UNDER the scorching sun, a woman dressed in traditional attire makes her way along a muddy dirt road in a remote Bangladeshi village. In her hand she carries a visibly worn register. She does not just knock on doors; she carries lifelines to families. Inside a tin shed house, she hands out iron tablets to a malnourished mother, offers family planning advice to a young couple, and makes the critical decision to refer a pregnant woman to a health centre. This is the daily routine of a family welfare assistant, a community health worker employed under the Family Planning Wing of the Ministry of Health and Family Welfare. For nearly half a century, these women have served as the first point of contact for millions in rural Bangladesh, quietly driving the country鈥檚 health achievements. Yet, their legacy is today at risk of being undone by neglect, discrimination and chronic shortages.
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Legacy of service
FAMILY welfare assistants were first introduced in 1976 to bring family planning services to households directly. Over time, they became a trusted and integrated part of the rural landscape. Every two months they return to the same households, registering new couples, distributing contraceptives, and making referrals for maternal and neonatal care. Beyond reproductive health, they hand out iron pills, monitor nutrition, and offer health information that ensures no family is left behind.
An FWA once explained: 鈥榃e know every mother, every child, and every household in our communities. We are the bridge between the people and the health care system.鈥� It is this bridge that has enabled Bangladesh to post some of the most remarkable health indicators among low- and middle-income countries. Maternal mortality declined from 434 deaths per 100,000 live births in 2000 to 173 in 2017. Neonatal mortality fell from 44 per 1,000 live births in 2000 to 17 in 2020. Fertility dropped from 4.5 children per woman in 1990 to 2.0 in 2019, while life expectancy rose by more than 16 years between 1990 and 2020.
These gains are rightly hailed as success stories in global health. But they would not have been possible without the persistent, unseen labour of FWAs.
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Beyond family planning
THE role of FWAs is already broader than their original mandate. In many villages they provide counselling on parenting, early childhood care, and even postpartum depression. With proper resources and training, they could contribute to preventive health services, nutrition programmes, and child development monitoring.
Bangladesh continues to face deficits in rural health infrastructure. Yet, the country already has a ready-made workforce embedded within communities, capable of addressing gaps if they are properly supported. The untapped potential of FWAs represents both a missed opportunity and an urgent call to policymakers.
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Neglect
DESPITE their central role, FWAs face systemic neglect. A glaring example came with the 2015 National Pay Scale. Before its revision, male and female field workers were in the same tier. After the revision, male Family Welfare Inspectors were promoted to Grade 16, while FWAs 鈥� overwhelmingly women 鈥� were relegated to Grade 17, a lower tier. Almost 23,500 women were downgraded, while about 4,000 male colleagues were upgraded.
Amena Akhter, president of Bangladesh Paribar Kalyan Sahakari Samiti, condemned this as 鈥榗learly gender discrimination鈥� during a Dhaka news conference in 2019. The injustice is more than symbolic. Lower pay grades and absence of benefits affect motivation, retention and dignity.
For decades, FWAs have worked without proper recruitment rules. They are denied career advancement, salary increments and promotions. As one worker said bitterly: 鈥楾he position you join in is the position you retire from.鈥� A system that permanently confines women to the bottom rung is one that erodes both morale and efficiency.
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Struggle for recognition
FWAs have not remained silent. Since 2017, the Bangladesh Family Welfare Assistants Association has pursued advocacy through memoranda, petitions and dialogue. They submitted a seven-point demand to the chief adviser and all district commissioners, calling for recruitment rules, filled vacancies and pay equity.
This is not simply a professional grievance; it is a demand for dignity and equality. FWAs are challenging a system built on entrenched gender disparity, seeking recognition as agents of change rather than invisible labourers.
Their protests, including human chains and legal petitions, have so far yielded little. Bureaucratic inertia and frequent transfers of senior officials stall progress. An association member remarked during a recent meeting: 鈥楨ven if I don鈥檛 get the benefits, I want my juniors to experience it.鈥� Their persistence reflects both the urgency of reform and the resilience of those who have long been sidelined.
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Challenges
BEYOND policy neglect, FWAs face harsh operational challenges that undermine service delivery.
According to regulations, Bangladesh requires 40,500 FWAs to serve its population. In practice, only 23,500 are employed, leaving almost 17,000 posts vacant. This shortage has led to crushing workloads. In Matarbari union, for example, one inspector noted there should be nine workers for 9,000 fertile couples; in reality, there are only three FWAs and one volunteer.
Shortages of supplies further cripple their work. Basic contraceptives, iron tablets, blood pressure machines, glucose kits and menstrual health medicines are often unavailable. Government data show condoms and implants are missing in over 20 districts, oral contraceptives absent in six districts and even delivery kits unavailable in two. When essential supplies run out, FWAs can offer little more than counselling, reducing community trust in their services.
Training is also outdated. The last refresher sessions took place in 2017鈥�18, leaving workers ill-equipped with knowledge of modern contraceptive methods or updated maternal health protocols. Even administrative tools are lacking: registers meant to be replaced every three years often remain unreplaced for much longer, crippling data collection.
The consequences are visible. Fertility decline, once hailed as a success story, has stagnated at around 2.3 children per woman since 2011. Experts warn that without sufficient manpower, supplies and monitoring, Bangladesh risks reversing decades of progress.
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Public health at risk
THE plight of FWAs is not merely an employment dispute within the ministry. It is a public health issue with national consequences. Rural families depend on these women as their first, and often only, point of access to the health system.
One FWA asked poignantly: 鈥榃e work for the people every day. When will someone work for us?鈥� It is a question that demands an answer not only from policymakers but from the wider society that has benefited from their sacrifices.
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Way forward
ADDRESSING the neglect of FWAs requires urgent action. Filling the 17,000 vacancies, restoring pay parity, and introducing a promotion ladder are essential steps. Supplying essential medicines and equipment, alongside regular refresher training, is not a matter of benevolence but of investment in national health security.
Recent dialogues between BFWAA, the Family Welfare Inspectors Association and Sapran, a civil society initiative, have provided some hope. Sapran has pledged to strengthen unionisation and connect these groups with international organisations to amplify their advocacy. But civil society alone cannot shoulder the responsibility. The state must act decisively to institutionalise reforms.
Bangladesh has repeatedly demonstrated the power of community-based health interventions. But the infrastructure is only as strong as the people who sustain it. FWAs have proven their worth through decades of dedicated service. To deny them fair treatment is to weaken the very foundation of public health progress.
These women are more than service providers. They are confidantes, educators and guardians of health. To neglect them is to neglect the future of Bangladesh鈥檚 health system.
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Sanjid Tahsin Rakin is working as a researcher at Sapran 鈥� Safeguarding All Lives.
