives under the MIYCN Programme. If an SS can sell six boxes of Pushtikona, she receives 50 BDT as an incentive. Moreover, an SS receives 150 BDT when she ensures a child in her area is fed 120 Pushtikona sachets within 12 months with the condition of ensuring 60 sachets were sold within six months. After introducing these incentives in the MIYCN programme, SS sales of MPN increased.

Timely programme-specific training improves SS’s performance. Generally, BRAC provided basic training through the training division of BRAC when they started a new programme with SS. The training department of BRAC organised such training in batches with each batch containing 20 participants. The training department of BRAC is a separate department from the MIYCN programme department. They only organised training for newly recruited SS when they had 20 SS to fulfil a batch. Consequently, when BRAC field office recruited a new SS to fill a vacancy, they could not provide basic training to that SS immediately. Usually, a SS waits about four to six months to get the basic training even though they have started work (Table 3). This creates additional challenges for untrained SS which influenced to their performance in home-fortification implementation as they were unable to respond to questions from community members, which undermined their credibility. There were some other challenges in organising timely training, including delays in allocating a training budget.

Competition with other programmes is challenging for the SS. We observed that multiple organisations in the same community have provided interventions of home-fortification with MNP. In that situation, differences in the programme modalities among the organisations affected their workers at the community level. BRAC’s MIYCN Programme followed a market-based approach–where SS purchased MNP from BRAC’s local office and sold it to the caregivers of her community with a profit margin. Other organisations working in the same communities followed a free-distribution model by providing MNP to the caregiver free of charge and they implemented a piloted intervention. Having two programmes created confusion among the community members and created a difficult situation for the SS (Table 3). Our analysis revealed that an NGO was freely distributing MNP in one sub-districts of a BRAC community; therefore, BRAC SS stopped selling Pushtikona in these communities.