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JAMES P GRANT SCHOOL OF PUBLIC HEALTH, BRAC UNIVERSITY
Revitalizing Health for All Developing a Comprehensive Primary Health
Care Model for Bangladesh
Lead Researcher: Taufique Joarder Research Mentor: Anwar Islam
Research User: Aftab Uddin
April 30, 2011, 2011
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Contents Introduction .................................................................................................................................................. 4
Nature of the Study in Bangladesh ............................................................................................................... 6
Background ............................................................................................................................................... 6
Operational Definition .............................................................................................................................. 8
Comprehensive PHC .............................................................................................................................. 8
Community Empowerment ................................................................................................................... 8
Devolution ............................................................................................................................................. 8
Upazila ................................................................................................................................................... 8
Objective ................................................................................................................................................... 9
General Objective ................................................................................................................................. 9
Specific Objectives ................................................................................................................................ 9
The Composition and Evolution of the Project ............................................................................................. 9
Research Methodology ............................................................................................................................... 10
Study Design and Sampling ..................................................................................................................... 10
Study Site ................................................................................................................................................ 11
Data Collection and Analysis ................................................................................................................... 12
Ethical Consideration .............................................................................................................................. 12
Status of the project ................................................................................................................................... 12
Historical Evolution of PHC in Bangladesh .............................................................................................. 12
Screening Survey in 20 UHCs .................................................................................................................. 19
In-depth Study in Two UHCs ................................................................................................................... 21
General Background Information about Dhamrai .............................................................................. 21
General Background Information about Mehendigonj ...................................................................... 21
Household Survey Findings ................................................................................................................. 22
Qualitative Findings ............................................................................................................................ 33
PRA Findings ........................................................................................................................................ 53
Discussion, Recommendation and Conclusion ........................................................................................... 60
Discussion of KTE ........................................................................................................................................ 62
Triad Experiences .................................................................................................................................... 62
Outcome Mapping Exercise .................................................................................................................... 62
Boundary Partners .............................................................................................................................. 62
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Expected BC from Boundary Partners ................................................................................................ 64
Expect, Like, Love ................................................................................................................................ 65
Bibliography ................................................................................................................................................ 66
Acknowledgment ........................................................................................................................................ 68
Annex A: Methodology Matrix .................................................................................................................... 69
Annex B: Screening Survey Questionnaire .................................................................................................. 73
Annex C: Key informant interview checklist ............................................................................................... 80
Annex D: IDI guideline for UH&FPO ............................................................................................................ 81
Annex E: IDI guideline for MO/MA ............................................................................................................. 88
Annex F: IDI guideline for field staffs .......................................................................................................... 93
Annex G: IDI guideline for patients ............................................................................................................. 95
Annex H: IDI guideline for Local Government leader ............................................................................... 101
Annex I: Guideline for observation of UHC ............................................................................................... 103
Annex J: PRA guideline .............................................................................................................................. 105
Annex K: Document review guideline ....................................................................................................... 106
Annex L: Household Survey Questionnaire .............................................................................................. 107
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Introduction Since the advent of modern medicine, its chief beneficiaries were the rich people, the people who could afford to avail its bounty. It is for the first time in the history that the health of the poor people of the planet gained its ground through the concept of Primary Health Care (PHC) in the policy processes. This is particularly true for the countries like Bangladesh, which bears the legacy of colonial oppression for long 200 years by the British followed by its Pakistani successors till 1971 when Bangladesh got true independence. The wheel of world policies experienced the first counter-rolling in 1960s when the United Nations (UN) started advocating ‘new economic order’ with a focus towards the basic needs of the common people. Individualistic medical approach of the physician centered health policies faced a turned tide of community centeredness with a view to ensure not only medicine but also shelter, food, clothing, safe water, education and health care (Walt & Rifkin, 1990). The executive board of World Health Organization (WHO) came to a concrete decision by 1972 of revamping the focus of the organization towards the people who are the most in need of health care. Since then WHO went through rigorous exploratory processes with partnership of interested organizations, conceptualized the various aspects of health care which became crystallized later in 1978 (Bryant & Richmond, 2008).Thus evolved the concept of Primary Health Care with the compassionate ideologies of equity and social justice. In 1978 the governments of 134 countries along with several voluntary agencies met in Alma-Ata (then USSR) at the Joint WHO-UNICEF conference and called for the acceptance of the WHO goal of Health for All by 2000 AD and asserted PHC to be the key to achieving the target (Park, 2008).
Emergence of PHC was not absolutely greeted with clement approval from all the international stakeholders. Right after its commencement it was faced with stern criticisms starting from as early as 1979 till even today. Some of these criticisms obtained the grace of classic debates in the field of public health e.g. comprehensive vs. selective, horizontal vs. vertical, social justice vs. cost effectiveness, bottom-up vs. top-down etc. Some people even termed it as ‘poor treatment for the poor people’ for its being cheap and low-technology options (Sanders, Schaay, & Mohamed, 2008). Walsh and Warren (1979) criticized it for being too costly and unrealistic for most countries (Odaga, 2004). Some developed countries became skeptic about it arguing that PHC is irrelevant for them and relevant for only the developing and least developed countries (Baum, 2007). Clinicians considered it as a threat to their long predominance of medical establishment. It also lacked the presently growing concerns for environmental sustainability issues (Baum, 2007). Even one of the greatest health leaders of the time, Halfdan Mahler, a prime advocate of PHC and the then Secretary General of WHO, could not foresee the changing economic and political climate of the globe giving way to ‘free market’ paradigm shift. Oil crisis, global recession, structural adjustment programs introduced by the development banks- all these factors played a role to take the national budgets away from the social services like health care.
Economic intricacy coupled with neoliberal politico-economic ascendancy during the 80s and early 90s influenced the health system specialists to adopt ‘efficiency’ and ‘sustainability’ based ‘health sector reform’ rather than ‘equity’ and ‘social justice’ based ‘health for all’ movement. Due to the diminishing resources and a tendency of coarsely depending on the objectively verifiable indicators as imposed by the large donor organizations, selective approaches or package programs gained popularity over the comprehensive approach. Emergence of HIV/AIDS, re-emergence of tuberculosis, failure of malaria
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control programs added fuel to this propensity of changing policy priorities. These selective, rapid and easily measurable approaches seemed attractive to the large funders. Several such selective models then got erected out of the ground rapidly e.g. child survival revolution championed by James P Grant, GOBI-FFF, Essential Service Package (ESP) and many more (Lawn, Rohde, Rifkin, Were, Paul, & Chopra, 2008). These approaches had some relative advantages over the comprehensive approach e.g. its ability to give impressive output within a short period, aggressive attack on high prevalence health problems, readily available support from some donor agencies, less resource demanding nature and most notoriously its ability to enable politicians to exploit people by shifting their focus from the deep rooted and grossly disappointing socio-politico-economical shortfalls.
These constant challenges posed by the paradigm shift of the world policy personnel along with normal desire to evaluate a long expected program like PHC, called for a mid-term review in Riga, Latvia in 1988. The outstanding achievement of the PHC had been recognized and highly praised, however slowness and even stagnation in some countries were also shed some light upon. Revitalization of whole program was demanded with new analyses, partnerships, mechanisms and resources. The meeting suggested peoples’ empowerment, district health system strengthening, emphasizing the issues of the least developed and developing countries etc (Bryant & Richmond, 2008). However, the target of Health for All by 2000 had not been met, the necessity for its further headway is well reflected by the Director General of WHO Dr. Margaret Chan’s remarks in the introductory message of The World health report 2008: Primary health care now more than ever, “While our global health context has changed remarkably over six decades, the values that lie at the core of the WHO Constitution and those that informed the Alma-Ata Declaration have been tested and remain true” (World Health Organization, 2008). This warrants an in-depth understanding of the current PHC scenario at the local level, its evolution in the light of changing contexts and a strong evidence base.
Keeping the issues of evidence regarding PHC in mind, a group of researchers from several parts of the globe, under the ‘Teasdale-Corti’ Research program initiated a multi-country research program. The program was funded by Canadian Global Research Initiative with an aim of systematically reviewing recent past experiences of comprehensive primary health care (CPHC) from different regions of the world, train early career researchers in PHC, providing financial support to the regional research teams, building regional networks of researchers and research users, creating sound knowledge base on CPHC in improving health equity that can be used in advocacy and finally strengthening People’s Health Movement in being a global voice for CPHC. The teams had been selected from South Asia, Africa, Latin America and indigenous/aboriginal peoples of Canada and Australia. All the projects are currently lead by renowned globalization expert and CPHC activist Professor Ronald Labonte, the Canada Research Chair of University of Ottawa.
Responding to calls of a renewal of CPHC system by the WHO, the Pan-American Health Organization (PAHO), health ministries and civil society groups around the world, a team of researchers from James P Grant School of Public Health and ICDDR, B submitted their concept note with an aim to “develop a culturally sensitive, demand based comprehensive primary health care delivery model for Bangladesh” and was successfully awarded a grant from the region 1: India and South Asia. After the initiation of the project an International Research Training Program was held in Bangalore, India from October 13 to 24,
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2008 to prepare the young researchers to undertake the research in the respective regional settings and to develop them as an efficient advocate of CPHC in alignment with the current global circumstances. The Centre for Public Health and Equity, SOCHARA organized the first regional training program for the India and South Asia region. This was the first phase of training being conducted as part of the inter-country research project on “Revitalizing Health for All- Learning from Comprehensive Primary Health Care”. Teams from India, Pakistan, Iran and Bangladesh (Gonoshasthaya Kendra and JPGSPH, BRAC University) joined the training program. Some of the core content of the training was HFA-PHC background, Values, Context, Effectiveness of CPHC, Revitalization of CPHC, Research Methods in CPHC and CPHC in the Regions. It provided a very good opportunity to create knowledge base on the role of CPHC. The training also supported to develop the Expression of Interest into more detailed proposal. It also provided the opportunity to build CPHC researchers and research user’s network in the region. The JPGSPH team was lead by Professor Dr. Anwar Islam, the then Associate Dean and Director of JPG SPH, Dr. Aftab Uddin, Senior Manager, Technical Training Unit, ICDDR, B and Dr. Nahitun Naher, Research Associate, JPG SPH. The second regional meeting was scheduled to take place from January 31 to February 04, 2010 in Dhaka, Bangladesh with an objective of reviewing the accomplishments since the last meeting in Bangalore. The second regional meeting was organized by James P Grant School of Public Health, BRAC University with close collaboration of BRAC Health Program.
Nature of the Study in Bangladesh
Background Since independence in 1971, Bangladesh has made significant progress in many areas of social development including health. Per capita income increased from around $100 during the 1970s to almost $690 by 2009 (BBS, 2009). Life expectancy at birth increased from 49 years in 1984 to almost 65 years by 2007 (DHS, 2008). Similar progress has been seen in child health, i.e. infant mortality rate (IMR) and under-5 mortality rate (U5MR), which were 100 and 149 in 1970 while they are 52 and 69 in 2006, respectively. The maternal mortality ratio (MMR) also declined from over 6 during 1970 to 3.2 per 1000 live births at present. The total fertility rate (TFR) has been dropped to 2.9 in 2006 from 6.4 in 1970 (BHW, 2006). These gains in Bangladesh can largely be attributed to the Primary Health Care (PHC) system.
Bangladesh is one of the signatories of Alma-Ata declaration in 1978. Guided by the principles of Alma Ata, Bangladesh adopted Primary Health Care (PHC) as the key approach to reach the goal of Health for All by 2000. There are 31-50 bedded hospitals known as UHC functioning in 481 Upazilas (Sub-district) of Bangladesh. UHCs act as the hub of PHC delivery and first point of referral in Bangladesh where all the treatment are supposed to be given absolutely free of cost. Above these UHCs there are district level secondary care hospitals, regional teaching hospitals and national specialized institutions for tertiary level specialized care with modest user fees. On an average each UHC covers a catchment area of 250,000-300,000 populations (Osman, 2004). Although Upazila is geographically equivalent to sub-district in most of the countries, in terms of population density of Bangladesh it is comparable to Districts in other countries. Below the level of UHCs there are Union Health and Family Welfare Centers (UH&FWC) covering approximately 25,000 to 30,000 populations. The government is trying to re-establish Community Clinics with a view to take the PHC services closer to the grass root level people. Provision of services through health centers is an approach that has been used by Government of
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Bangladesh (GoB) as well as NGOs and other private organizations in Bangladesh to deliver PHC, however like most other countries GoB is the prime mover (Perry, 2000), and mandated by the Bangladesh Constitution.
Under the sector-wide approach, the services offered through PHC are selective and known as essential services package (ESP), covering reproductive health care, child health care, communicable disease control, limited curative care and behavioral change communication (BCC). Many of the improvements in basic health indicators i.e. TFR, MMR and IMR are largely due to the PHC system; however, the critical issue of equity across socio economic strata still remains. The health system faces challenges in terms of shortage and maldistribution of staff, skill mix imbalance, a negative work environment and weak knowledge base- all the five obstacles identified by the Joint Learning Initiative (2004). At one hand, PHC coverage is below 50% and safe water supply and basic sanitation are still a crying need (Osman, 2004) and on the other a wide array of problems such as lack of medicine, absence of doctors and other providers, payment under the table, lack of cleanliness, lack of privacy and confidentiality, neglect and maltreatment of the patient, lack of health system responsiveness towards the non-medical expectation of the patients, discriminatory treatment practice put hurdle on the way of developing an efficient and effective health system in Bangladesh. Consequently, persistent inequality between the rich and the poor continues to pervade all major health indicators (Razzaque & Streatfield, 2005). For example, the under-5 mortality rate though declined from 151 per 1,000 live births in 1991 to 62 in 2006, it varies from 43 in the highest income quintile to 86 among the lowest income quintile. Since most of the achievements are celebrated at an aggregate national level, there is clear negligence in achieving the objective of health for all, and the vulnerable groups i.e. poor, women, children and disabled are the main victims of this negligence.
Studies in Bangladesh highlighted that health centers in public sector are not utilized by all segments of the community, and service providers’ inefficiency was responsible for such a situation. As a result, there has been increased utilization of the private formal and informal sectors’ health facilities. According to Bangladesh Health Watch (2007), the whole group of ‘unqualified practitioners’ (including the Rural Medical Practitioners – RMPs and Polli Chikitshok – PC) in the private sector is responsible for providing 60% of treatment services in rural Bangladesh. This fact underscores that the conventional PHC delivery system in the public sector is inadequate to reflect the needs of the community and it supports the anecdotal evidence which shows that the current public sector health workforce attends to only 40% of the population’s needs. Although, the public sector employs about 38% of the registered doctors (HRD Datasheet, 2007), the high rate of absenteeism makes them ghost doctors (only in registers not in person) adding plight to the government health care setup. The above context and the prevailing constraints demands the delivery of health services to all in a manner that is acceptable, universally available and accessible to all-a challenging task though. In order to meet this challenge, this project has been conceptualized to develop culturally sensitive primary health care service delivery model.
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Operational Definition
Comprehensive PHC CPHC has been defined as a package or set of activities that
1. Contains, if not more, a minimum of 8 core activities mentioned in the Alma Ata declaration as follows:
a. Education concerning prevailing health problems and the methods of preventing and controlling them
b. Promotion of food supply and proper nutrition c. An adequate supply of safe water and basic sanitation d. Maternal and child health care, including family planning e. Immunization against the major infectious diseases f. Prevention and control of locally endemic diseases g. Appropriate treatment of common diseases and injuries h. Provision of essential drugs
2. Ensures effective referral system among a. Primary level b. Secondary level c. Tertiary level
3. Considers principles of a. Promotive, preventive, curative and rehabilitative service b. Equity c. Appropriate Technology d. Intersectoral Collaboration e. Community Empowerment (Instead of Community Participation) f. Devolution (Instead of Decentralization)
Community Empowerment Communities are empowered if they
1. Have access to information 2. Are included and participate in forums where issues are discussed and decisions are made 3. Can hold decision-makers accountable for their choices and actions 4. Have the capacity and resources to organize to aggregate and express their interests and/or to
take on roles as partners with public service delivery agency
Devolution Extended version of ‘Decentralization’ where Local Government is subject to national norms, but sets local policies and priorities, plans autonomously in response to local preferences and needs. Local Government determines own form and structure.
Upazila The Upazila is the lowest level of administrative structure in Bangladesh. In 1983, the Local Government Ordinance of 1982 was amended to re-designate and upgrade the existing thanas as Upazilas. Thus a few Upazilas (sub-districts) comprise a district and an Upazila is consisting of a few unions.
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Objective
General Objective To design a Comprehensive Primary Health Care Model appropriate for Bangladesh.
Specific Objectives 1. To review the historical evolution of PHC system in Bangladesh
2. To analyze current situation of existing PHC system and its comprehensiveness in terms of
a. Measuring health system performance of existing PHC delivery centers
b. Finding out weaknesses in existing PHC delivery system in Bangladesh
3. To measure equity status in PHC in terms of Social Determinants of Health
4. To suggest recommendations for designing and developing an acceptable Comprehensive Primary Health Care model for Bangladesh
The Composition and Evolution of the Project The project commenced in April 2008 under the supervision of Professor Dr. Anwar Islam. Professor Islam was Associate Dean and Director of James P Grant School of Public Health, BRAC University who relocated to Bangladesh following a 34-year professional career in the health sector in Canada that included working for the International Development Research Centre (IDRC), Ottawa during the 1990s as a Senior Program Officer/Medical Sociologist with its Health Sciences Division. In this capacity, Professor Islam reviewed, funded and monitored research projects in various areas of the health sector in Africa, Asia, the Middle East and Latin America. Immediately prior to his relocation to Bangladesh, Professor Islam was with the Canadian International Development Agency (CIDA) as the Principal Advisor, Health Systems at its Policy Branch. While in Canada, he also contributed as an academician and researcher to numerous universities (Carleton University in Ottawa, University of Winnipeg and the University of Manitoba in Manitoba, and the University of Alberta in Alberta) teaching courses on Medical Sociology, Complex Organization and Management, Comparative Health Care Systems, and Health Care Financing and Health Sector Reform. Professor Islam also worked as an Associate Professor and Head of the Health Systems Division in the Department of Community Health Sciences at the Aga Khan University in Karachi, Pakistan during 1998-2002. He brought his rich academic expertise, extensive knowledge in international health and multicultural teaching skills to the mentorship of this project.
An early career researcher Dr. Nahitun Naher started to work with the project initially and developed the research questions based on the knowledge gap found out through literature review. The research questions were discussed and reviewed in the CPHC regional conference in Bangalore during October 13-24, 2008. Due to health reasons Dr. Nahitun Naher took a long term leave from James P Grant School of Public Health and another early career researcher Dr. Taufique Joarder took over the project. Based on another round of extensive literature reviews and comments, suggestions from the international research mentors and experts including Professor Ronald Labonte the research questions were finalized, definition of CPHC was set, methodology was developed and research tools were also developed by
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February 2009. Mr. Shafiun Nahin, a Health Economist, was involved with the project since April 2009 to develop the Health Systems Performance Index and also to assist in dealing the quantitative and economical issues. Mr. Jahid Ali, an Anthropologist, was recruited as Qualitative Data Collector who conducted the in-depth study at the selected UHCs based on the Health System Performance Index. His expertise in anthropological field work synergized the effort of the Lead Researcher of the Project Dr. Taufique Joarder. A Field Research Assistant was recruited to collect data from the Screening Survey of 20 UHCs and from the Household Survey in two villages in the catchment area of the two UHCs selected for in-depth study.
Apart from the Research Mentor and the Researcher there was a Potential Research User- Dr. Aftab Uddin, a renowned public health professional, currently working as the Senior Manager of Technical Training Unit of ICDDR,B. The Research User played a vital role in keeping the track of the research as well as in providing the research team with valuable comments, suggestions, and feedbacks. Besides, he facilitated the Key Informant Interviews by dint of his long career involvement with the health system of Bangladesh. He also assisted the research team in accessing and using the rich ICDDR,B library for reviewing literature and documents.
Research Methodology
Study Design and Sampling The study was a mixed-method (QUAN-qual) one with three distinct phases. The first phase of the study comprised Key Informant Interviews (KII) and Document Reviews (DR) to understand the historical evolution of PHC in Bangladesh. Key informants were selected purposively and included one government high official in charge of PHC delivery in Bangladesh, three veteran public health professionals who had been involved in the early PHC policy formulation and implementation process in Bangladesh and one Public Administration specialist from University of Dhaka who conducted her PhD thesis and did extensive ground work on the health policy process of Bangladesh.
The second phase was entirely quantitative, involving cross sectional survey in 20 UHCs of Bangladesh. 10 UHCs were selected from around the capital city of Dhaka and the other 10 from around a distant, hard to reach district of Barisal. The WHO Health System Performance Assessment guideline was modified according to Bangladeshi situation and was applied to rank the 20 UHCs based on their performance. Interviewing the Upazila Health and Family Planning Officer (UH&FPO, the Head of the UHC), the Medical Officers (MO, the registered medical doctors), the administrative staffs and the patients, the data was used to develop ‘Health Systems Performance Index’ based on three Health System Goals and four Health System Functions. Based on the index the 20 UHCs were ranked and the ‘highest performing’ and the ‘lowest performing’ UHC was selected for further in-depth study.
The third phase was the in-depth study carried out in the low performing and high performing UHCs and their catchment areas. The in-depth study contains three parts: ethnographic study at the UHC, household survey in a randomly selected village within the catchment area of the UHC and Participatory Rapid Appraisal (PRA) in the same village. The ethnographic study involved observation of the UHC and
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its functions for 15 days; in-depth interview of the local government leader, UH&FPO, MOs, Medical Assistants (Paramedics), field staffs and purposively selected in-door and out-door patients. A village was randomly selected from the list of the villages which fall under catchment area of the UHC. From that village, using the systematic random sampling, 5% of the total population was interviewed to investigate ‘equity in health service utilization’. A PRA session was arranged in the village where 30 people from different socio-economic strata participated.
Study Site UHCs were selected based on some assumptions. It was assumed that the Upazilas near Dhaka will be better performing due to its proximity to the Capital drawing more availability of Human Resource for Health (HRH), facing external monitoring and enjoying better communication as opposed to the UHCs in and around Barisal.
Upazilas selected from in and around Dhaka Upazilas selected from in and around Barisal
UHC District UHC District
Dhamrai Dohar Keraniganj Nawabganj Savar
Dhaka Agailjhara Babuganj Bakerganj Banaripara Gaurnadi Hizla Mehendiganj Muladi Wazirpur
Barisal
Kaliakoir Gazipur
Harirumpur Manikgonj
Belabo Narshingdi
Sonargaon Bandar
Narayanganj
Bamna Barguna
Screening survey revealed Dhamrai UHC in Dhaka district as the ‘highest performing’ and Mehendigonj UHC in Barisal district as the ‘lowest performing’. Accordingly, in-depth studies were carried out in
Dhaka
Barisal
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Dhamrai and Mehendiganj upazila and for the purpose of household survey and PRA two villages were selected randomly from these two upazilas: Kashimpur from Dhamrai and Charlata from Mahendiganj.
Data Collection and Analysis A range of tools and techniques (e.g. check lists, semi-structured questionnaires, PRA guidelines) were pretested and employed to collect data for this study. Qualitative data were collected using checklists and PRA tools and quantitative data were collected using semi-structured questionnaire. The Lead Researcher made quality control visits for quality checks during data collection. PRA was conducted by the Lead Researcher with assistance from the Qualitative Data Collector and the Field Research Assistant. The interviews were all tape recorded and transcribed. Qualitative data were coded according to grounded and a-priori themes using ATLAS.ti 5.5 software. Quantitative data were analyzed using SPSS 13.0 and Microsoft Excel 2007 version.
Ethical Consideration Respondents agreed to take part in the research by giving their verbal informed consent. They
were informed about how they were selected, about their rights not to answer the questions, to
leave the project any time, to be protected from revealing their identity, and to know their roles
in the process of collecting data before joining the project. Each respondent was compensated for
his or her time by a gift item offered by the research team. The researchers also responded to the
queries at the end of each conversation. The research project passed through the Ethical Review
Committee of James P Grant School of Public Health, BRAC University and received due
approval.
Status of the project Historical Evolution of PHC in Bangladesh
Time Development
Antiquity Ayurveda and Unani medicine had been the main medication in Indian sub-continent including Bangladesh.
1714 Introduction of Indian Medical Service by the British colonial government on a limited scale
1816 Local Self Governance Act passed to provide limited curative care; hospitals with few beds were established in small towns
1859 Royal Commission report published
1894 Public Health Commission report published
1904 Report of Plague Commission
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1919 Decentralization of health care to Provincial Governments excluding research
1938 Formation of National Health (Sokhey) Sub Committee of the National Planning Committee of Indian National Congress. The Sokhey Committee under the chairmanship of Colonel S. Sokhey emphasized on maintenance of the health of the people by the State and integration of preventive and curative health services.
1940 First Drug Policy by British government recognizing only allopathic medicine
1942 Attempt of British government to develop first Health Policy impeded by the Second World War
1943 Formulation of historical and significant Bhore Committee (Health survey and Development Committee) which shaped the future of health system in Indian sub-continent under the Chairmanship of Sir Joseph Bhore.
1946 Publication of Bhore Committee report recommending radical reform of the entire health system for providing community oriented care for entire population.
The Bhore Committee extensively studied the health and health system of India and recommended an integrated public health service amalgamating both curative and preventive services. In order for community penetration, the committee recommended to establish rural health centers, ensure equity and community participation. Thus, the concepts of preventive care, community participation, social justice, equity well ahead of Alma Ata declaration.
1947 Independence of British India and emergence of two different countries by the name of India and Pakistan. The part we now call Bangladesh became a part of Pakistan with the name East Pakistan. Bhore Committee report could not be implemented.
Unfortunately the Pakistan regime did not take sincere steps to indigenize the health care system in contrast to the Indian government.
1947 Holding of First All Pakistan Health Conference at Lahore, West Pakistan which ideologically adopted the Bhore Committee report.
1948 Establishment of Medical Council of Pakistan under the Medical Council Act with dual function of maintaining a uniform standard of medical education in the country and liaison with medical councils of foreign countries on the issue of mutual reciprocity in the matter of recognition of medical degrees.
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1949
Nursing Council of Pakistan was constituted in June 1949. Three nursing training centers were established at Mitford Hospital, Dhaka Medical College Hospital and Chittagong Sadar Hospital.
Government decision to take over the administration 100 Thana dispensaries with 4-bedded emergency ward and to establish 50 new rural dispensaries and 22 maternity and child welfare centers in East Pakistan.
1950 Promulgation of General Practitioners (National Service) Act for conscription of medical graduates to serve anywhere in Pakistan.
1951 Holding of Second All Pakistan Health Conference at Dhaka which approved a six year plan for increasing beds in existing hospitals, increasing the number of rural dispensaries, conversion of medical schools into colleges and to set up Institute of Hygiene and Preventive Medicine, Medical Research Council and Drug Testing Laboratories.
Establishment of a combined Public Health Laboratory for testing water and drugs and for production of vaccine and sera.
Airport Health Department started functioning at Dhaka Airport.
1955 First Five Year Plan was introduced where family planning was given more emphasis than the overall health sector.
1956 Diabetic Association of Bangladesh (then Pakistan) was established.
1957 Chittagong Medical College started functioning.
1960 The world famous Cholera Research Laboratory was established (Now ICDDR,B).
1961 Government designed the Rural Health Center Scheme which incorporated the provision of establishing one Rural Health Center in each Thana (now Upazila) with three sub-centers to serve a population of about 50,000
1965 Creation of separate administrative infrastructure for family planning under the Ministry of Health. Health infrastructure started becoming neglected.
Government-controlled postgraduate institute named Institute of Postgraduate Medicine and Research (popularly called PG Hospital) was established.
1966 Demographic Surveillance System in Matlab was established under Cholera Research Laboratory (Now ICDDR,B)
1967 Thana Health Complex Scheme was approved and advocated establishment of a 31 bed hospital in each rural thana. The hospitals are the precursors of present UHCs. The scheme also envisaged the strengthening of the Directorate of Health Services and the
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administration at the various levels.
1968 First successful clinical trial of Oral Rehydration Solution was done by Cholera Research Laboratory (Now ICDDR,B)
1970 East Pakistan now has 140 Rural Health Centers. Three vertical projects namely Malaria Eradication, Family Planning and Smallpox Eradication Programs were also launched.
1971 War of independence starting on March 26 and giving rise to a new sovereign country on December 16. Bangladesh inherited eight medical colleges, one post graduate medical institute, 37 TB clinics, 151 rural health centers and 91 maternity and child welfare centers.
1972 Introduction of Thana Health Complex Scheme upgrading the Rural Health Centers.
Establishment of National Health Library and Documentation Center.
Establishment of Bangladesh Medical and Research Council
Upgrading of Dhaka Medical School and Mitford Hospital into Sir Salimullah Medical College and Mitford Hospital
Establishment of Bangladesh College of Physicians and Surgeons for post-0graduate medical education.
Establishment of BRAC.
Establishment of Gonoshasthaya Kendra (GK) with first non-government approach to deliver primary level health care to the rural people with an experience gained during the war of independence.
1973 First Five Year Plan launched.
Promulgation of the Medical Council Act. Establishment of Bangladesh Medical and Dental Council.
1974 Establishment of Institute of Public Health Nutrition, Dietetic and Food Science.
Amendment of the Pharmacy Act 1957. Promulgation of Children Act.
1975 Population and Family Planning Division was created.
Establishment of national Nutrition Council
Order of Bangladesh Red Cross Society (now Bangladesh Red Crescent Society) passed.
Promulgation of Blind Relief Act.
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1976 Establishment of the Institute of Epidemiology, Disease Control and Research
Thana Health Complex Scheme with 31 beds each and 4 or 5 Sub-centers was approved.
Modification and reorganization of undergraduate teaching in Hygiene and Preventive Medicine. Department of Community Medicine strengthened.
National Population Policy was adopted.
1977 Promulgation of Environmental Pollution Control Ordinance.
Creation of the Directorate of Nursing Services by the order of the President.
Introduction of the Voluntary Health Workers or Shasthyo Shebika concept by BRAC to overcome the shortage of health workers in rural areas.
1978 Bangladesh signed the Alma Ata declaration and recognized PHC as the key to achieving Health for All by 2000.
Establishment of National Institute of Ophthalmology.
Commencement of first formal academic post-graduate institute of public health in Bangladesh called National Institute of Preventive and Social Medicine (NIPSOM).
Government of Bangladesh Ordinance establishing International Center for Diarrheal Disease and Research, Bangladesh (ICDDR,B) signed.
National Institute of Population Research and Training was established.
1979 Establishment of National Institute of Cardiovascular Diseases.
Launching of Expanded Program on Immunization.
Bangladesh Medical Association was established.
Center for Rehabilitation of the Paralyzed was established.
Between 1979 and 1990, BRAC started and scaled up a massive National Oral Rehydration Therapy Project in collaboration with the government and ICDDR,B. Female Oral Replacement Workers visited every household of every village of the country (12.5 million in all).
Bangladesh started PHC pilot projects in six Upazilas.
1980 The post of Director of Health Services upgraded to Director General of Health Services.
PHC program started.
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Interventions of operationalizing PHC in Bangladesh were based on three important strategies: 1) training of staff on the elements and principles of PHC 2) provision of basic essential equipments and 3) ensuring uninterrupted supply to facilitate effective preventive, curative and rehabilitative services to the vulnerable, the disadvantaged and the poor.
1981 Palli-chikitshak Scheme (in line with the barefoot doctors of China) introduced but abandoned after few years.
Introduction of PHC pilot project in six UHCs.
1982 Private Clinic and Laboratory Ordinance adapted by Government of Bangladesh.
Creation of specialists’ post in UHCs.
Promulgation of Drug Control Ordinance.
1984 BRAC started DOTS therapy in collaboration with the government.
1985 The National EPI Program initiated by government involving numerous NGOs.
1986 Foundation of the Cancer Institute and Research Hospital.
The first evaluation of the National HFA strategy was done.
The evaluation revealed that due to various constrains such as inadequacy in managerial process, lack of adequate resources, bias towards curative medicine, lack of coordination and community involvement the concept and principle of PHC could not be translated into action.
1988 Government of Bangladesh initiated the program known as Intensified PHC Program.
Intensified PHC Program started in two Upazilas in two districts and gradually extended over the country. This program has demonstrated success in developing useful working mechanism at Upazila level and below by adopting functional integration of health and family planning services under the package of PHC; community mobilization through the involvement of Village Health Volunteers (VHB) and Trained Birth Attendants (TBA); inter-sectoral action at different levels; and strengthening of project management at Union, Upazila and District levels.
1990 Narcotics Control Act promulgated.
1991 The Demand Side intervention through Income Generating Scheme was introduced in PHC and piloted in three Upazilas of Hathazari, Bakerganj and Fakirhat under three districts of Chittagong, Barisal and Rajshahi respectively.
1994 Emergency Obstetric Care project started by Directorate of Family Planning with funding from United Nations Population Fund (UNFPA)
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1995 Initiation of Bangladesh Integrated Nutrition Project, the first large scale nutrition project in the country.
1996 Bangladesh introduced major reforms in health sector by adopting Health and Population Sector Strategy (HPSS).
1997 BRAC started its BRAC Health Centers to deliver quality primary level care at a low cost.
1998 Institute of Post Graduate Medicine and Research was renamed as Bangabandhu Sheikh Mujib Medical University by an act passed by the National Assembly of Bangladesh. This is the first medical university of Bangladesh
Five year Health and Population Sector Program (HPSP) was adopted by the government as a part of its Sector Wide Approaches (SWAp). PHC was made part of the HPSP.
Urban Primary Health Care project was started.
Particularly from this point of time Bangladesh moved away from the comprehensive approach of PHC to selective PHC through Essential Service Package (ESP). The ESP covers reproductive health care, child health care, communicable disease control, limited curative care and behavioral change communication.
2000 Government of Bangladesh approved the National Health Policy, one of the major goals of which is to ensure essential services.
Under HPSP, Local Level Planning (LLP) was piloted in 39 Upazilas of 5 districts.
After an independent review of the progress and outcome of the piloting initiative, LLP was rolled out country wide.
2001 Integrated Management of Childhood Illness (IMCI) was started.
2003 A new component ‘nutrition’ was added to the ongoing HPSP and it became Health, Nutrition and Population Sector Program (HNPSP).
2004 James P Grant School of Public Health, BRAC University was established with a unique community based MPH program gaining significant attention from international public health community.
2007 Maternal Health Voucher Pilot Scheme implemented in 21 Upazilas of 21 Districts.
This pilot scheme is considered the largest demand side financing in health. This initiative receives technical and financial support from WHO and other agencies in collaboration with GoB from the UHCs.
2009 National Health Policy, for the first time through public opinion, expert discussions and by circulating the draft through the internet for comments and suggestions, has been proposed.
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Decision has been made to establish Community Clinics for every 6,000 population in rural Bangladesh.
The Community Clinics will be run by direct community involvement and management. One Health Assistant and one Family Welfare Assistant will deliver the health service. The initiative had been taken in 1998 and 11,500 Community Clinics had been established by 2001. But due to change of the government this initiative was stopped by the new government.
The chronology of public health events has been developed by key informant interviews, document and literature reviews (WHO Bangladesh, 1996; Ensor, Dave-Sen, Ali, Hossain, Begum, & Moral, 2002; El-Naggar, 1992; WHO, 1991; Perry, 2000; Khan, 1997; Osman, 2004; Rashid, Rahman, & Hyder, 2008; Nundy, n.d.). The analysis of evolution of PHC in Bangladesh reveals certain characteristics such as follows. During the early 80s till early 90s emphasis was primarily on infrastructure development as evident that most of the health care delivery institutions were established during that period. However, since early 90s there was a paradigm shift in policy, focusing on systems issues rather than infrastructure as evident from the vertical program initiatives of the government such as demand side interventions, emergency obstetric care, Bangladesh integrated nutrition project etc. Change of government appears to be as one of the important predictors for change in policy by Bangladesh. For example, it caused the health policy to suffer from a long standing deadlock in being declared publicly, and good initiatives like provision of health services through Community Clinics have been stopped or postponed by the successive government without acceptable excuse. The shift of priority from health to family planning and vice versa caused some confusions among the beneficiaries as well as the field level staffs leading to disintegration and sometimes duplication of services. For these, very often there have been tensions between the two cadres in Ministry Of Health and Family Welfare (MOHFW) and wastage of human resources. Also, there has been a lack of coordination between NGO and the government, though. Bangladesh has long been considered as an outstanding model for efficient cooperation between these two sectors. However, late 90s observed some successful initiatives such as urban primary health care project as an indication of good cooperation between government and the NGOs.
Screening Survey in 20 UHCs UHCs were screened from systems perspective rather than commonly approached health indicators and tried to find out the causes why one UHC was doing good while the other did not. In order to evaluate the Health Systems Performance we considered the ‘goals’ and ‘functions’ of a health system as mentioned in the World Health Report 2000: Health systems: Improving performance (WHO, 2000). The goals are health status, responsiveness and fairness in financial contribution. Functions of a health system are stewardship, financing (collecting, pooling and purchasing), service provision and resource generation. We developed the Health System Performance Index based on the book Health Systems Performance Assessment: Debates, Methods and Empiricism by Christopher J.L. Murray and David B. Evans (2003). The relative performance of all 20 UHCs has been given below in all the mentioned fields along with the index of overall performance.
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Name Health Status
Responsiveness
Fairness in Finance
Stewardship
Financing
Service Provision
Resource Generation
INDEX of Performance
Sonargaon
5.00 7.03 3.50 2.49 2.50 7.41 8.00 51.45
Savar 7.50 6.28 6.00 3.36 2.50 8.07 9.00 62.49
Kaliakoir
8.50 6.99 1.50 3.40 3.75 7.26 5.00 53.38
Harirampur
5.50 6.07 9.50 3.54 2.50 6.24 6.50 60.93
Dhamrai
8.50 6.83 5.50 7.63 3.00 8.50 7.50 68.30
Nababganj
8.50 5.74 1.50 3.64 3.00 6.71 7.50 52.33
Keraniganj
3.75 5.86 5.00 3.10 5.00 7.93 6.75 52.00
Dohar 8.00 6.25 4.00 2.91 3.50 7.10 7.50 57.51
Belab 6.00 4.88 4.00 2.60 5.50 6.89 7.00 51.74
Bandar 2.50 6.17 6.50 3.56 3.50 7.77 7.00 52.16
Ujirpur 7.50 6.36 3.50 1.23 4.50 7.19 6.50 54.15
Muladi 8.00 5.61 5.00 1.44 4.00 8.50 9.00 60.16
Babuganj
6.50 4.00 7.50 1.66 4.00 6.46 6.00 54.12
Agoiljhara
8.50 4.57 3.50 1.06 4.00 6.44 6.00 50.63
Gournadi
9.00 5.10 0.50 1.24 4.50 7.88 8.50 51.32
Banaripara
8.00 4.78 7.50 1.38 6.50 7.76 6.00 62.19
Bakerganj
7.00 4.51 3.50 1.07 4.50 5.79 6.00 47.39
Hizla 8.00 4.51 4.50 1.03 5.00 6.56 6.50 53.12
Mehendiganj
5.00 4.36 2.50 1.84 3.50 8.25 6.50 43.82
Bamna 7.00 4.29 2.50 1.07 5.00 6.71 7.00 47.36
For each UHC we got the average rating of three goals or objectives and four functions of health system. To convert them in Index we used both weighted average and simple average method. We took some expert opinion regarding what weight should be given to goal and functions of health system. Most of the experts suggested that objectives should be given priority or more weight than functions; because whatever the function unless they can bring optimum or desired outcome, it is worthless. Hence, 60% weight was given to the objectives and 40% to the functions. Using these weights, we got a score for each UHC and all of them were expressed in an INDEX (where 100 is the base category which is a usual practice for forming an index).
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It is evident from the graph that Dhamrai UHC of Dhaka District scored highest (68.30) and Mehendiganj of Barisal District scored the lowest (43.82).
In-depth Study in Two UHCs
General Background Information about Dhamrai Dhamrai is one of the five Upazilas (sub-district) under Dhaka district, situated 20 kilometers west of the capital city of Dhaka. The Upazila Health Complex (UHC) is situated in Islampur, adjacent to Dhaka-Aricha highway, one of the busiest highways of the country. The UHC is located at the end border of Dhamrai, right at the bank of Dhamrai River. It was established in 1965 as 31 bedded hospital which has been upgraded as 50 bedded one on October 14, 2008. Dhamrai enjoys a very good communication facility which is approachable both by road and river.
General Background Information about Mehendigonj Mehendigonj is one of the nine Upazilas of Barisal district, one of the southern districts of Bangladesh, crisscrossed by many rivers, making communication very difficult. However the Barisal city itself is approachable by road (and river as well) but Mehendigonj is reached only by river. It takes on average two hours to go to Mehendigonj from Barisal city by motor launches. It takes much longer time with other vehicles such as traditional boats. Mehendigonj UHC was also a 31 bedded one which has recently been upgraded to 50 bedded one and the construction work is going one, hindering the treatment temporarily.
51.45
62.49
53.3860.93
68.30
52.3352.0057.51
51.7452.1654.1560.16
54.1250.6351.32
62.19
47.3953.12
43.8247.36
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
INDEX of Performance
22
Household Survey Findings
General Features
We conducted the household survey in two villages called Kashipur and Charlata. Kashipur falls under the catchment area of the ‘highest performing’ Dhamrai Upazila whereas Charlata under ‘lowest performing’ Mehendiganj Upazila.
The educational status, income status and health status of the villages correspond with the performance of the Upazilas they fall under.
Household Income in the Villages
Name of Village Mean Std. Deviation P-value
Kashipur 14015.0000 22157.10833 0.000
Charlata 4576.8000 3994.37379
8.00 Higher Secondary
(11-12)
Secondary(6- 10)
Primary(1-5) Illeterate
Educational Qualification
80.0%
60.0%
40.0%
20.0%
0.0%
Percent
0.0% 0.0% 0.0%
22.41%
77.59%
1.0% 3.0% 6.0%
43.0% 47.0%
Charlata Kashipur
Name of Village
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Occupational Profile of the Main Earning Member of the Household (Multiple responses considered)
Kashipur Charlata
Farming in own land 30.1 20.7
Agricultural Labor 4.6 5.9
Day Labor 10.5 16.5
Poultry Farming 2.6
Dairy Farming 2.0
Service 13.7 10.1
Trade and business 15.0 39.9
Lives abroad 20.9 5.3
Other .7 1.6
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Good Moderate Bad
General Health Condition
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Percent
Charlata Kashipur
Name of Village
25
Comparison of the Two Villages across CPHC Parameters
Health Education
In both of the villages almost all our respondents (96% in Kashipur and 100% in Charlata) reported that they had not been visited by any health worker ever.
Food and Nutrition
In both the villages 95% of the villagers ate three meals a day.
Water and Sanitation
In both the villages almost all the respondents (98% in Kashipur and 99% in Charlata) drank safe water from tube-well and had sanitary latrine at their home (99% in Kashipur and 90% in Charlata). Almost all of them washed to use their hands with soap before eating and cooking and after latrine use (98% in Kashipur and 93% in Charlata). We only found difference in receiving information on safe water, health and sanitation in the two villages: 97% respondents of Kashipur as against only 21.6% of Charlata (p-value < 0.001) reported to have received the information.
MCH and FP
Most of the child birth took place at home or paternal home of mother (85% in Kashipur and 100% in Charlata). Only 18.5% in Kashipur and 12% in Charlata received Ante Natal Care (ANC). In case of Post Natal Care (PNC) only 4% in Kashipur and none in Charlata received the care.
Where did the last child born
Private hospital/cli Home/paternal home
Percent
120
100
80
60
40
20
0
Name of Village
Kashipur
Char Lata
100
8
92
26
EPI
80% children in Kashipur and 98% children in Charlata received vaccination according the government vaccination schedule. Local vaccination outpost came out to be the most utilized place for vaccination (97% in Kashipur and 98% in Charlata).
Locally Endemic Diseases
Measles (55%) and Pyrexia of Unknown Origin (PUO) (30%) was the most reported disease by the respondents in Kashipur. In Charlata it was PUO (82%) and Chicken Pox (15%). 91% people in Kashipur reported that they didn’t know whether there was any preventive activity from the government against locally endemic diseases. In Charlata 98% people said that there was no activity.
Treatment of Diseases and Injuries
In both the villages standard of treatment of common diseases and injuries had been reported as bad to moderate.
Essential Drugs
In Kashipur 92% and in Charlata 100% respondents reported that required drugs were rarely available at the health center.
Access to Information
In Kashipur all the people reported TV as the mass media giving most information. On the contrary people of Charlata reported it to be the radio (p-value <0.001).
Standard of treatment of common diseases and injuries
Very bad Bad Moderate Good Very good
Percent
70
60
50
40
30
20
10
0
Name of Village
Kashipur
Charlata
49 50
36
59
27
Mass media giving most information
Kashipur Charlata Television 100.0% 4.0%
Radio .0% 95.2%
News Paper .0% .8%
100.0% 100.0%
Participation in Decision Making Forum
63% respondents in Kashipur said there were no decision making forums on health while 35% said that they did not know whether there is any. In Charlata all the respondents said that there was none. None of the respondents ever participated in any type of decision making forum on health issues. The only two persons who reported that they participated in a decision making forum, again said that their opinions had not been taken into consideration.
Demand Accountability
Since there was no formal way of demanding accountability from the decision makers, we used ‘client feedback mechanism’ as a proxy. 93% respondents from Kashipur said that they did not know whether there was any client feedback mechanism or not. In Charlata 99% respondents said that there was no formal client feedback mechanism. 83% people in Kashipur and 100% people in Charlata suggested that a person must be appointed at the health center to listen to their complaints and suggest a solution. 15% people in Kashipur suggested that a complaint box can be installed for the purpose.
Partnership with Public Service
Half of the respondents from Kashipur said that there was no scope to work in partnership with the government in health issues whereas the other half expressed their ignorance over the issue. In Charlata all the respondents said that there was no such scope. None of the respondents in any of the villages were found to have any experience of working in partnership with the government health sector.
Other Health System Issues
We found that the people of Charlata more tends to go to the UHC for service seeking than the people of Kashipur. It may be due to the availability of private health care facilities in Kashipur which is near the capital city. Moreover, Charlata is situated in a remote island where there is no other health facility nearby except the UHC. Secondly, the better income status of the people of Kashipur enables them to buy health care from private providers than from the government run health centers (UHCs) which have a bad reputation for poor service. It means that, however good service the UHCs near the capital provides, it attracts less patients than the poor performing UHCs in remote areas as the people of that area does not have any other alternative.
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In Kashipur, 98% of the people who accessed care from UHC said that they went to UHC because of the free treatment, whereas in Charlata, 95% people went to UHC because of the lack of suitable transportation to go elsewhere.
The error bar above shows that mean time taken to reach the UHC is higher in Charlata than Kashipur (p-value<0.001).
Where do they go for PHC
Village doctorChameber of MBBS doc
UHC/Government facilPrivate facility
Perc
ent
100
80
60
40
20
0
Name of Village
Kashipur
Char Lata9
88
9
90
125 100 N = Char Lata Kashipur
95% CI Time taken to reach nearest facility 45
44
43
42
41
40
39
29
Equity across Social Determinants
We analyzed the service seeking of the respondents in both the villages across their age, gender, educational qualification, occupation, marital status, family size, age of marriage, income quintile and wealth index. Important findings are provided below:
In terms of using mass media as source of health messages- though large families tend to depend on the radio and s small families on television, however, theuse of newspaper as a source of information was scanty.
Utilization of UHC across Gender Have ever gone to UHC Total
Yes No
Male % within Have ever gone to UHC 58.6% 41.0% 55.6%
Female % within Have ever gone to UHC 41.4% 59.0% 44.4%
Total 100.0% 100.0% 100.0%
News Paper Radio Television
Mass media giving most information
80.0%
60.0%
40.0%
20.0%
0.0%
Percent
1.61%
62.9%
35.48%
0.0%
50.98% 49.02%
0.0%
20.0%
80.0%
Large family Medium family Small family
Family Size
30
Male dominance in utilization of UHC was clear as 58.6% (p-value 0.045) of the people who went to the UHC ever for care seeking were male. But most fascinating findings were observed across income quintiles and wealth index. User of UHCs/government health facilities were mostly the people from the three lower quintiles whereas the user of the private health facilities were from higher quintiles.
Error bar below shows the mean time taken to reach UHC across different groups based on wealth index. It appears that mean time decreases with increasing wealth.
Village doctor Chameber of MBBS doctor
UHC/Government facility
Private facility
Where do they go for PHC
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Percent
6.98% 0.0%
9.3%
83.72%
4.44% 0.0%
44.44% 51.11%
13.04%
0.0%
65.22%
21.74%
8.96% 0.0%
64.18%
26.87%
12.77% 2.13%
61.7%
23.4%
Highest Quintile 4th Quintile 3rd Quintile 2nd Quintile Lowest Quintile
Household Income Quintile
31
Television is used by the people of higher income quintiles and radio by the people of lower.
News Paper Radio Television
Mass media giving most information
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Percent
0.0% 9.3%
90.7%
0.0%
40.0%
60.0%
4.35%
65.22%
30.43%
0.0%
70.15%
29.85%
0.0%
74.47%
25.53%
Highest Quintile 4th Quintile 3rd Quintile 2nd Quintile Lowest Quintile
Household Income Quintile
75 19 131 N = Higher economic grou
Middle economic grou Lower economic group
45
44
43
42
41
40
39
38
95% CI Time taken to reach nearest facility
32
None except two respondents participated in any decision making forum regarding health. The two people who reported to have participated in such a forum belonged to the highest income quintile.
33
Qualitative Findings
Health Education
One of the interesting features of Dhamrai UHC was the presence of a ‘health education get-together’ (Shastho Shikkhar Ashor) at the premise of the health complex. The visibility of the place along with the label itself attracts the attention of the patients and as a consequence influences them to attend the early morning health education session conducted by the trained health educators. A 21 inch television was kept there to show documentaries covering various aspects of health and healthy living. Sufficient number of chairs was also arranged.
Apart from this session which takes place every day between 08:30 to 09:00 am, doctors are also instructed to provide relevant health education to the patients. In front of the Ticket Counter, where people spend idle time before collecting the ticket, there were boards where posters and other visual materials were mounted to raise health awareness among the people. There we found posters informing the preventive aspects of bird flu, cancer, snake bite and diarrheal diseases. There are five Union Sub-centers under Dhamrai UHC. These sub-centers also arrange health education sessions and are instructed to maintain a register book to note down the topics of discussion, number of participants and the name of the instructor. The Community Clinics just started functioning but lacks health education facility. The UH&FPO is planning to take the service even till that far in near future. Some sort of health education is also given in the EPI outreach centers.
There is a specific health education guideline supplied by the DGHS for the health educators or field staffs who are formally designated as the Health Assistants. They also receive a 21 day health education training followed by yearly refresher training. They are not only trained on the diseases or health issues but also on how to organize courtyard meeting (Uthan Boithok). They educate the people regarding diarrheal diseases, Acute Respiratory Infection (ARI), breast feeding practice, vaccines, daily hygiene practices, nutrition value in foods, disease outbreaks such as swine flu (H1N1), and healthy cooking practices among many other issues. The clinical doctors also provide relevant health education along with the clinical treatment. Doctors are not only formally instructed but also particularly trained to provide proper health education message during their consultation.
When asked, about the health education services, the people of the community expressed their satisfaction and added that the sincerity of the hospital administration in delivering health education along with general clinical services was praiseworthy. They appreciated the early morning ‘health education get-together’ session in the hospital premise but demanded more frequent field staff visit to the community indicating the usefulness of such arrangements for the community
When asked about the obstacles they face, the field staffs mentioned their mixed feelings. The positive aspect was that the community based programs are so common in Bangladesh that people are well aware about the presence of field staffs not only from the health sector but also from other sectors. Overall, they have good social acceptance as well as social penetration. However, they face problem in dealing with the uneducated mothers who take much longer than usual time to learn a health education message; Also, behavior change is much difficult for them.
34
Every month the UHFPO holds a meeting with the field staffs, receives their feedback and suggestions, listens to the obstacles they had faced and finally gives instructions regarding effective health education delivery. But the UH&FPO firmly believes that strong commitment from the staff is the most important success factor for effective health education program.
As a result of all these activities a clear benefit is now evident- more than 80% mothers give colostrums to their neonate which was previously a social taboo. All the mothers know how to prepare ORS and when to give it to the patient. Diarrhea is now-a-days a less common disease, diphtheria has almost disappeared, and polio is eliminated. People know about TB and the available treatment facilities. One field staff commented, “Previously people did not even know how to use tooth brush. Now you see how commonly they brush their teeth. If you ask any school kid, he or she knows the proper way of brushing.”
In Mehendigonj upazila,, the scenario was not much optimistic as in Dhamrai although UH&FPO claimed as such. We did not find any evidence of health education session anywhere in the UHC during our period of stay. The people were found to be dissatisfied regarding health education both at the health center as well as in the community setting. The staff mentioned that the difficult terrain, lack of resources, climatic conditions etc. were responsible for their inefficient health education dissemination. The region being an island with scattered Chars (a strip of sandy land rising out of the bed of a river or a sea above the water-level) (Biswas, 2000, pp. 348) is hard to reach and requires speedboats to carryout field visits and disseminate health education. Things come to a head particularly during Kalboishakhi (a storm or strong wind that rises in the afternoons of April and May, a nor'wester) (Biswas, 2000, pp. 231) which this area is highly prone to. Female workers, in particular, face added disadvantage due to lack of regular water transport facilities needed to ensure their safe travel to and from the field.
Food and Nutrition
The issue of promotion of food supply and proper nutrition was found grossly neglected in the PHC delivery everywhere although there were some vertical and temporary nutrition projects implemented without any follow up and scaling up mechanism. In Dhamrai UHC, there is a tin shed ‘semi pucca’ building which was previously used as ‘Nutrition Unit’ under a vertical nutrition project. This structure has been found useless for nutrition activity and serving as a recreation room for the nurses. There was no ownership of the project by the staff. When asked about the utility of the building the UH&FPO replied, “It was their (donor/government) project. As the project is over, the necessity of the building is as well over”. The most striking issue was the narrow concept of food and nutrition promotion in the community. In both the UHCs we found nutrition means only education concerning nutrition. There was no facility for growth monitoring, supplementary feeding, breast feeding counseling or any related nutritional activities in the center let alone initiatives for household food security which was one of the commitments of comprehensive PHC.
The DGFP is responsible for ensuring Maternal and Child Health (MCH) care and growth monitoring is carried out only for the pregnant mother. The personnel suggested establishment of a separate nutrition unit under the aegis of DGHS which can provide exclusive nutrition services with specially trained nutrition health workers. Recently the government has renewed her commitment through SWAp known as Health, Nutrition and Population Sector Program (HNPSP).
35
Water and Sanitation
Although adequate supply of safe water and basic sanitation is one of the components of PHC, there is no formal responsibility of the health sector in this regard. Providing safe water and basic sanitation is sole responsibility of Department of Public Health Engineering. NGOs, especially NGO Forum for Drinking Water Supply and Sanitation, BRAC etc. are involved in providing safe water and sanitation working with government. Government health personnel are involved in ‘WatSan Committees’ and through monthly coordination meetings, they provide their views/feedbacks on diseases and conditions related to water and sanitation in the community. However, it appears that there is a lack of clear guidelines for them and their job description lacks clear tasks i in this regard. In general, their responsibilities are limited principally to providing health education concerning water and sanitation and occasional inspection of sanitary latrines during diarrheal disease outbreaks.
It is obvious that Bangladesh has achieved a remarkable success in ensuring safe water supply and sanitary latrine usage chiefly due to efficient mass media mobilization and NGO involvement. Unfortunately, this success is not shared equally by all parts of the country. We found almost all the people claimed to be the user of tube-well water and sanitary latrine in both the UHCs, though the proprietorship of those varied greatly in the UHCs. In Dhamrai, which is close to Dhaka and people were relatively well off, people used the facilities which they themselves owned. On the contrary, in Mehendigonj, people were found to use tube-well and sanitary latrine of the neighbors or the nearby mosque. Some people even brought water from far away. Some people used pond or river water after boiling.
Most of the people knew about the importance of using safe drinking water and washing hand after defecation and before meal in both the UHCs although some respondents in Mehendigonj were found to be indifferent in this regard. In Dhamrai, people were more concerned about Arsenic in ground water, which is currently a major public health threat in Bangladesh, rather than germs. People were well informed about the health risks of unsafe water and the different alternatives for safe water such as rain water harvesting, water purifying tablets etc. This awareness can be credited to the NGOs and the mass media in conjunction with the benevolence of the government.
Maternal and Child Health Care Including Family Planning
Both health and population sectors are responsible for delivering maternal and child health care and family planning services, DGFP is particularly responsible for family planning services. This results in duplication of services and wastage of human resources in addition to creating tension between the personnel of these two cadres at the field level. At one hand, the health staffs encourage the patients for institutional delivery, and the family planning staffs do not emphasize it on the other hand. Therefore,there is lack of coordination between these two sectors with consequent lack of synergy in using scarce resources.
In Dhamrai UHC MCH and Family Planning (FP) services are delivered by Medical Officers (MO) and specialist Consultants in the center and Skilled Birth Attendants (SBA) in the community. The SBAs are trained by the government through DGHS. In some UHCs a vertical program called ‘Emergency Obstetric
36
Care’ (EOC) is running. Neither Dhamrai nor Mehendigonj has this program. But the services provided in Dhamrai UHC, as claimed by the providers and supported by the clients, are comparable to the UHCs having EOC.
Apart from Antenatal Care (ANC) and Postnatal Care (PNC) corners in the Dhamrai UHC there is every facility for Caesarian Section of complicated cases. The arrangements for Caesarian Section was made by the UH&FPO with the support from his colleagues at the UHC and the local wealthy people and local government leaders. The center being close to the capital city Dhaka enjoys adequate presence of consultant gynecologists, pediatricians and anesthesiologists. The only deficit the UHC faces in terms of MCH care is a post operative room. The patients are kept in common ward with other female patents where chances of post operative infection are very high. As the health center was not planned or designed for these sorts of advanced services it lacks the structural capacity to contain a post operative room.
Although Dhamrai does not have EOC program, it has another vertical program called Integrated Management of Childhood Illness (IMCI). There are eight IMCI trained physicians and all the Nurses are also trained in IMCI.
Like Dhamrai, in Mehendigonj also most of the deliveries are still conducted in the house rather than the hospital. In both the areas people as well as the health care providers claimed sharp decline in MMR in recent years.
Mehendigonj UHC has neither EOC nor IMCI project. Moreover, hospital delivery is far less common than Dhamrai due to the lack of good transport facility. Most of the deliveries are conducted by Traditional Birth Attendants (TBA) who are locally called ‘Dai’. If they fail to manage a case they refer the patient to the UHC. But if it is complicated case the patient has nothing to do but to pray to God and wait for the fate to convene. The nearest city to Mehendigonj is the district town of Barisal which is only connected by launches or steamers which are again not available all the time. As there is no facility for water ambulance, patients have to wait which is often fatal.
Providers in both the UHCs suggested the integration of health and family planning sectors centrally in order to improve the MCH and FP services. People in Dhamrai demanded ultra-sonogram facility while people in Mehendigonj demanded a water ambulance.
Immunization against Major Infectious Diseases
Immunization program is one of the most successful programs of the health sector of Bangladesh which is also a model of collaboration between government and the NGOs. Unlike many other programs, we found the documentation of this program in both the UHCs to be satisfactory. The EPI target and achievement chart was placed visible in the room of UH&FPO of both Dhamrai and Mengendigonj UHC.
Expanded Program on Immunization (EPI) is carried out both in the UHC and in the field by organizing regular EPI camps. The EPI staffs announces in the community where and when the vaccination program will take place. Prior to that, they organize courtyard meetings in the community and prepare a list of families which have unvaccinated children. If anyone from the list does not show up in the vaccination
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program the EPI staffs directly go to their home and vaccinate the child. They also maintain a register of pregnant women in the community in order to give them Tetanus Toxoid (TT).
The EPI camps are arranged usually in the yard of a local elite. Sometimes that person finds the gathering problematic and refuses to comply. Sometimes some families feel discouraged to go to the household of a certain person due to local politics or due to some social causes. These problems are expected to be solved with the introduction of Community Clinics which can be utilized for EPI programs. Moreover, if Community Clinics are used, people will know that there is a permanent facility where they can go for vaccination. Apart from the space problem the staffs sometimes face another problem when the vaccinated child develops any complication which may or may not be due to vaccination. Some reactions are normal, such as fever after DPT vaccination; but the parents hold the EPI staffs responsible.
The EPI staffs, like other health staffs, also suggested that if family planning staffs could be included in the immunization efforts, the program would yield much better coverage. In Dhamrai the EPI coverage was said to be above 90% and in Mehendigonj it was above 80%. The reason behind relatively low coverage in Mehendigonj was the lack of proper transport facilities to the Chars, adverse weather especially during rainy season. To compensate this shortcomings the EPI staffs carryout special drives during the months of October, November and December which are usually winter months and Bangladesh being a monsoon country, winter seasons are usually dry.
Most of the people know about the immunization program and are interested to get their children vaccinated. This remarkable coverage of vaccination and the information regarding its benefits can be attributed to the television and radio advertisements and field visit by the health staffs.
Prevention and Control of Locally Endemic Diseases
Kalazar (Visceral Leishmaniasis) is endemic in some areas of Dhamrai. Diarrhea is also a common disease however the prevalence came down significantly during the recent years. There is little effort for specifically targeted preventive measures for endemic diseases. Health education again came out to be the most important preventive approach against Kalazar. The authority informed that they are planning vector control measures against sand-fly in endemic areas.
In Mehendigonj the most common diseases or health conditions are malnutrition, diarrhea, ARI and common skin diseases. Typhoid fever and Malaria are also not very uncommon. No specific preventive activity was seen against locally endemic diseases in Mehendigonj.
However there are some preventive programs in the UHCs, designed through top-down approach from the DGHS e.g. de-worming program many of the locally endemic diseases are not properly taken care of based on the feedback from the community. Every UHC is instructed to maintain Disease Profile which is supplied by the DGHS. The list of diseases in Disease Profile often does not contain the name of a certain disease which may be prevalent in that particular area. No epidemiological survey has been conducted to formally identify locally endemic diseases in order to devise appropriate prevention and control strategy.
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Treatment of Common Diseases and Injuries
Dhamrai UHC being situated near the highway to Dhaka, Road Traffic Accident (RTA) is the most common form of injury. One of the four branches of National Institute of Trauma and Orthopedics (NITOR) is under construction in Dhamrai, close to the UHC. Emergency treatment is being given from the UHC and complicated patients are being referred to Dhaka. Treatment of Kalazar is available in the UHC but there is no facility for Aldehyde Test. Therefore specimens are sent to Dhaka for diagnosis of Kalazar.
Mehendigonj being an area surrounded with water and having a lot of ponds encounters an alarming number of drowning cases. Snake bite and injuries due to physical assaults as a result of fighting over land, Chars, fishing etc. are also common sorts of injuries. One MO reported, “Almost 90% patients admitted in the inpatient department (ward) are cases of physical assault”.
One official shared his experience that, he observed in one UHC that an NGO was conducting a program against drowning. However this sort of program is more necessary for Mehendigonj there is no sign of introducing such program. Intubation facility and oxygen supply are also lacking which is critical for treatment of drowning cases. There is a chronic shortage of polyvalent anti-venoms which is essential for snakebite treatment.
Provision of Essential Drugs
Bangladesh adopted essential drugs list containing 117 drugs. Unfortunately in none of the two UHCs all the essential drugs were available. The chief administrators of both the UHCs mentioned that they only know that there is a list of essential drugs but none could say what those drugs are or where they can find the list. The doctors were found to be completely unaware of such a thing as ‘Essential Drugs List’. Their perception of essentiality of certain drugs was only based on their own clinical experience.
While asked to the patients about their experience regarding the availability of necessary drugs, patients in Dhamrai UHC replied that sometimes they are asked to buy drugs from outside which are not available in the UHC. But drugs which are available can be obtained free of charge from the UHC Drug Corner. But situation was much worse in Mehendigonj. All of our respondents complained that they could not obtain even a single free drug from the UHC.
Referral System
There is no functioning referral linkage in Bangladesh. Officially UHC is the first referral where people referred from the Community Clinics, Union Health and Family Welfare Centers or Satellite Clinics come. District hospitals are the second line of referral where patients referred from the UHC are supposed to admit. Medical college hospitals and specialized hospitals are the final stage of referral. But this pathway is seldom maintained as most of the people visit the health facilities according to their sweet will.
In order to prevent congestion at the higher referral level with simple ailments, patients must follow a particular referral line-up. But to convince people to maintain proper referral line-up, quality service must be ensured at every referral stage. Unfortunately in most of UHC there is not enough HRH to, provide quality service. In Dhamrai each MO attends 100 patients on an average. In Mehendigonj it is
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150 to 300 per day. Lack of equipments and medicine is also a major hindrance for quality service. Therefore there is always a tendency of the patients to overtake one level and seek care from the upper level if the patient can afford it. As a consequence the upper referral levels such as district hospitals and medical college hospitals face a tremendous pressure of patients who could easily be treated in PHC centers i.e. UHCs. It also calls upon the quality of service delivered from that referral level as well. Finally the patients become deprived of good service from both the UHC level and the higher level.
In Dhamrai UHC the referral from the lower level is not satisfactory. But from the UHC to the upper level is reasonably well practiced. There is a functioning ambulance service. The only problem is there is only one Driver for the ambulance. Therefore when the Driver is on leave patients have to make the way of their own. Still there is a problem as there is no allocation of budget for the fuel and the maintenance of ambulance. Therefore, the UHC authority collects some money from the patients in order to meet the fuel cost.
But in Mehendigonj UHC, the scenario is very pathetic. The UH&FPO of Mehendigonj UHC mentioned, “Yes, there is one ambulance for sure. But where is the road here in this desolate island to run this ambulance? Each UHC was allotted one ambulance, so we also got one. No one even thought where the ambulance will run and how patients will be carried from here to somewhere else; there is no road connection from Mehendigonj to any place.” Mehendigonj would need a Water Ambulance. When there is a critical patient they have no other way but to wait for the steamer to arrive. Relatively solvent patients hire speedboats from Barisal and carry the patient. There are 13 Unions under Mehedigonj Upazila among which only three are connected by road and that also is not paved one. Moreover, the roads are too narrow for the ambulance. Therefore, patients usually travel to the health center by ‘rickshaw-van’ while the ambulance along with its driver lies idle without any visible utility.
While asked about the cause of overtaking the UHC level to seek care from the higher level, the patients attributed it to the low quality service and unavailability of desired service providers. On the contrary, the service providers held the ignorance of the patients responsible for this. They also mentioned that there are some Dalals (agent) who work for some private clinics or private practitioners (physician) who influence the patients and convince them to get admitted in their clinic.
Patients are not likely to overtake one level and seek service from the higher one if quality service is ensured in every level. Because, travelling itself costs a lot of money, let alone the cost of treatment at the higher level.
Condition of Promotive, Preventive, Curative and Rehabilitative Services
Health promotion, as discussed earlier, is better functioning in Dhamrai than Mehendigonj. It is partly due to the management efficiency in Dhamrai and partly due to difficult geography in Mehendigonj. Preventive activities are also better in Dhamrai. Disease profile is properly maintained and reported in Dhamrai. Curative services are also better in Dhamrai due to its geographic proximity to Dhaka. There are sufficient doctors and other staffs. Rehabilitative services are absent in both of the UHCs.
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Appropriate Technology
We considered various activities as ‘appropriate technology’ which we considered Innovative approaches both in terms of managing the health center and clinical practices. We tried to discover what the service providers took on in a situation when there had been no formal means to tackle certain managerial and/or clinical setback.
In Dhamrai we came to see some hospital beds which were made by dead trees at the health center premise. When the health center was upgraded from 31-bed to 50-bed hospital, government supplied 19 extra bed which went out of order within two weeks. The UHC authority utilized the already dead trees in front of the UHC and made hospital beds out of those trees. The UH&FPO told, “Many things will come to a standstill situation if we leave things up to the government only. We have to take some local initiatives”. Another example of such local initiative was arrangement of Caesarian Section operation at the UHC. The local people contributed to buy the Operation Theatre (OT) lights. The oxygen and nitrous oxide cylinders were managed by the donation from a local government leader which was mediated by the local administrative personnel.
Dhamrai UHC authority did another innovation by converting the diesel run ambulance into Compressed Natural Gas (CNG) run one. In Bangladesh CNG is much cheaper than petrol or diesel and Dhamrai is an area where CNG pumps are abundant. Apart from these, there is another unique arrangement which is preparation of Chorine Solution in the health center. Thus locally produced Chlorine Solution is utilized as antiseptic.
In Mehendigonj, the doctors formed a diabetic association thorough which they screen and treat diabetic patients once a week totally free of cost. They also refer the complicated patients to the Barisal Diabetic Association Hospital or Barisal Sher-e-Bangla Mediacal College Hospital. They also undertake some innovative therapeutic practices such as using the strap of saline set as surgical tape, using bricks as traction weight for orthopedic patients etc.
Intersoctoral Collaboration
Importance of intersectoral collaboration was accepted by all the service providers. Personnel in both the UHCs as well as the key informants pointed to the definition of health which advocates social well-being in addition to physical and mental ones. One key informant, who was the Director of PHC in DGHS, mentioned, “Suppose I have everything to my satisfaction, but I cannot sleep at night. Because the Sharbahara (Maoist insurgents in some parts of Bangladesh, notorious for their brutal way of killing people) may kill me anytime. Am I living a healthy life? If not, then who but the police can ensure a healthy life for me, not a doctor”. They emphasized the importance of department of fisheries and livestock, agriculture, local government, road transport authority, roads and highways, education, housing, water and sanitation and labor to work in harmony with the health sector in order to achieve the common goal of a healthy life for the population.
The UH&FPOs mentioned about the EPI programs where they seek collaboration from department of primary education and law enforcing agencies such as police, ansar (Para militia force), Village Defense Police (VDP) etc. who provide necessary manpower and security which would otherwise be impossible
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to implement on part of health personnel solely. He also mentioned that there is neither proper guideline from the higher government authority regarding the coordination between different departments nor there is any mechanism to ensure accountability of these sectors. Therefore if any sector refuses to cooperate, the health authority has very little to do against them. The UH&FPO of Mehendigonj also mentioned the similar issues and involvement of the same departments in undertaking their programs.
Community Empowerment
The term ‘Community Empowerment’, which we are suggesting instead of ‘Community Participation’, entails four components: whether the people has access to information (Access to Information); are included and participate in forums where issues are discussed and decisions are made (Participation in Decision Making Forums); can hold decision makers accountable for their choices and actions (Demand Accountability from Decision Makers); and have the capacity and resources to organize to aggregate and express their interests and/or to take on roles as partners with public service delivery agency (Ability to Work in Partnership with the Public Service).
Access to Information
Government has made it mandatory to mount Citizen Charter in all government facilities in order to inform the people of their entitlements. However creditable decision this might be, low literacy rate of the people hinders in achieving the desired outcome from this initiative.
We observed clearly visible Citizen Charter in Dhamrai UHC. Besides, a large Billboard was also erected just in front of the UHC entrance informing the patients about available facilities. Inside the UHC building there was a black board where available services are enumerated again in a familiar language. The UH&FPO holds monthly coordination meeting with field staffs where he insists them to inform the rural people about the services which at the same time would be economical. As for example, the Caesarian Section has become popular among the poor rural people within a short time by means of this approach. They also use local musical band party to attract the attention of the people regarding DOTS-TB services. Relevant services are advertized in mosques by the Imams during Friday prayers and also in Hindu religious sessions.
In Mehendigonj also we found a Citizen Charter but it was not clearly visible. It was painted on the wall which became damp and the text was hardly visible. The UH&FPO strongly acknowledged the importance of Citizen Charter but expressed his skepticism over the utility of it because of the low literacy level among the people. But he expressed his optimism about the decision of the government in reviving the Community Clinics which he thinks can be utilized competently for empowering people through information.
Participation in Decision Making Forums
Almost none of our patient respondents were found to be involved in a forum where issues related to health are discussed and decisions are made. Only one person, who was a Village Organization (VO) member of BRAC, said that she regularly attends weekly health meetings organized by BRAC where they
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discuss about different health issues and how they can get involved in improving the community health. All of the respondents unanimously and strongly expressed their opinion over the necessity of such a forum. While asked why then they are not involved with such initiatives the answer was plain and simple, ‘There is none’. One respondent from Dhamrai said, “There are big people like Doctors; among them how do I expect to make a scope to talk?” Another patient from Mehendigonj also had the same expression, “Even if I want to get involved, they will include only the local elites. They will never include common folks like me.”
The government is launching Community Clinics for every 6,000 population. Community Clinics are designed to run by Community Groups. Each group will consist of 11 members. Among these 11 members only two will be from health department of the government. The rest nine will be drawn from the respective community. There is a specific guideline from the government about the membership of Community Groups. The committee will consist of local government member, local elites, retired teacher or government staff, land owners etc. The two members from the government side will be one Health Assistant (under DGHS) and one Family Welfare Assistant (under DGFP). These 11 members will decide who will be the President, Vice-President, Secretary General and Treasurer. Thus Community Clinics are a potential source of participation in decision making on health by the community people themselves.
Demand Accountability from Decision Makers
One patient from Mehendigonj acerbically remarked, “Here we get some medication however trivial it might be; that’s all we can expect. How can we hold these important persons responsible?” There is no formal way to challenge the accountability of the UHC personnel. As a result a set of informal ways have developed ranging from shouting and quarreling to even inflicting physical abuse to the health care providers. Previously the Health Management Committee had been being headed by the Upazila Chairman. According to the current decision by the government along with certain other authorities this very authority has also been curtailed from the Upazila Chairmen and given away to the MP instead. The local government leaders feel that, on account of their greater involvement with the common people, they should be in charge of monitoring the UHC. The MP may stay as an adviser only.
We heard many stories from the patients about negligence and misbehave of the health care providers which they could do nothing against. According to them, accountability is there, but it can be sought only by the influential people; not by the common patients.
Ability to Work in Partnership with the Public Service
Bangladesh is a disaster prone country. During natural calamities people from all walks come voluntarily to work in partnership with the government agencies e.g. UHC. The recent Community Clinic approach of the government also depends greatly on the voluntary contribution of the people. Government is only responsible for building the structure, supplying the equipments and medicines and employing staffs. The management, maintenance and security are the responsibility of the community. The land is also to be donated by the local people. This approach is going to be the example of continued partnership of the community with the health sector.
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One of the most successful programs of the government is EPI, which is also a great example of partnership of the people with the government. The community volunteers had been recruited and trained by the health department for the program which turned out to be a huge success. Reflecting on this success story one MO of the Dhamrai UHC told, “You know about the monumental success of National Immunization Day (NID) and EPI. Because of this program Bangladesh became free from Polio and it still is. This reputation could never have been achieved without the participation of the people”.
Devolution
Our model of CPHC proposes ‘devolution’ of services instead of ‘decentralization’. By the term ‘devolution’ we advert to an advanced version of ‘decentralization’ where Local Government is subject to national norms, but sets local policies and priorities, plans autonomously in response to local preferences and needs. In Bangladesh health system decisions are made through a top-down approach. Ministry of Health and Family Welfare, headed by Minister of Health and Family Welfare and a State Minister is the supreme policy, planning and decision authority of health. Under the Minister there is the Secretary for Health who is the administrative head. He has some Additional Secretaries and Joint Secretaries who work in the Ministry. The Secretary of Health has three other institutions under him each headed by a Director General (DG): Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP) and National Institute of Population Research and Training (NIPORT). DGHS is responsible for implementing policy decisions by the ministry and for providing technical guidance to the ministry. It regulates the health services through different Directors including one for PHC, Line Directors, Project Directors, institution heads, District and Upazila health managers and Union health staffs. Under the DG there are Divisional Directors (DD) who again supervise Civil Surgeons (CS) one in each 64 districts of Bangladesh. Under the CS there are UH&FPOs in each sub-districts or Upazilas. UH&FPO is the administrative head of the UHC as mentioned earlier. But the voice of the UH&FPOs is seldom heard in decision process of the DGHS which was reflected in our findings discussed earlier.
However the UHC is also run entirely under the administrative authority of UH&FPPO, it has a Health Management Committee which includes the Member of Parliament (MP), Upazila Chairman (Local Government Leader), UH&FPO, Upazila Nirbahi Officer (UNO, the administrative head of the Upazila) and other government high officials at the Upazila level. But there is no direct linkage between the community and the Health Management Committee except for the involvement of the MP and the Upazila Chairman. These public representatives are not formally linked with the community in terms health issues unless an individual approaches them of his/her own. Secondly these members are not empowered by the state formally regarding their administrative domain of involvements and roles and responsibilities.
Most of the key informants and the health personnel opined strongly in favor of delegating more authority to the UHC administration. The UH&FPO of Dhamrai was telling one day, “Suppose the ceiling fan of the patient waiting area has gone out of order. They repeatedly come to me and complain. If I send a requisition to the authority for it to be fixed I have to go through protracted administrative hassles. It may take even such a long time that summer may subside. By the time the fan is repaired
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there is no necessity for a fan anymore, because it is winter. The patients are not going to understand my limitations; they will simply blame me.” One key informant shared his experience of visiting health centers in Malaysia and Thailand where, he claimed, “Health centers enjoy much more autonomy both in terms of finance and recruitment. They can raise their own money, spend it according to need and can employ the type of personnel particularly required for that health center.”
Nevertheless the health personnel demanded autonomy, they did not agree with the idea of complete devolution where local leaders will have their administrative superiority over the health sector personnel. During the dictatorial regime of General Hussain Muhammad Ershad such reform was attempted which were faced by strong opposition from the doctors. “Doctors will never agree to be held accountable by less educated local leaders”, mentioned one of our key informants who spent his whole career in PHC delivery and finally retired as the Director (PHC) from DGHS. He added, although there are examples of such local level committees supervising the health facilities in developed countries, it will not work in Bangladeshi context where local leaders are rather more corrupted on top of being uneducated.
Health care providers pointed out many incidences of misuse of local power by the local government leaders and their accomplices. As for example a considerable number of medico-legal cases come to the health center many of whom are related with political conflicts. Many victims of different forms of physical assaults also come to the center, many of whom are in conflicting interests with local leaders. These people, according to the health providers, will be victimized if local leaders assume the charge of the UHC. Demanding ‘grievous hurt certificate’ for a minor injury in order to get benefit in court against the opposition, influencing the simple patients to take them to quacks in exchange of money from the quacks etc. are some of the allegations pronounced against the sycophants of the local leaders if not against the local leaders themselves. Our respondent local government leaders also admitted that such incidences are taking place in many areas. Referring to these instances the health care providers advocated ‘supportive supervision’ by the local leaders rather than completed devolution where local leaders will be all in all.
Grounded Themes
In course of our qualitative data analysis we came across many grounded themes which emerged from within the respondents which principally denotes to different problems of the PHC service delivery and uptake.
Resource Constrain including Human Resource
Complains regarding resources, particularly human resources, were pronounced mostly from Mehendigonj UHC personnel. Due to the scarcity of electricity they cannot run the computer to send the data related to Health Management Information System (HMIS) to the higher authority. Therefore they have to prepare all the reports manually and send it through an inefficient media to the center engaging already scarce human resources. Moreover due to lack of contingency budget allocation they cannot repair the instruments including the computer. There is no budget for the kerosene or candle or any other means for lighting the UHC which they succumb to during frequent power failures. During our stay
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at Mehendigonj we hardly found any electricity during most of the times. Shortage of surgical instruments, medical supplies, medicine etc. needs no mention. There is shortage of oxygen for critical patients.
Human resource shortage is another burning issue in Mehendigonj. Due to the lack of good transport system, education facility for children and electricity doctors don’t want to stay there for long. There is only five doctors present among nine posted. Among these five doctors, during much of our observation period, we found only two doctors working including one UH&FPO. The UH&FPO, however overburdened with administrative works, becomes coerced to attend patients because of doctor shortage. Thus lack of separate Public Health cadre in the health service of Bangladesh deprives the people from getting proper clinical service from the clinicians in one way (as they become compelled to oversee the administrative, preventive i.e. public health issues leaving behind their clinical jobs which they are trained in) and getting professional public health service from the trained personnel in the other way (as there is no scope in the government of Bangladesh to include non-clinical health systems specialists, managers, epidemiologists i.e. qualified public health professionals). The manpower shortage is not limited to doctors only; there are only six nurses while at least 18 nurses are required. There was only one dental doctor posted who also left the health center without notice.
Though not as serious as Mehendigong, Dhamrai also is facing manpower shortage. The UHC which has been upgraded from 31 beds to 50 beds has not yet been appointed with 4th class employees (sweepers, ward boys, ayas) required for the increased number of beds.
To overcome this HRH scarcity the then military dictator in power tried to implement ‘point system’ for the doctors. He introduced some scores for the doctors which they can earn only if they serve in rural areas. This score would again help them to get enrolled in higher education which is highly competitive in Bangladesh. One key informant said, “He could not succeed with it because of the lack of legitimacy of his government. But now, under the democratically elected government it is very much possible.”
Monitoring, Transparency and Accountability
Lack of monitoring has been pointed out by the key informants as one of the main reasons behind poor service delivery which is again related to resource constrain as well as the mindset of the manager. There is no car, allocation of transportation cost or any other required facility for undertaking monitoring and supervision of service delivery by the managers. In Mehendigonj higher officials come for monitoring only once or twice in a whole year and that too not singularly for monitoring purpose. They come with different programs and do the so called monitoring alongside. Internal monitoring was also not found to the satisfactory extent. Many of the rooms of the doctors were found closed even as long as 11:00 am whereas the office hour starts at 09:00 am.
The scenario was completely opposite in Dhamrai UHC. When we reached the UHC for the first time we found the UH&FPO minutely visiting every nook and corner of the UHC, taking information about every tiny aspect from the health care providers, talking with the patients, examining the cleanliness of the toilets and other places. Apart from regular and rigorous internal monitoring the UHC undergoes sudden
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but frequent visits by the superior authorities. Sometimes high officials come to visit the center even twice even thrice a week. The Dhamrai UHC authority sends reports on different aspects of service delivery and HMIS to the DGHS through CS office four times a day by email.
The transparency of the authority of Dhamrai UHC was evident additionally by the display of all the daily information of the UHC. Name of the present and absent doctors; amount of available medicines; month-wise inventory of in-door, out-door and emergency patients; death records; accomplishment of regular hospital tasks (change of bed sheet, cleaning the hospital wards, sterilizing the instruments, disposing off the hospital wastes etc.) etc. are constantly updated in a display board placed in an easily visible space at the UHC. The financial and other information are also collated to display in the UH&FPO’s room. On the contrary, In Mehendigonj there was a list of available medicines in the pharmacy which was not updated.
Responsiveness and Client Satisfaction
In none of the UHCs client feedback mechanism was found satisfactory. The formal way is to lodge a written complain to the UH&FPO. Given the literacy level of the people and the position of the government staff in the social hierarchy, this method is not deemed as an appropriate one. Most of the people don’t know even the formal way of giving any feedback or complaint. They usually go to the local leader in case of serious issues which often give rise to unwanted circumstances. Patients, especially in Mehendigonj, perceived that the formal complaint to the UH&FPO will also not bring any result because they think the UH&FPO who is always a doctor will not take any action against any other doctor. But in Dhamrai patients reported that the UH&FPO usually takes prompt actions based on the complaints. One patient remarked, “Sure it works. Suppose if any doctor is late in his work and if I go to UH&FPO’s room and tell him that there is no doctor in a particular room, he would go there himself and inquire about the doctor. We appreciate his sincerity.”
Respondents talked about the health system responsiveness i.e. to what extent the non-medical expectation of the patients are met. Both the patients and providers in Mehendigonj indicated that the rush of patients hinders the doctors from giving quality service to the patients. But the patients rated the attitude of the doctors satisfactory while attitude of the nurses requiring improvement. Regarding cleanliness of the health center the patients complained about it while the providers attributed it to the shortage of manpower as well as the cleansing materials. The UH&FPO maintained, “You yourself observed the area of the UHC. There are only two cleaners for such a large area. How is it then possible to keep it clean?” Regarding the lack of privacy of the patients, the providers held the structural insufficiency liable for it. But in case of female patients the doctors try to maintain the privacy with a screen.
The issue of patient load is applicable in Dhamrai also which calls upon the quality of service. Everyday each doctor has to attend 70-100 patients on an average. The picture is similar to Mehendigonj in terms of different domains of responsiveness except cleanliness. Patients highly praised the cleanliness of Dhamrai UHC. Despite their satisfaction they demanded to install a complaint box in the UHC.
Provider Satisfaction
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“Only a satisfied provider can provide a satisfactory service. You are concerned about the client satisfaction but hardly talk about the satisfaction of the health service providers”, mentioned one of our key informants. Even a high official like CS is not entitled for a car whereas junior staffs from other government cadres than the health cadre get a car for field work and supervision. Doctors and nurses sometimes do not get proper lodging facility. But most important of all is the complications of career progression. One MO from Dhamrai told, “If you are asked to act as even a Prime Minister for 30 years, I doubt you will accept. I know some Medical Officers who spent whole 30 years of their career in the same post as a Medical Officer. I myself am passing my 27th year in the same position. So did our UH&FPO before becoming UH&FPO.” The UH&FPO also reflected the same tone, “Many of government officials suffer from the agony of unmet needs. Our colleagues from other cadres have already become Joint Secretary or Additional Secretary at their respective ministries. But we, having been the best students of our schools or colleges, having scored the good marks in the public service competitive exams, finally end up like this. Many doctors, who retire as Medical Officers, what have they got from the nation? They get neither money nor honor. A government doctor gets nothing.”
Health Care Financing
Since there is no social health insurance or community based health insurance coverage in either of the Upazilas, out of pocket payment is the only mode of health care payment. In most of the UHCs there is no user fee imposed and the health care is supposed to be absolutely free of cost as long as the required service is available. But Mehendigonj is an exception which was brought under a pilot project to evaluate the functionalities of imposing user fee at UHC level. However the project time has been well over, as no government directive came to withdraw the temporarily and experimentally imposed user fee, the Mehendigonj UHC authority kept on collecting user fee. The money thus collected, as claimed by the UH&FPO, is deposited in the government treasury and it is not possible to use the money locally for the benefit of the UHC. Each patient is liable to give 3 taka (4 cents approximately) to get entry into the health center. Apart from that they are supposed to give money for laboratory facilities, indoor facilities and other hospital facilities according to the government-decided rate. They are supposed to get the medicine for free only if it is available.
In both the UHCs we found patients who had been encumbered with impoverishing health expenditures. Shortage of medicine and therefore being required to buy it from outside was a common complaint, however less frequent in Dhamrai. In Mehendigonj, in addition to providing user fee, patients vehemently complained of doctors embarking on private practice and that in the health center premise and during the office hour. One patient commented, “We have to buy the total medication of the patient. On top of that we have to bear the doctor’s fee. Otherwise the doctor doesn’t attend the patient sincerely. Sometimes even they unnecessarily send the patient to Barisal just to harass us. That certainly costs us a lot more than the doctor’s fee. We most despise such practice during the office hour. If we do not give them the private practice fee of 20 taka (30 cents approximately) and buy a user fee ticket of 3 taka; then we have to wait hours after hours while the doctors remain busy with their private patients.” We found the claim of the patients true regarding the private practice during office hour.
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Mr. Alim Mondal, an elderly of 50 years came to Dr. Shanjib Dhar with a complaint of shortness of breath and mild fever. It was 11:30 am and there was long queue in front of the doctor’s chamber. He managed to enter the room after two hours but we observed that when he came out of the room, instead of going home he again sat in the queue to be attended by the doctor. Curious by the case we approached him and came to know that he visited the doctor with regular three taka user fee and the now he is not satisfied with the treatment. The doctor did not even listen properly to him and prescribed a lot of diagnostic tests and many expensive medications. So, he sent his son to go to home and bring 50 taka (approximately 70 cents) so that he can visit the doctor again but this time as private patient of the doctor. He believes, in this way he will get proper attention and treatment from the doctor and the cost of the diagnostic tests and medications will also come down.
When enquired about the private practice of the doctors in the health center and during office time, the doctors also responded amiably delineating their part of the story. Private practice by the public service doctors is not prohibited in Bangladesh, rather widely practiced all over the country as a profitable means for ill-paid doctors’ livelihood. Mehendigonj being a desolate island, disconnected from surrounding scattered small islands, cannot be approached easily by the patients whenever they desire or need. Therefore, their doing practice during the office time, as a matter of fact, is helping the patients who are managing somehow to come to the Mehendigonj island once and are willing to get treated privately by a doctor. If the doctors, like other parts of the country, practice in the evening they will get no patients because of the geography of the region. Therefore, posting in Mehendigonj itself being a difficult posting for the doctors, how can they afford further disadvantage in terms of becoming deprived of their legitimate income through private practice? The exceptional geography and condition of the area impels the doctors to do their private practice during the office hour and as they cannot leave the office during that time they do it in the health center premise. But they claimed that, they attend both the private patients and general patients simultaneously. They dissented the accusation of discriminating the patients.
We found effectual mechanism to avert the patients from catastrophic health expenditures in neither of the UHCs. The patients often take loans with high interest rate (commonly known as Dadan) which, in addition to their forgone income due to illness, further pushes them below the abject poverty line. But there is hardly any mechanism in the UHC except from exempting the trivial user fee. There are some unofficial mechanisms practiced in both the UHCs, such as storing the unutilized medicine bought b wealthier patients and giving it to the poorer ones. Sometimes the local people gather money from the locality to help the poor patients.
Special Care for the Elderly, Disabled and Psychiatric Patients
With a view to appraise the PHC delivery system in Bangladesh whether it is upgraded and adjusted with the current situations and needs, we discovered a dismal picture. There is no special care or facility for the elderly or the disabled except for informal individual benevolence of the providers. The Non Communicable Diseases (NCD) attracted attention only recently while Bangladesh is facing an Epidemiological Transition with double burden of both Communicable and Non Communicable Diseases. Recently the doctors have undergone training on NCDs organized by the DGHS. There is no facility in the
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UHCs to deal with cardiovascular diseases, cerebro-vascular diseases, diabetes malietus, psychiatric disorders and several other NCDs. In Dhamrai, some personnel from National Institute of Mental Health (NIMH) held meetings in some Unions (lower administrative tier than Upazila) of Dhamrai Upazila. They particularly aware people about drug addiction as it is being abused in an alarming extent.
Suggestions Pronounced by the Respondents
Suggestions by the Key Informants
• Involving the male persons in the community: Most of the health and development programs are targeted towards females in Bangladesh. However women empowerment is essential, it should be achieved through the understanding, responsiveness and involvement of male counterparts as well.
• Career planning for the health care providers: Health care providers should know their definite career path. It must include the information about how many years a staff should serve in a certain post and a certain area and how he/she will be allocated for higher studies. It should also address the pathways for both clinical and non clinical staffs serving under MoHFW
• Needs assessment and bottom-up decision: Resources are allocated with a top-down approach without knowing the needs of the particular area. There should be studies regarding the epidemiological patterns in an area to decide upon what kind of drugs to be dispensed there and in which season. Studies should be done or local authorities should be asked before allocating certain resources e.g. an ambulance where there is no paved way or petrol pump.
• Number and skill mix of HRH: Not enough physicians are posted against required number per population. Sufficient doctors and other health professionals should be employed and cares should be taken to root out absenteeism. There is a malignant shortage of Nurses in Bangladesh which gives rise to distorted Doctor to Nurse Ratio. Therefore more Nurses should be trained and Doctors are to be ensured to stay where they are posted.
• Removal of health and family planning dichotomy: It is observed that field staffs from both the health and family planning department are going to the same households with similar health messages. This duplication not only causes wastage of scarce human resource but also sometimes causes confusion among the local people. Moreover, sometimes it may evoke tension between the two cadres.
• Allocation of adequate resources: Without sufficient resources no plan can be implemented properly. Most of the problems are directly or indirectly linked with the scarcity of resources.
• Invoking community ownership: People of the community must be involved in a way that they develop a sense of ownership over the health center. Community mobilization can be achieved through community empowerment.
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• Involving media in community empowerment: Information is imperative in empowering the community. Mass media can play a pivotal role in informing people of their health entitlements. In order the achieve community empowerment, therefore, media should be sensitized regarding their role and potential in this regard.
• BCC materials on health entitlements: Behavior Change Materials (BCC) are now developed only to inform people about different diseases and health conditions. BCC materials can be developed to inform people about their entitlements and the available facilities in the nearby health centers.
• Monitoring and evaluation: There must be scrupulous internal and external monitoring of the health center and the staffs. The health center authority must have clear guideline regarding his/her role in monitoring other staffs. Higher authority from the central level should also have the drive to visit the peripheral centers frequently with specified guideline.
• Performance based payment: There must be incentives for a staff that is dedicated and punitive measures for someone who is negligent. Otherwise it calls upon the morale of the staffs.
• Hospital autonomy: The health center must have certain level of autonomy over the resources it generates. Looking forward to central decision for petty expenditures compromises the quality of services and at the same time puts people at the greater risk of being deprived of emergency medical services.
• Addressing newer health issues: The existing PHC model in Bangladesh is devised based on the scenario of the past when communicable diseases were more prevalent. In accordance with the epidemiological transition pervading Bangladesh, emphasis should be given on NCD, elderly population, psychiatric disorders, and disabled persons. Urban health care must also be improved.
• Ensuring transport and accommodation: Doctors, nurses and other staffs must be provided with wholesome lodging facilities. Transportation should be made available both for field visits, monitoring and personal commute of the staffs.
• Addressing management deficiency at central level: Sometimes postings are not made from the DGHS based on the expertise and interest of the HRH. A doctor trained in a certain discipline is posted against a post which he/she has no expertise on. Staffs are sometimes sent out for expensive trainings which may not have any implication in his/her career path. They are even posted in a field where their trainings may be found absolutely useless. There is lack of coordination of human resource management issues.
• Need of research: Bangladesh lacks the local knowledge base concerning many fields including health. One key informant maintained, “Research is absent in our national culture.” There is a post called Line Director, Research and Planning in DGHS who receives and disperses only scanty amount of money in the name of research. These funds go to NIPSOM and Bangladesh Medical
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Research Council (BMRC). But a strong research network is necessary to understand the condition of PHC along with different aspects of it in Bangladesh.
• Ensuring accountability and transparency: Local people and local government must have a mechanism of monitoring and ensuring transparency and accountability of the health centre staffs. Local health authorities encompassing people from different arena e.g. local government, civil society, other government cadres etc. can be commissioned for forming the authority which will be mandated to take the health staffs responsible for their activities. Health personnel should be accountable first to the local health authority and then to the District level health authority and eventually the DGHS and MoHFW.
• Compulsory service in rural areas: Medical interns should be made obligated to serve one year period in rural health facilities. Government staffs also should serve in rural areas followed by attractive incentives regarding higher education and training. Monitory incentives can also be considered such as rural allowance.
Suggestions by the Providers
Many of the suggestions from the Providers overlapped with that of the Key Informants e.g. the issue of HRH, logistic support, authority over the generation and utilization of local resources, amalgamation of health and family planning form the central level, community empowerment through community clinics, needs assessment and bottom-up planning, involvement of local government. Apart from these they pronounced certain other suggestions:
• Enhancing motivation of the providers: There should be some social mechanisms involved in enhancing the motivation of the providers. Providers should be committed to their responsibilities but at the same time it should be acknowledged by the people they serve.
• Establishing nutrition unit: Each health center should have a nutrition unit so that the mothers can learn how to maintain the family nutrition.
• Inter-sectoral coordination: Issues related to health should be brought under a unique coordinating body. For example water and sanitation is closely related to health and the activities of that department directly influence the health outcomes. Therefore there should be clear guideline regarding the coordination among different departments a propos health.
• Improving general education: Health and education are closely related. Therefore emphasis must be given to improve the general education level of the population. Updated health issues should be addressed in the curriculum.
• In-service training: Training facilities must be provided regularly both in clinical fields and non-clinical fields.
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• Provision for alternative resources: Chlorine solution can be locally produced for infection prevention purposes. Electricity shortage was a menacing problem which can be resolved through the provision of solar power panel.
• Separation of clinical and non-clinical posts: A separate cadre for non-clinicians should be developed who will be responsible for public health responsibilities, management and research. It will unshackle the clinicians to conduct their clinical responsibilities, at the same time endow the people to get professional public health services.
Suggestions by the patients and local leaders
Many of the suggestions, especially concerning community empowerment, were pronounced by the clients e.g. necessity of mass media involvement. Some other important suggestions are as follows:
• Provision for emergency and minor surgeries: Amenities should be made available to carry out minor surgeries such as appendicectomy, herniotomy, hydrocelectomy, circumcision etc. Facilities for emergency and critical care should be installed.
• Availability of essential drugs: A list of essential drugs must be finalized and availability of those drugs should be ensured. The availability of those drugs should be displayed to the people in order to prevent the pilferage.
• Poor fund: A fund should be developed to aid the poor patients who may not be capable to pay the expenses instantaneously.
• Diagnostic facility: There is a massive complain against the reliability of the pathological tests done at the UHC. In addition to that, most of time the X-ray machine and other equipments allegedly remain out of order. Improvement of diagnostic facility has been suggested.
• Involvement of government field workers in community empowerment: There is already a wide network of government health workers who are primarily responsible for disseminating health education messages. These existing workers can play a fundamental role by informing people about the available services and the entitlement of the people beside their usual health education messages.
• Role of local government in community empowerment: Local government can organize regular community meetings where health issues can be discussed. These meetings can inform people of their health entitlements. The meetings can also inform people about available resources and services at the nearby health facilities. These local government meetings can also pave the way for the community members to express their complaints and experiences regarding their encounter with the health facilities.
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PRA Findings
Problems Related to PHC Services
In Dhamrai (The Best Performing Upazila)
Serial Number of the Problems
Name of the problems
Serial Number of the Problems Score Rank
1 2 3 4 5 6 7 8 9 10
1 Low quality of treatment
1 3 1 1 6 1 1 9 1 6 3rd
2 Unavailability of free medicine
3 4 2 2 7 8 9 2 3 5th
3 Lack of empathy of the staffs
3 3 3 3 3 9 3 8 1st
4 Lack of cleanliness
5 6 7 8 9 4 2 6th
5 Lack of privacy of women
5 7 8 9 5 3 5th
6 Disparity of treatment between rich and poor
7 8 9 6 3 5th
7 Low quality of diagnostic facility
8 9 7 5 4th
8 Unavailability of doctors
8 8 7 2nd
9 Lack of information regarding available facilities
9 8 1st
10 Long waiting time
0 7th
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In Mehendigonj (The Worst Performing Upazila)
Serial Number of the Problems
Name of the Problems
Serial Number of the Problems Score Rank
1 2 3 4 5 6 7 8 9
1 Lack of cleanliness 1 1 4 5 6 7 8 9 2 5th
2 Disparity of treatment between rich and poor
2 4 5 6 7 8 9 1 6th
3 Long waiting time 4 5 6 7 8 9 0 7th
4 Unavailability of proper transport facility
5 6 7 8 9 3 4th
5 Unavailability of free medicine
6 7 5 9 5 3rd
6 Lack of information regarding available facilities
7 8 9 5 3rd
7 Unofficial fee 7 9 7 2nd
8 Low quality of diagnostic facility
9 5 3rd
9 Difficulties if the patient is referred to higher level hospital
8 1st
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Summary
Rank of the Problem
In Dhamrai (Best performing Upazila) In Mehendigonj (Worst performing upazila)
1st Lack of empathy of the staffs
Lack of information regarding available facilities
Difficulties if the patient is referred to higher level hospital
2nd Unavailability of doctors Unofficial fee
3rd Low quality of treatment Unavailability of free medicine
Lack of information regarding available facilities
Low quality of diagnostic facility
4th Low quality of diagnostic facility Unavailability of proper transport facility
5th Lack of privacy of women
Disparity of treatment between rich and poor
Unavailability of free medicine
Lack of cleanliness
6th Lack of cleanliness Disparity of treatment between rich and poor
7th Long waiting time Long waiting time
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Positive Traits of PHC Services
In Dhamrai (The Best Performing Upazila)
Serial Number of the Positive Traits
Name of the Positive Traits Serial Number of the Positive Traits Score Rank
1 2 3 4 5 6 7
1 Good facilities of diarrheal disease treatment
1 1 4 5 6 1 3 3rd
2 Free treatment and medication
2 4 5 6 7 1 4th
3 Free indoor hospital facilities 4 5 6 7 0 5th
4 Emergency care 4 6 7 4 2nd
5 Availability of tuberculosis treatment
6 5 4 2nd
6 Free vaccination 6 6 1st
7 Health education 3 3rd
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In Mehendigonj (The Worst Performing Upazila)
Serial Number of the Positive Traits
Name of the Positive Traits Serial Number of the Positive Traits Score Rank
1 2 3 4 5 6 7
1 Health care providers maintain the privacy of the female patients
2 3 4 5 6 7 0 7th
2 Free vaccination 2 4 2 2 2 5 2nd
3 Antenatal care 4 3 3 3 4 3rd
4 Emergency care 4 4 4 6 1st
5 Availability of tuberculosis treatment
5 7 2 5th
6 Health education 7 1 6th
7 Free indoor hospital facilities 3 4th
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Summary
Rank of the Positive Traits
In Dhamrai (Best performing Upazila)
In Mehendigonj (Worst performing Upazila)
1st Free vaccination Emergency care
2nd Emergency care
Availability of tuberculosis treatment
Free vaccination
3rd Good facilities of diarrheal disease treatment
Health education
Antenatal care
4th Free treatment and medication Free indoor hospital facilities
5th Free indoor hospital facilities Availability of tuberculosis treatment
6th Health education
7th Health care providers maintain the privacy of the female patients
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Ranking of Components of PHC
Name of the PHC Component Condition in Dhamrai (Best performing Upazila)
Condition in Mehendigonj (Worst performing Upazila)
Score Rank Score Rank
Education concerning prevailing health problems and the methods of preventing and controlling them
3 4th 2 6th
Promotion of food supply and proper nutrition 2 5th 1 7th
An adequate supply of safe water and basic sanitation
8 2nd 9 2nd
Maternal and child health care, including family planning
8 2nd 5 4th
Immunization against the major infectious diseases
11 1st 13 1st
Prevention and control of locally endemic diseases
2 5th 3 5th
Appropriate treatment of common diseases and injuries
5 3rd 6 3rd
Provision of essential drugs 1 6th 1 7th
Suggested Sources of Health Information
Suggestions from PRA respondents of Dhamrai Suggestions from PRA respondents of Mehendigonj
1. Participatory research 1. Participatory research
2. Training of the community members who will in turn educate other people of the community
2. Involving the local government authority to carry out health education programs
3. Galvanizing already existing health education program
3. Health center authority can organize health education sessions regularly in the health center premises
4. Involving the mass media (television) 4. Through school health education program
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Discussion, Recommendation and Conclusion The quantitative findings yielded by the household survey and the qualitative findings were in keeping with the assumptions of screening survey of the 20 UHCs. Our in-depth study finding was consistent with the screening survey as we found in the in-depth part that in all the CPHC parameters the status of the ‘highest performing upazila’ Dhamrai was better than the ‘lowest performing upazila’ Mehendigonj. The in-depth study helped us to identify the strengths and weaknesses of each of these two upazilas in respect to CPHC. This understanding eventually helped us to formulate recommendations in developing a model of CPHC appropriate for Bangladesh.
The household survey, qualitative interviews and the PRA were done to find the condition of education concerning prevailing health problems and the methods of prevention and controlling them, promotion of food supply and proper nutrition, supply of safe water and basic sanitation, maternal and child health care including family planning, immunization against major infectious diseases, prevention and control of locally endemic diseases, treatment of common diseases and injuries and provision of essential drugs. In terms of only water and sanitation and immunization the findings were satisfactory, although the village under the ‘highest performing’ Upazila fared slightly better in most of the indicators. Essential Service Package (ESP) is the mainstay of health care delivery in Bangladesh which is done under a Sector Wide Approach (SWAp) known as Health, Nutrition and Population Sector Program (HNPSP). Health education is covered under ESP with the name of Behavior Change Communication (BCC). The nutrition component is not functioning in most of the UHCs including the two UHCs we conducted our in-depth study and the outcome is comprehensible. The supply of safe water and basic sanitation is not the responsibility of the health sector, rather the Department of Public Health Engineering (DPHE) under the Local Government Division of the Ministry of Local Government. MCH is delivered under the Directorate General of Health Services (DGHS) whereas Family Planning is under the aegis of Directorate General of Family Planning (DGFP). Although both the directorates are under the Ministry of Health and Family Welfare (MoHFW), the health versus family planning dichotomy creates resource mismanagement, professional agitations, confusions, frustrations and consequently inefficiency. Immunization is the best acclaimed program of health sector which declined the child mortality considerably. But provision of essential drugs is one of the worst things to mention as there is still no recognized list of essential drugs, let alone ensuring their availability. Considering these findings we suggest a comprehensive approach instead of the existing fragmented approach towards PHC. In addition to that, the comprehensive approach should take into consideration the recent trends of demographic and epidemiologic transitions. NCDs, elderly health, urban health and the health concerns of the disabled persons should be included in the package.
The survey also shed some light upon the referral system, which is again related with number of issues such as the service delivery, accessibility and equity in service utilization. The study found that there is no functional integrity in the referral system. Service delivery and utilization is inequitably distributed among the population across their gender and income quintiles. Richer people can access the health centers more quickly than the poor. Long waiting time, less contact time, lack of responsiveness of the service providers, scarcity of medicine and equipment, unavailability of proper HRH and lack of trust provoke the people to overtake the lower referral level and succumb to distant health facilities
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notwithstanding higher cost. Furthermore if critical patients are referred to higher health facility, it becomes difficult due to unavailability of appropriate referral facility in place. Continuity of care, in addition to comprehensiveness of care, warrants commitment of the service providers, availability and proper management of services, effective HMIS, internal and external monitoring, progressive prepayment health financing mechanism, transparency, accountability and responsiveness towards the patients’ needs. Taking these indivisible issues into account, proper referral mechanism should be integrated in the CPHC model.
Ensuring comprehensiveness and continuity of care is impossible without commitment of the HRH. Patient satisfaction is imperative in an effective CPHC model, which is again unattainable without provider satisfaction. A committed and satisfied HRH should be ensured by providing them with basic amenities, hospital autonomy, Local Level Planning (LLP), necessary hospital supplies, up to date training, career planning for both clinical and non-clinical cadres, rural allowance and performance based payment. Non clinical cadre should be separated from the clinical staffs in order to maximize the service quality of both the clinicians and the public health professionals. Appropriate skill mix should be maintained and corruption, red-tape-ism and undue political influence should be removed from the service domain of the HRH. A context specific social incentive mechanism can be developed in order to retain the HRH in the peripheral areas of the country.
Finally, the most important proposition of our CPHC model is the inclusion of ‘community empowerment’ as an integral part of the model. Having access to information, participating in decision making forum, ability of challenging the transparency and accountability of the decision makers and having the scope to play a partnership role with the public service were considered as determinants of community empowerment. This is noteworthy that we proposed ‘community empowerment’ instead of ‘community participation’ as a principle indicator of our Comprehensive Primary Health Care definition. We believe ‘community participation’ is but a subset of ‘community empowerment’ which cannot be attained without a concerted approach to combine the other related determinants. Our quantitative survey found the condition really dire except some improvement in access to information which may be attributed to the use of mobile phones, electronic mass media and the community penetration of the NGOs. We also looked into the concept of ‘devolution’ surpassing the older concepts of ‘de-concentration’ and ‘delegation’ in the terrain of UHCs of Bangladesh. In this light we suggest invoking community ownership over the health facilities, involving the media in empowering people, developing BCC materials on health empowerment, and involving the existing government field workers in informing people of their health entitlements. Local government can play a pivotal role in these regards, especially in developing and continuing community based health entitlement meetings.
Adoption of these recommendations demands further operational research. Pilot studies should be commissioned to understand variable dynamics of different components of CPHC, to comprehend how much resource may be required for upgrading the existing system to a comprehensive model. Prospective studies can be carried out in one or two UHCs to evaluate the functionality of all or some of the components of our suggested model of CPHC.
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Discussion of KTE
Triad Experiences
Outcome Mapping Exercise
Boundary Partners
Government Officials and Policy Makers
• Secretary, MoHFW
• Director General of Health Services
• Director General of Family Planning
• Line Director of Primary Health Care at DGHS
• Joint Chief Planning at MoHFW
• Health Economics Unit at MoHFW
• Director, NIPSOM
• DPHE
• NIPORT
• Drug Administration
• IPHN
• IEDCR
Political Arena
• Minister, MoHFW
• Health Advisor to Honorable Prime Minister
• LGRD Minister and Representatives at Local Government
• Major Political Parties
Local Communities
• NGOs (health and social sector) e.g. BRAC
• CBOs
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• Religious Leaders
• Opinion Leaders e.g. School Teachers
• Adibashi Group Leaders
Private Sector
• Health related institutions (hospitals, clinics, diagnostic centers)
• Health Practitioners
• Bangladesh Medical Association
• Bangladesh Private Medical Practitioners Association
• Bangladesh Nurses Association
• Pharmaceutical companies
• Social Marketing Company
• Multi-national companies operating in Bangladesh
Media
• National Press Club
• Dhaka Reporters Unity
• BSS
• TV Channels
• News Dailies
Traditional Medicine Practitioners
• Board of Unani and Ayurvedic Medicine
• Bangladesh Homeopathic Association
Academic and Research Organizations
• ICDDR,B
• BRAC School of Global Health
• Private universities with MPH program
• BIRDEM/BIHS
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• BSMMU
• Center for Policy Dialogue
• Human Development Research Center
• Bangladesh Institute of Development Studies
• IBS
• Institute of Health Economics, University of Dhaka
• NIPSOM
UN and Multi-lateral Agencies
• WHO
• World Bank
• UNICEF
• UNFPA
• UNDP
• UNAIDS
• Save the Children USA
• Save the Children UK
• CARE Bangladesh
• Helen Keller International
• Red Crescent
• Medicine Sans Frontiers
• Oxfam GB
• European Union
• USAID
• DFID
• GTZ
• JICA
• CIDA/IDRC
• SIDA
• GFATM
• EC
• Gates Foundation
• Rockefellers Foundation
Expected BC from Boundary Partners • Greater Sensitivity to CPHC
• Greater commitment for equity and social justice
• Introducing/reinforcing supportive policy changes towards CPHC
• Allocating/reallocating adequate resources for CPHC (human and financial)
• Strengthening stewardship of Health Systems emphasizing CPHC
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Expect, Like, Love Expect Like Love
Government Officials
Commit time to read findings Commit to implement findings in PHC projects
Adopt the suggestions to make the system comprehensive
Political Arena
Policy review and change Initiate proactive change in favor of equity and social justice
Take the leadership role in CPHC
Local Communities
Understand the principles of CPHC
Recognize the necessities of installing CPHC
Influence the policy makers for CPHC
Act proactively in community empowerment
Comes forward to set example of CPHC through their programs
Private Sector
Understand the concept of CPHC Advertize in favor of CPHC as a social movement
Sponsor the organizations in carrying out components of CPHC
Media
Comes forward in helping in dissemination of research findings
Media campaigns in favor of CPHC
Follow up and cover CPHC programs
Run TV programs on CPHC
Publish articles on CPHC
Traditional Medicine
Become more sensitive to PHC
Readiness to work in CPHC
Academics and Research
Accept and use the knowledge in their own capacity
Further research Monitoring and evaluation of already implemented CPHC programs
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Share among themselves
Interact with civil society
UN and Multi-lateral agencies
Acknowledge the necessities of CPHC
Support the government with policy advise
They will not do anything that might undermine CPHC programs
Readiness to fund CPHC
Commit fund for CPHC
Actively fund CPHC
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Park, K. (2008). Man and Medicine: Towards Health for All. In K. Park, Park's textbook of preventive and social medicine (19 ed., p. 10). Jabalpur, India: Bhanot.
Perry, H. B. (2000). Health for All in Bangladesh: Lessons in Primary Health Care for the twenty-first century. Dhaka, Bangladesh: University Press Limited.
Rashid, K. M., Rahman, M., & Hyder, S. (2008). The history of public health in Bangladesh. In K. M. Rashid, M. Rahman, & S. Hyder, Rashid, Khabir, Hyder's Textbook of Community Medicine and Public Health (4 ed., pp. 24-27). Dhaka, Bangladesh: RHM Publishers.
Razzaque, A., & Streatfield, P. K. (2005). Does health intervention improve health equity? Evidence from Matlab, Bangladesh. In I. Network, Measuring health equity in small areas: Findings from demographic surveillance systems (pp. 143-154). Aldershot, Hants, England: Ashgate Publishing Limited.
Sanders, D., Schaay, N., & Mohamed, S. (2008). Primary health care. In K. Heggenhougen, & S. Quah (Eds.), International encyclopedia of public health (Vol. 5, p. 306). San Diego: Academic Press.
Walt, G., & Rifkin, S. (1990). The political context of primary health care. In P. Streefland, & J. Chabot (Eds.), Implementing primary health care: Experiences since Alma-Ata (p. 13). Amsterdam: Royal Tropical Institute.
WHO Bangladesh. (1996). Primary Health Care Development in Bangladesh. Evaluation Report, World Health Organization Bangladesh Country Office, Dhaka.
WHO. (1991). Intensification of action programme for primary health care. SEARO. Delhi: WHO.
WHO. (2000). The world health report 2000: Health systems: Improving performance. Geneva: World Health Organization.
World Health Organization. (2008). The world health report 2008: Primary health care now more than ever. Geneva: WHO.
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Acknowledgment This work was carried out with support from the Global Health Research Initiative (GHRI), a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada.
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Annex A: Methodology Matrix Following page
UHC Screening Survey
Key Informant interview
Document Review
Quantitative survey at Household level
PRA
group Discussion following PRA
In-depth interview of local govt. leader
Observation
In-depth interview of UH&FPO
In-depth interview of MO/MA
In-depth interview of field staffs
In-depth inter of Patients
Informal discussion
Delphi
Perf Ass.
Historical Evo.
Health edu.
Food & Nutr.
Wat. San.
MCH- FP
EPI
Loc.End.Ds.
Rx of Ds. Inj.
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UHC Screening Survey
Key Informant interview
Document Review
Quantitative survey at Household level
PRA
group Discussion following PRA
In-depth interview of local govt. leader
Observation
In-depth interview of UH&FPO
In-depth interview of MO/MA
In-depth interview of field staffs
In-depth inter of Patients
Informal discussion
Delphi
Ess.Drugs
Referral
Prev. & Prom.
Equity
Appr. Tech.
Access to Info
Dec.mak. For.
Chall. Accoun.
Part. Pub. Ser
72
UHC Screening Survey
Key Informant interview
Document Review
Quantitative survey at Household level
PRA
group Discussion following PRA
In-depth interview of local govt. leader
Observation
In-depth interview of UH&FPO
In-depth interview of MO/MA
In-depth interview of field staffs
In-depth inter of Patients
Informal discussion
Delphi
Int.Sec.Coll.
Devolution
Weak. H. Sys.
Suggestion
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Annex B: Screening Survey Questionnaire
A. Health action Delivery of Primary Health Care (PHC) to the people of Bangladesh according to Alma Ata principles.
B. Boundaries Upazila Health Complex (UHC) - its functionaries beneficiaries either coming for service seeking.
C. Performance assessment
1. Introductory Questions 1. Name of the UHC
2. Number of unions under the Upazila
3. Population of the catchment area of the UHC
4. How far is the UHC from nearest town (Dhaka/Barisal etc) Km
5. How far is the UHC from the Zila Sadar Km
6. How far is the UHC from Capital city (Dhaka) Km
7. What is your opinion regarding introduction of User fee in the UHC Bad (0) Good (1)
2. Attainment of goals
a. Health 1. Morbidity profile 0 1 2 3 4 5 6 7 8 9 10 2. Maternal mortality ratio 3. Infant mortality rate 4. Neonatal mortality rate 5. Immunization coverage
b. Responsiveness 1. How would you rate your experience of
getting prompt attention at UHC considering waiting time for treatment and time of getting test reports?
0 1 2 3 4 5 6 7 8 9 10
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2. How will you rate the attitude of the Nurse during stay in the UHC?
0 1 2 3 4 5 6 7 8 9 10
3. How will you rate the attitude of the MO (MBBS doctor) in the UHC?
0 1 2 3 4 5 6 7 8 9 10
4. How will you rate the attitude of the MA in the UHC?
0 1 2 3 4 5 6 7 8 9 10
5. How will you rate the attitude of other staffs (clerks, pharmacist, and lab technician) in the UHC?
0 1 2 3 4 5 6 7 8 9 10
6. How often do the service providers listen carefully to your complains? Please rate in terms of 0-10 where 0 is never and 10 is always.
0 1 2 3 4 5 6 7 8 9 10
7. How often do the service providers explain things in a way you could understand? Please rate in terms of 0-10 where 0 is never and 10 is always
0 1 2 3 4 5 6 7 8 9 10
8. How often do the service providers give you time to ask questions about your health problems or treatment? Please rate in terms of 0-10 where 0 is never and 10 is always
0 1 2 3 4 5 6 7 8 9 10
9. How would you rate your experience of how well health care providers communicated with you in UHC?
0 1 2 3 4 5 6 7 8 9 10
10. How often did the providers ask your permission before starting the treatment or test? Rate in terms of 0-10 where 0 is never and 10 is always
0 1 2 3 4 5 6 7 8 9 10
11. How often were talks with providers done privately so that other people could not overhear what was said? Rate in terms of 0-10 where 0 is never and 10 is always
0 1 2 3 4 5 6 7 8 9 10
12. How will you rate the provision for maintaining confidentiality of data of the patients in the UHC?
0 1 2 3 4 5 6 7 8 9 10
13. How would you rate your experience of being able to use health care provider or service of your choice during your stay in hospital?
0 1 2 3 4 5 6 7 8 9 10
14. What is your reflection regarding the cleanliness of the UHC? 0 means absolutely dirty and 10 means completely clean
0 1 2 3 4 5 6 7 8 9 10
15. How would you rate your experience of how the hospital allowed you to interact with family, friends and to continue your social and/or religious customs during your stay in the hospital?
0 1 2 3 4 5 6 7 8 9 10
16. Is the visiting hour being maintained properly 0 1 2 3 4 5 6 7 8 9 10
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in the UHC?
c. Fairness in financial contribution 1. What do you do for living?
2. How much do you spend in a month for your family?
Taka
3. How much do you earn in a month? (on an average)
Taka
4. How much do you spend on an average in a month on food and subsistence?
Taka
5. How much do you spend for non food items?/Non food expenditure –in excess of food and subsistence
Taka
6. How much money have you spent for getting to the UHC?
Taka
7. How much money have you spent for doing the tests?
Taka
8. How much money have you spent for buying medicine?
9. How much did you have to pay to the doctor?
10. How much did you have to pay any other money to any other staffs/persons?
11. How much money did you pay for food, attendant or any other purpose other than the ones enquired earlier?
12. How much money will it take for you to get back to your home?
13. So, please tell me in total how much money you had to spend for health care seeking?
14. How did you get this money? Savings (o)
Borrowing from friend or relation(1)
From employer (2)
From money lender (3)
Sale and mortgage of land (4)
Ornament (5)
Livestock/poultry (6)
Crops (7) Furniture (8)
Other (9)
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15. What is the effect of your health care expenditure on your regular consumption?
Not compromised (0)
Slightly compromised (1)
Greatly compromised (2)
16. What medicines did you get from the UHC for free?
17. What tests did you do from UHC for free?
3. Accomplishment of functions
a. Stewardship 1. How will you rate the external monitoring
(visit by the higher authority/ external auditing/WHO surveillance team visit) in terms of 0-10 where 0 is no monitoring at all and 10 is absolutely perfect monitoring.
0 1 2 3 4 5 6 7 8 9 10
2. How will you rate the internal monitoring of the UHC (Log book maintenance/internal visit/disease profile maintenance/hygiene and sanitation) in terms of 0-10 where 0 is no monitoring at all and 10 is absolutely perfect monitoring.
0 1 2 3 4 5 6 7 8 9 10
3. How will you rate involvement of the local authority in management of the UHC? (Visit by local UNO/Upazila chairman/local committee meeting etc) in terms of 0-10 where 0 is no involvement at all and 10 is absolutely effective involvement?
0 1 2 3 4 5 6 7 8 9 10
4. How will you rate the involvement of people/community in service delivery of the UHC in terms of 0-10 where 0 is no involvement at all and 10 is absolutely effective involvement?
0 1 2 3 4 5 6 7 8 9 10
5. How will you rate the effectiveness of the client feedback mechanism in the UHC in terms of 0-10 where 0 is absolutely ineffective and 10 is perfectly effective?
0 1 2 3 4 5 6 7 8 9 10
6. How will you rate the accountability/ transparency of the UHC in terms of 0-10
0 1 2 3 4 5 6 7 8 9 10
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where 0 is the least transparent and 10 is the most perfectly transparent?
7. How will rate the Go-NGO collaboration/PPP in the UHC in terms of 0-10 where 0 is no collaboration at all and 10 is collaboration in perfect harmony and efficiency.
0 1 2 3 4 5 6 7 8 9 10
b. Financing
i. Revenue collection 1. Budget required/applied for the UHC Taka
2. Government health budget allowed for the UHC Taka
3. Contribution other than the government sector Taka
ii. Fund pooling 4. Do you have any mechanism to protect the poor from catastrophic health expenditure No Yes
5. Can you specify the mechanism?
6. If yes then rate the effectivity of the mechanism in terms of 0-10 where 0 is absolutely useless and 10 is perfectly effective.
0 1 2 3 4 5 6 7 8 9 10
i. Purchasing 7. Level of manageability with the revenue
collected for running the UHC in terms of 0-10 where 0 is absolutely unmanageable and 10 is perfectly manageable.
0 1 2 3 4 5 6 7 8 9 10
1. Service provision 1. Name/ID of the patient/respondent 2. Gender Male (0) Female (2) 3. What is your age? years 4. What is your level of education Illiterate (0) Primary (1) Secondary (2) HSC (3) Above (4) 5. Which Union are you hailing from?
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6. What is the distance of your home from the UHC? Km 7. How much time does it take to get to the UHC? Minutes 8. For what problem/disease have
you come to the UHC?
9. Which department have you come to seek care from?
OPD (0) IPD (1) Emergency (2) Other (3) specify
1. Does the UH&FPO practice as clinician in the UHC No (0) Yes (1)
2. Total number of consultants posted
3. Total number of consultants present
4. Total number of MO’s posted
5. Total number of MO’s present
6. Total number of MA’s posted
7. Total number of MA’s present
8. Total number of Nurses posted
9. Total number of Nurses present
10. Total number of vacant posts of 1st class staffs in the UHC
11. Total number of vacant posts of 2nd class staffs in the UHC
12. Total number of vacant posts of 3rd and 4th class staffs in the UHC
13. Total number of patients visit in a day (average)
14. Total number of patients come to the UHC in a year (OPD, IPD, Emergency)
10. What is your reflection regarding service delivery of Health education?
0 1 2 3 4 5 6 7 8 9 10
11. What is your reflection regarding service delivery of environmental sanitation especially of food and water?
0 1 2 3 4 5 6 7 8 9 10
12. What is your reflection regarding service delivery of MCH program (EOC)
0 1 2 3 4 5 6 7 8 9 10
13. What is your experience regarding service utilization of MCH program (EOC)
0 1 2 3 4 5 6 7 8 9 10
14. What is your reflection regarding service delivery of Immunization program (EPI)
0 1 2 3 4 5 6 7 8 9 10
15. What is your experience regarding service utilization of Immunization program (EPI)
0 1 2 3 4 5 6 7 8 9 10
16. What is your reflection regarding service 0 1 2 3 4 5 6 7 8 9 10
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delivery of Prevention of locally endemic diseases
17. What is your reflection regarding service delivery of Treatment of common diseases and injuries
0 1 2 3 4 5 6 7 8 9 10
18. What is your experience regarding service utilization of Treatment of common diseases and injuries
0 1 2 3 4 5 6 7 8 9 10
19. What is your reflection regarding distribution of essential drugs?
0 1 2 3 4 5 6 7 8 9 10
20. How will you rate the service delivery of the pathology?
0 1 2 3 4 5 6 7 8 9 10
21. How will you rate the service of pathology? 0 1 2 3 4 5 6 7 8 9 10 22. What is your reflection regarding service
delivery of promotion of nutrition? 0 1 2 3 4 5 6 7 8 9 10
23. What is your reflection regarding service delivery of OPD?
0 1 2 3 4 5 6 7 8 9 10
24. What is your experience regarding service of OPD?
0 1 2 3 4 5 6 7 8 9 10
25. What is your reflection regarding service delivery of IPD?
0 1 2 3 4 5 6 7 8 9 10
26. What is your experience regarding service of IPD?
0 1 2 3 4 5 6 7 8 9 10
27. What is your reflection regarding overall service delivery of the UHC?
0 1 2 3 4 5 6 7 8 9 10
28. What is your experience regarding service of the UHC
0 1 2 3 4 5 6 7 8 9 10
29. Is provision for traditional medicine included in the service delivery of the UHC No(0) Yes(1) 30. If yes, rate its condition? 0 1 2 3 4 5 6 7 8 9 10
2. Resource generation 31. Rate the training of health and other staffs 0 1 2 3 4 5 6 7 8 9 10
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Annex C: Key informant interview checklist
Respondents to be interviewed: Dr. A I Begum, Colonel Mozammel, Dr. A M Zakir Hussain
History of PHC in BD 1. Could you please tell us about yourself and your educational background and career? 2. Can you reflect on your involvement with the PHC in Bangladesh? 3. Is there any particular issue that you want to share that had taken place during your time? 4. What was your role in particular in respect of PHC? 5. Health status of Bangladesh before PHC introduction 6. How Bangladesh got involved with the concept of PHC 7. Does Bangladesh have any role in formulation of PHC policy 8. What was your role during those days 9. What was the early steps in Bangladesh to introduce PHC 10. How PHC had been implemented 11. What were the obstacles 12. What is the condition of PHC delivery in the initial days 13. Describe the evolution of PHC delivery in Bangladesh so far
Weakness in existing PHC delivery in Bangladesh 14. How will you evaluate the condition of PHC in Bangladesh now? 15. What are the weaknesses of PHC in context of Bangladesh
Recommendation for CPHC 16. What is your suggestion about the PHC keeping in mind the influence of a globalized, urbanized
and ageing world 17. What is your suggestion to improve the situation of PHC in Bangladesh? 18. How it can focus more on health needs of the people? 19. How can it be more enduring personal relationships especially in highly populous country like
Bangladesh? 20. What is your specific suggestion regarding delivering the care in a more comprehensive,
continuous and person centered way? 21. How can it answer the question of responsibility for the health of all in the community along
the life cycle; responsibility for tackling determinants of ill-health? 22. How to make people partners in managing their own health and that of their community? 23. How can we empower users to contribute to their own health? 24. How can we integrate the ICT with the PHC?
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Annex D: IDI guideline for UH&FPO
Introductory questions 1. Could you please tell us about yourself, your educational background and career?
2. Can you reflect on your work as UH&FPO in this UHC?
3. Is there any particular issue that you want to share regarding PHC delivery in this UHC?
8 components of PHC
Education concerning prevailing health problems and the methods of preventing and controlling them
4. Do you know what are the prevailing health problems in this area (catchment area of the UHC).
5. How do you know that?
6. Is there any way to inform it to the higher authority?
7. Is that maintained properly?
8. Is there any approach from the higher authority to address those particular problems?
9. Do you have any mechanism to educate the local people concerning prevailing health problems and the methods of preventing controlling them? What are those mechanisms?
10. Are those mechanisms effective?
11. How to improve that?
Promotion of food supply and proper nutrition 12. What is the condition of nutrition in this area (catchment area of the UHC)?
13. What measures are taken for promotion of food supply and nutrition?
14. How is it carried out?
15. Is there any problem in your effort for promotion of food supply and proper nutrition? What are the problems if there is any?
16. How to improve the condition?
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An adequate supply of safe water and basic sanitation 17. Is ensuring adequate supply of safe water and basic sanitation your responsibility (in the
catchment area of the UHC)?
18. Who is responsible for that?
19. What is your role regarding adequate supply of safe water and basic sanitation?
20. What is the condition of adequate supply of safe water and basic sanitation in this area (catchment area of the UHC)?
21. What do you think is the reason for this condition?
22. How to improve this scenario?
Maternal and child health care, including family planning 23. What is the MMR, IMR, CPR etc. in this area (catchment area of the UHC)?
24. What do you think the reason behind this condition?
25. What do you do for maternal and child health care, including family planning?
26. How to further improve the condition?
Immunization against the major infectious diseases 27. What is the Immunization coverage of this area (catchment area of the UHC)?
28. What do you think the reason behind this condition?
29. How to further improve the condition?
Prevention and control of locally endemic diseases 30. What are the locally endemic diseases?
31. Is there any formal way of determining the endemicity of those diseases?
32. Is it under your responsibility to prevent and control those locally endemic diseases?
33. How do you do that?
34. What are the limitations in doing that?
35. What do you think the reason behind this situation?
36. How to improve the situation?
Appropriate treatment of common diseases and injuries 37. Is there enough facility for providing appropriate treatment of common diseases and injuries?
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38. What are the common diseases and injuries that you provide service here?
39. What are the treatment facilities available for those?
40. Do you think these are sufficient for appropriate treatment?
41. What do you do if you fail to provide appropriate treatment of common diseases and injuries?
42. How will you rate the condition of appropriate treatment of common diseases and injuries in this UHC?
43. Can you share your experience in providing appropriate treatment of common diseases and injuries?
44. How to improve this situation?
Provision of essential drugs 45. What are the essential drugs?
46. Is there any mechanism to provide essential drugs from the UHC?
47. What are the available drugs in the UHC?
48. How to improve the situation?
Referral and Principles of PHC (except equity, community empowerment and devolution)
Referral 49. What diseases or conditions you treat here?
50. What do you do if you cannot provide the treatment?
51. Do you have any ambulance here?
52. Is if functioning?
53. What is the way of obtaining ambulance service?
54. What do understand by properly functioning referral service?
55. Can patients overtake the UHC and go to the secondary and tertiary level hospitals?
56. Why do you think people do so?
57. How to improve the scenario so that people does not do so?
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Health Prevention & Promotion 58. How do you rate the promotive, preventive, curative and rehabilitative services in your UHC?
59. How to improve that?
Appropriate Technology 60. Do you think that the treatment that people get from the UHC is culturally sensitive?
Intersectoral Coordination 61. What do you understand by inter sectoral coordination?
62. Do you feel it is necessary in maintaining the health of the population?
63. Can you share some instance where inter sectoral cooperation was crucial?
64. Do you have any guideline from higher authority in maintaining inter sectoral coordination?
65. Which sectors do you think you should maintain coordination with?
66. How to improve intersectoral coordination?
Community empowerment and Devolution
Have access to information 67. Do you acknowledge that people should be informed about their right to service?
68. Are the people of your area (catchment area of the UHC) informed about what services are available here?
69. How do you ensure that they are informed?
70. Do you think that this strategy is effective/perfect?
71. What else could be done to improve the situation?
Are included and participate in forums where issues are discussed and decisions are made
72. Do you know whether the people are included and participate in forums where issues related their health and health care are discussed?
73. Do you think it is needed at all?
74. Have you done or directed to do anything on this issue?
75. Are people in any way involved in decision making process of the UHC?
85
76. If not then what is the obstacle?
77. Is it necessary?
78. Is possible to ensure peoples participation in decision making?
79. How?
Can hold decision-makers accountable for their choices and actions 80. Can people hold you accountable for your choices and actions?
81. Can you describe any occasion when such thing took place?
82. How do you ensure your accountability in the UHC?
83. What is your suggestion regarding the issue?
Have the capacity and resources to organize to aggregate and express their interests and/or to take on roles as partners with public service delivery agency
84. Is there any option/scope that people work in partnership with the UHC in decision making of the UHC?
85. Can you share any such instance?
86. Is there any option/scope that people work in partnership with the UHC in service delivery?
87. Can you share any such instance?
88. Are these necessary at all?
89. How to improve the scenario?
Devolution 90. Do you have any connection with the local government?
91. Do you have any committee where local government people are involved?
92. When did the last meeting take place?
93. What issues were discussed?
94. Is it necessary to involve them?
95. How to make the system more effective?
96. Do they create any problem for the UHC?
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97. Do they come to visit or put any suggestion in improvement of the service of the UHC?
98. What would be your reaction if they do so?
99. What are the negative sides?
100. What problems do they create?
101. Does local government have any role in monitoring the service of the UHC? Have ever practiced the role?
102. Does local government have any opportunity to see the audit report and question the authority about it?
103. Does local government have any say about the budget of the UHC?
104. How to improve the relation with the local government?
Weakness of the health system 105. What do you understand by HMIS
106. What is the condition of the HMIS in your UHC? Is it done properly? Can you give some example?
107. What are the Problems regarding financing of the UHC? Are the funds adequate?
108. If not, how do you tackle that?
109. How external monitoring is carried out? Is it adequate/effective?
110. How internal monitoring is done? Do face any problem in that?
111. How many personnel are missing in your UHC?
112. What problems do you face for this?
113. How do you tackle the problems of absenteeism?
114. Can you give some examples of PPP in your UHC?
115. What is your reflection regarding that?
116. Are there vertical programs running in the UHC?
117. Do you face any problem in undertaking the vertical programs?
118. How to integrate the vertical programs so that your activities are smoother?
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119. Is there any client feedback mechanism in your UHC? Or, what if any problem occurs to any patient and he/she wants to file any complain to the authority? Or give any suggestion? Is there any mechanism for that?
120. Do you think the mechanism is effective/practical?
121. How to improve the client feedback mechanism?
122. Is there any direction from the higher authority in taking into account the changes due to globalization, urbanization, population migration etc?
123. Is there any direction from the higher authority in taking into account the NCDs, ageing issues, youth issues?
124. Is there any mechanism for protecting the poor patients from catastrophic health expenditure?
125. Is there any poor fund/medicine bank etc?
126. Do you think responsiveness is maintained in the UHC (in terms of prompt attention, dignity, clear communication, autonomy, confidentiality, choice of health care provider, quality basic amenities, access to social support network)
127. What is the condition of in-service training of the staffs of the UHC? Is it adequate?
128. What trainings/activities do you suggest to improve the quality of the UHC personnel?
129. Is visiting hour possible to maintain here? What is the condition?
Suggestion 130. Please recommend some suggestions in improving the PHC delivery in your
UHC/Bangladesh?
Thank you very much
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Annex E: IDI guideline for MO/MA
Introductory questions 1. Could you please tell us about yourself, your educational background and career?
2. Can you reflect on your work as MA/MO in this UHC?
3. Is there any particular issue that you want to share regarding PHC delivery in this UHC?
Components of PHC (MCH-FP, treatment of disease and injuries, essential drugs)
Maternal and child health care, including family planning 4. What is the MMR, IMR, CPR etc. in this area (catchment area of the UHC)?
5. What do you think the reason behind this condition?
6. What do you do for maternal and child health care, including family planning?
7. Do you face any problem in providing MCH and FP?
8. How to further improve the condition?
Appropriate treatment of common diseases and injuries 9. Is there enough facility for providing appropriate treatment of common diseases and injuries?
10. What are the common diseases and injuries that you provide service here?
11. What are the treatment facilities available for those?
12. Do you think these are sufficient for appropriate treatment?
13. What do you do if you fail to provide appropriate treatment of common diseases and injuries?
14. How will you rate the condition of appropriate treatment of common diseases and injuries in this UHC?
15. Can you share your experience in providing appropriate treatment of common diseases and injuries?
16. How to improve this situation?
Provision of essential drugs 17. What are the essential drugs?
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18. Is there any mechanism to provide essential drugs from the UHC?
19. What are the available drugs in the UHC?
20. How to improve the situation?
Referral and principles of PHC (prevention-promotion, appropriate technology, inter-sectoral collaboration)
Referral 21. What diseases or conditions you treat here?
22. What do you do if you cannot provide the treatment?
23. Do you have any ambulance here?
24. Is if functioning?
25. What is the way of obtaining ambulance service?
26. What do understand by properly functioning referral service?
27. Can patients overtake the UHC and go to the secondary and tertiary level hospitals?
28. Why do you think people do so?
29. How to improve the scenario so that
Health Prevention & Promotion 30. How do you rate the promotive, preventive, curative and rehabilitative services in your UHC?
31. How to improve that?
Appropriate Technology 32. Do you think that the treatment that people get from the UHC is culturally sensitive?
33. Can you share with us some instance where you thing the technology was not appropriate in delivering the service?
Community empowerment and devolution (Challenging accountability)
Can hold decision-makers accountable for their choices and actions 34. Can people hold you accountable for your choices and actions?
35. Can you describe any occasion when such thing took place?
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36. How do you ensure your accountability in the UHC?
37. What may happen to you if do something wrong with the patient or neglect your duty?
38. Have you ever faced such situation?
39. What is your suggestion regarding the issue?
Devolution 40. Do the local government people create any problem for the UHC?
41. Do they come to visit or put any suggestion in improvement of the service of the UHC?
42. What would be your reaction if they do so?
43. What are the negative sides?
44. What problems do they create?
45. Does local government have any role in monitoring the service of the UHC? Have ever practiced the role?
46. Do you think involvement of the local government is necessary at all?
47. How to improve the relation with the local government?
Health system weakness 48. What are the Problems regarding financing of the UHC? Are the funds adequate?
49. If not, how do you tackle that?
50. How external monitoring is carried out? Is it adequate/effective?
51. How internal monitoring is done? Do face any problem in that?
52. Can you give some examples of PPP in your UHC?
53. What is your reflection regarding that?
54. Is there any client feedback mechanism in your UHC? Or, what if any problem occurs to any patient and he/she wants to file any complain to the authority? Or give any suggestion? Is there any mechanism for that?
55. Do you think the mechanism is effective/practical?
56. How to improve the client feedback mechanism?
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57. Is there any direction from the higher authority in taking into account the changes due to globalization, urbanization, population migration etc?
58. Is there any direction from the higher authority in taking into account the NCDs, ageing issues, youth issues?
59. Is there any mechanism for protecting the poor patients from catastrophic health expenditure?
60. Is there any poor fund/medicine bank etc?
61. How much time do you give per patient while they come for service seeking? Is it adequate?
62. Why can’t you give quality time to each patient?
63. How much time on an average patients need to wait before he/she can visit a service provider/doctor?
64. How you yourself rate you attitude with the patient? If it is not proper then why so?
65. What is the attitude of the nurses?
66. What is the attitude of the MAs
67. What is the attitude of the other staffs with the patients?
68. How often do you listen carefully to the complaints of the patients? Why?
69. How often do you explain things in a way that patients can understand? Why?
70. Do you think it is necessary at all?
71. How often do you give patients time to ask questions about their health problems or treatment?
72. Do you ask permission before starting the treatment or test? Why?
73. How often you talk with patient privately so that other people could not overhear what was said? Why?
74. Is confidentiality of data of the patients possible to maintain here? Why?
75. What becomes your reaction if the patients want to choose their own provider?
76. How will your rate the cleanliness of the UHC?
77. Does UHC allow the patients to interact with family, friends?
78. Is it possible for them to practice religious customs during stay in hospital?
79. Is visiting hour being maintained properly in the UHC? What are the problems you face?
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80. What is the condition of in-service training of the staff?
Suggestions 81. Please recommend some suggestions in improving the PHC delivery in your UHC/Bangladesh?
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Annex F: IDI guideline for field staffs
Introductory questions 1. Could you please tell us about yourself, your educational background and career?
2. Can you reflect on your work as a field staff in this UHC? Share your experiences in carrying out your duty.
3. Is there any particular issue that you want to share regarding your service delivery in this UHC?
Components of PHC (Health education, EPI)
Education concerning prevailing health problems and the methods of preventing and controlling them
4. Do you know what are the prevailing health problems in this area (catchment area of the UHC).
5. Do you educate the people regarding those health problems?
6. What are the things you give health education about?
7. How do you do that?
8. Do you face any problem in doing that?
9. How do you know about what education should be given to the community?
10. Do you think your health education is effective?
11. How do you know that?
12. How to improve that?
Immunization against the major infectious diseases 13. What is the Immunization coverage of this area (catchment area of the UHC)?
14. How do you do your work for immunizing the children?
15. Do you face any problem?
16. What do you think the reasons for such high/low immunization coverage?
17. How to further improve the condition?
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Community empowerment (Access to information)
Have access to information 18. Do you acknowledge that people should be informed about their right to service?
19. Are the people of your area (catchment area of the UHC) informed about what services are available here?
20. How do you ensure that they are informed?
21. Do you think that this strategy is effective/perfect?
22. What else could be done to improve the situation?
Suggestions 23. Please recommend some suggestions to improve your service in your UHC/Bangladesh?
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Annex G: IDI guideline for patients
Introductory questions 1. Why have you come here? What are your problems?
2. Tell about yourself, your family, education etc?
3. Why didn’t you go somewhere else for service seeking?
8 components of PHC (except equity)
Education concerning prevailing health problems and the methods of preventing and controlling them
4. Do you know what are the prevailing health problems in this area (catchment area of the UHC).
5. How do you know that?
6. Where do you get health educations from?
7. How often do the health educators visit your household/locality?
8. Do you think this health educations are effective?
9. What else could be done?
10. What according to you are the best ways to get health education?
11. What is your suggestion regarding education concerning prevailing health problems and the methods of preventing and controlling them?
Promotion of food supply and proper nutrition 12. What is the condition of food supply in your family?
13. What do you eat in your family usually?
14. How often do you eat meat?
15. What is the condition in your area?
16. What happens if there is shortage of food supply?
17. Is there any way that you know someone of your family members is suffering from malnutrition?
18. If any person from your family or area is suffering from malnutrition what do you do?
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19. How to improve the condition of food supply and proper nutrition?
An adequate supply of safe water and basic sanitation 20. What type of latrine do you use?
21. Who gave you the knowledge/information about using this latrine?
22. Where do you get drinking water?
23. How do you know that it is pure or not?
24. What happens if there is no proper provision for adequate supply of safe water and basic sanitation?
25. Who installs tube-well and sanitary latrines?
26. How to improve adequate supply of safe water and basic sanitation?
Maternal and child health care, including family planning 27. What do you do when a mother is pregnant? Do you send her for check-up?
28. Where is the delivery usually taking place?
29. How often do you hear now-a-days about maternal death?
30. Is there any improvement from before?
31. What about child death?
32. What do you do for maternal and child health care?
33. What is the condition of family planning? Do you think it is necessary?
34. How to further improve the condition of maternal and child healthcare, including family planning?
Immunization against the major infectious diseases 35. Are your children immunized against the major infectious diseases?
36. How do you know about vaccination?
37. How to further improve the condition?
Prevention and control of locally endemic diseases 38. What are the locally endemic diseases?
39. Have you noticed any activity in preventing and controlling those diseases?
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40. Whose responsibility do you think is this?
41. How to improve the situation?
Appropriate treatment of common diseases and injuries 42. What do you do in case of common diseases and injuries?
43. Are the treatment facilities sufficient to treat common diseases and injuries? How will you rate the condition of appropriate treatment of common diseases and injuries in this UHC?
44. Can you share your experience in receiving treatment of common diseases and injuries from the UHC?
45. How to improve this situation?
Provision of essential drugs 46. What are the available drugs in the UHC?
47. Do you get the drugs for free?
48. What do you do if you don’t find necessary drugs?
49. What do you do if the drugs needed to buy from outside are unaffordable?
50. How to improve the situation?
Referral and Principles of PHC (except equity, community empowerment, inter-sectoral collaboration and devolution)
Referral 51. Is there functioning ambulance here? What is the way of obtaining ambulance service?
52. Can you overtake the UHC and go to the secondary and tertiary level hospitals?
53. Why do you do so?
54. What will prevent you from going to the higher referral centers overtaking the UHC?
Health Prevention & Promotion 55. How do you rate the promotive, preventive, curative and rehabilitative services in the UHC?
56. How to improve that?
Appropriate Technology 57. Do you think that the treatment that people get from the UHC is culturally sensitive?
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Community empowerment and Devolution
Have access to information 58. Do you acknowledge that you should be informed about your rights to service?
59. Are you informed about what services are available here?
60. Do you feel it is quite enough? Or do you think you need more information regarding the available health care facilities?
61. How do you usually get information about different public facilities, be it health or other?
62. Do you have access to mass media? What are those?
63. How can you be more informed about getting service from the UHC? What according to you are the best ways for you to get informed?
Are included and participate in forums where issues are discussed and decisions are made
64. Are you included and participate in forums where issues related their health and health care are discussed?
65. Do you think it is needed at all?
66. Are you in any way involved in decision making process of the UHC?
67. If not then what is the obstacle?
68. Is it necessary?
69. How to make you involved in decision making?
Can hold decision-makers accountable for their choices and actions 70. Can you hold UHC personnel accountable for their choices and actions?
71. Can you describe any occasion when such thing took place?
72. What is your suggestion regarding the issue? How to make them more accountable?
Have the capacity and resources to organize to aggregate and express their interests and/or to take on roles as partners with public service delivery agency
73. Is there any option/scope that you work in partnership with the UHC in decision making of the UHC?
74. Can you share any such instance?
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75. Is there any option/scope that you work in partnership with the UHC in service delivery?
76. Can you share any such instance?
77. Are these necessary at all?
78. How to enhance your participation and partnership with the UHC service delivery?
Weaknesses of health system 79. Are medicines available in times of need? 80. Do the doctors treat you properly? Do they charge extra money? 81. What is the condition of the pathology? Do you get free service from there? Are the reports
reliable? 82. Are there adequate doctors/personnel at all times? 83. How competent are the personnel of the UHC?
84. Is there any client feedback mechanism in the UHC? Or, what if any problem occurs to you and you want to file any complain to the authority? Or give any suggestion? Is there any mechanism for that?
85. Do you think the mechanism is effective/practical/useful?
86. How to improve the client feedback mechanism?
87. Is there any good facility for the elderly people?
88. Is there any good facility for the disabled people?
89. Is there any mechanism for protecting the poor patients from catastrophic health expenditure?
90. Do the doctors give quality time while giving you treatment?
91. How much time on an average you need to wait before you can visit a service provider/doctor?
92. What is the attitude of the Doctors (MO)
93. What is the attitude of the MAs
94. What is the attitude of the nurses?
95. What is the attitude of the other staffs with the patients?
96. How often do they listen carefully to your complaints of the patients?
97. How often do they explain things in a way that you can understand?
100
98. How often do the doctors give you time to ask questions about your health problems or treatment?
99. Do they ask permission before starting the treatment or test?
100. How often they talk with you privately so that other people could not overhear what was said?
101. Do you think confidentiality of your data is maintained or possible to maintain?
102. What becomes their reaction if you want to choose your own provider?
103. How will your rate the cleanliness of the UHC?
104. Does UHC allow you to interact with family, friends?
105. Is it possible for you to practice religious customs during stay in hospital?
106. If you want to be treated by a traditional practitioner is it possible to get it from the UHC? Do you think it should be there?
107. Do you think that it is possible for patients to face catastrophic health expenditure? Can you share some such stories?
Suggestions 108. How to improve the service of the UHC? What are your suggestions?
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Annex H: IDI guideline for Local Government leader
Date
Place
Background questions 25. Could you please tell us about yourself, your educational background and career? 26. Can you reflect on your involvement with the UHC if there is any? 27. Is there any particular issue that you as a local leader want to share regarding the UHC?
Empowerment 5. To what extent do the people of your constituency have access to information regarding the
services provided by the UHC? 6. How can the people be more informed about their rights about getting service from the UHC? 7. Is there any way so that people can be included and participate in forums where issues are
discussed and decisions are made? 8. If there is none then what do you suggest to develop such mechanism so that people can be
included and participate in forums where issues regarding health and health care delivery are discussed and decisions are made?
9. Can people hold decision-makers accountable for their choices and actions? 10. If there is any objectionable/bad occurrence in the UHC can you or the people hold the
authority responsible for what has happened? 11. What can be the ways of enhancing the accountability of the UHC personnel? 12. Do the people have the capacity and resources to organize to aggregate and express their
interests and/or to take on roles as partners with public service delivery agency? 13. How to do that?
Devolution 14. Does the local government have any role in the governance issues of the UHC? 15. What are the roles? 16. Do you ever get the opportunity to set local policies and priorities, plans autonomously in
response to local preferences and needs? 17. Does local government have any program of disseminating information regarding health and
health care service to the people? 18. Do you have any opportunity to see the audit report and question the authority about it? 19. Do you have any say about the budget of the UHC? 20. What at best you can do if something bad/objectionable happens to any patient of the UHC?
Can you describe any such occurrence?
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21. Who are the members of civil society in your locality? Do you maintain any link with them? 22. What do you or can you do to ensure the rights and interest of the people of your constituency
who are coming to the UHC? Can you share your experience? 23. Do you have any role in monitoring the service of the UHC? Have ever practiced the role? 24. Is there any problem that might be created by the local government itself?
Weakness of the UHC 25. How responsive is the UHC to the patients in terms of prompt attention, dignity, autonomy,
clarity of communication, quality of basic amenities, access to family and community support and confidentiality?
26. What are the weaknesses of the UHC in terms of medicine, practice of the doctors, pathological tests, and other services?
27. What is the condition of UHC in HRH? Is there adequate doctors, nurses and other staffs? If not then do you know why? Have you done anything in this regard?
28. How competent are the personnel of the UHC?
Suggestion 29. Do you have any suggestion to improve the service of the UHC?
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Annex I: Guideline for observation of UHC
Date of observation
Place of observation
Dimension of observation 1. Space- physical space 2. Object- physical things that are present 3. Actor- the people involved 4. Act- single action that people do 5. Activity- a set of related acts (formal/informal) 6. Event- set of related activities (sequence)
Checklist for observation
Maternal and child health care, including family planning 7. Observation of in-door wards (male and female), nursing station and labor room. 8. Observation of patients coming for service regarding MCH and FP 9. Privacy of the patients 10. Responsiveness
Appropriate treatment of common diseases and injuries 11. Observation of outdoor facility and doctor patient interaction? 12. Observation of innovative therapeutic practices 13. Availability of resources, drugs etc 14. Availability of HRH
Appropriate technology 15. Observation of morning round 16. Observation of discharge of the patients 17. Observation of the treatment of different diseases and observation of reaction of patients to the
treatments
Weakness of the health system 18. Observation of the pharmacy to see availability of essential drugs, other drugs? 19. Observation of pharmacy to see the interaction between provider and clients and the reaction
of clients to medicine shortage. 20. Observation of the ticket room
104
21. Observation of the client feedback mechanism 22. Waste management 23. Sterilization 24. Diet of the patient 25. Referral practices 26. Privacy of the patients
105
Annex J: PRA guideline
Date
Site
Number of participants
Methods Free listing
Pair ranking
Items 1. Free list the problems you face in seeking care from the UHC? 2. Rank the problems you face in seeking care from the UHC (Pair ranking)? 3. What are the best things about the UHC? 4. Rank the best things about the UHC (pair ranking)? 5. Can you tell me what are the services offered in the UHC (free listing then matching with the
citizen charter with frequency of response)? 6. What are the best possible ways to obtain information regarding available services (free listing)? 7. Score the following services in terms of their effectiveness
a. Education concerning prevailing health problems and the methods of preventing and controlling them
b. Promotion of food supply and proper nutrition c. An adequate supply of safe water and basic sanitation d. Maternal and child health care, including family planning e. Immunization against the major infectious diseases f. Prevention and control of locally endemic diseases g. Appropriate treatment of common diseases and injuries h. Provision of essential drugs
106
Annex K: Document review guideline
Name of the reviewer
Name of the document
Location of the document
Short description of the document
Finding from the document
Remarks
107
Annex L: Household Survey Questionnaire
REVITALIZING HEALTH FOR ALL: DEVELOPING A COMPREHENSIVE PRIMARY HEALTH CARE MODEL FOR BANGLADESH
Questionnaire for Household Survey at Village
Respondent ID Date---------------
Name of the village
Consent form:
We are conducting a research on ‘Comprehensive Primary Health Care’ on behalf of James P Grant
School of Public Health, BRAC University. As part of this research we will ask you few questions. Your
identity and the information provided by you will be kept confidential. You conserve every right not to
answer any question at any point of the interview. If you develop any query regarding any of our
questions we will try to explain it to you. Are you agreed to give the interview.
Yes No
Signature of the respondent: Signature of the interviewer
Name of the respondent: Name of the interviewer:
108
Answer code Skip
1 Gender 1. Male
2. Female
1
2
2 Age (Year)
3 Marital status 1. Unmarried
2. Married
3. Divorced/separated
4. Widowed
1
2
3
4
If answer 1 then skip question 5 and 6
4 Educational Qualification 1. Illiterate
2. Primary (1-5)
3. Secondary (6-10)
4. Higher secondary (11-12)
5. Higher than that
1
2
3
4
5
5 Age at the time of marriage (Year)
66
Not applicable
6 Duration of married life (Month)
66
Not applicable
7 Religion 1. Muslim
2. Hindu
3. Buddhist
4. Christian
5. Other (Specify)
1
2
3
4
55
8 Occupation of the main earning member of the household (More than one answer acceptable)
1. Farming in own land
2. Agricultural labor/ farming in others land
1
2
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3. Day labor
4. Fishing using own boat
5. Poultry farming
6. Dairy farming
7. Service holder
8. Trade and business
9. Lives abroad
10. Jobless
11. Other (Specify)
3
4
5
6
7
8
9
10
55
9 What is the number of your family members?
10 What is your household income?
11 Are you owner of this house? Yes (1) No (2)
Type of house Brick built wall (1)
Corrugated iron made wall (2)
Mud/ Bamboo made wall (3)
Have own tube-well Yes (1) No (2)
Have sanitary latrine Yes (1) No (2)
Electricity Yes (1) No (2)
Mobile phone Yes (1) No (2)
Do you have any table? Yes (1) No (2)
Do you have cot? Yes (1) No (2)
Do you have wall clock? Yes (1) No (2)
Do you have radio? Yes (1) No (2)
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Do you have TV? Yes (1) No (2)
Do you have bi-cycle? Yes (1) No (2)
Do you have any cattle? Yes (1) No (2)
12 What is the general health condition of the people in your locality?
1. Very bad
2. Bad
3. Moderate
4. Good
5. Very good
1
2
3
4
5
13 Who usually treat people in your locality (More than one answer acceptable)?
1. Traditional healers (Kabiraj, ojha, baidya, hujur, peer, fakir)
2. Homeopathy
3. Village doctor
4. Village health worker
5. Medicine seller/ pharmacy
6. Private hospital/ clinic
7. NGO run health center
8. Chamber of MBBS doctor
9. Union sub center
10. Upazila health complex
11. Other (Specify)
1
2
3
4
5
6
7
8
9
10
55
14 Do you know that there is an Upazila Health Complex in your locality?
1. Yes
2. No
1
2
15 Have you ever gone to the Upazila Health Complex?
1. Yes
2. No
1
2
If answer 2 skip to 17
16 Why did you go? (Most 1. Free treatment 1
111
relevant one) 2. Near to home
3. Transportation easier
4. Better treatment
5. Better diagnostic facility
6. Availability of indoor admission facility
7. Availability of operation facility
8. Other (Specify)
10. Not applicable
2
3
4
5
6
7
55
66
17 Why didn’t you go? (Most relevant one)
1. Don’t know what facilities are available
2. Poor treatment
3. Far away from home
4. Transport difficulty
5. Long waiting time
6. Unavailability of time
7. Non-cooperative attitude of the service providers
8. Money is charged
9. Medicine not available
10. Other
11. Not applicable
1
2
3
4
5
6
7
8
9
55
66
18 How much time does it take on an average to get to the nearest health center?
112
19 Do you know whether any fee is taken for health care in the health center?
1. Fee taken
2. Fee not taken
3. Don’t know
1
2
3
If ans. 1 skip to ques. 21
20 If user fee is introduced will you still go to seek care?
1. Yes
2. No
3. Don’t know
1
2
66
21 Will you still go if facilities are increased?
1. Yes
2. No
1
2
22 Do the doctors take any fee/money in the UHC?
1. Yes
2. No
3. Don’t know
1
2
3
23 Where do you usually go to seek primary health care?
1. Private facility
2. UHC/ Government facility
3. Chamber of MBBS doctor
4. Homeopathic
5. Village doctor
6. Kabiraj/ fakir/ ojha/ hujur
7. Home treatment/ self medication
8. No treatment
9. Other
1
2
3
4
5
6
7
8
55
24 Which facilities are provided from the UHC as per your information? (More than one answer acceptable)
1. Essential health care for all
2. Round the clock service
3. Special care for diarrhea
1
2
3
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4. Necessary pathological tests
5. Emergency obstetric care
6. Outdoor service
7. Emergency care
8. Indoor (admission) service
9. Vaccination
10. Health education
11. Ambulance/ referral
12. Other
4
5
6
7
8
9
10
11
55
25 How do you know about these facilities?
26 Has anybody ever visited you from the UHC to give health education?
1. Yes
2. No
1
2
If ans. 2 skip to ques. 28
27 How frequently does he visit?
Per month/ year
28 Which mass media do you get the most information from?
1. Television
2. Radio
3. News paper
4. Video
5. From no mass media
6. Other
1
2
3
4
5
55
29 How many times a day can you afford to eat satisfactorily?
1. Less than 2 times
2. 2 times
3. 3 times
1
2
3
30 After how many days do you get an opportunity to eat
114
meat?
31 Where do you manage drinking water from?
1. Tube well
2. By boiling river/ pond water
3. Directly from river/ pond
4. Other
1
2
3
55
32 Do you have sanitary latrine in your household?
1. Yes
2. No
1
2
33 Do you wash your hand with soap before eating or cooking and after using the latrine?
1. Yes
2. No
3. Sometimes
1
2
3
34 Have you ever received any information regarding the safe water, health and sanitation?
1. Yes
2. No
1
2
35 Do you have any child? 1. Yes
2. No
1
2
If ans. 2 skip to ques. 45
36 Where did the last child born?
1. Home/ paternal home
2. Government hospital/ UHC
3. Private hospital/ clinic
4. Other
5. Not applicable
1
2
3
55
66
37 Did you receive ANC from the UHC (education regarding ANC, regular checkup by doctor, identifying danger signs, receiving vitamin/iron
1. Yes
2. No
3. Not applicable
1
2
66
If ans. 2 skip to ques. 40
115
tablet)?
38 Where did you receive ANC from?
1. Government facility/ UHC
2. Private facility/ clinic
3. Health worker
4. Other
5. Not applicable
1
2
3
55
66
39 How many times did you receive ANC?
1. 1 time
2. 2 times
3. 3 times
4. More than that
5. Not applicable
1
2
3
4
66
40 Did you receive any PNC from the UHC (Checkup by the doctor, education regarding breast feeding)?
1. Yes
2. No
3. Not applicable
1
2
66
If ans. 2 skip to ques. 43
41 Where did you receive PNC from?
1. Government facility/ UHC
2. Private facility/ clinic
3. Health worker
4. Other
5. Not applicable
1
2
3
55
66
42 How many times did you receive PNC?
1. 1 time
2. 2 times
3. More than that
4. Not applicable
1
2
3
66
43 Did your child receive vaccination against 6 dangerous diseases?
1. Yes
2. No
1
2
If ans. 2 skip to
116
3. Don’t know
4. Not applicable
3
66
ques. 45
44 Where did you get vaccination?
1. Local vaccination center
2. Government hospital
3. Private hospital/ clinic
4. Other
5. Not applicable
1
2
3
55
66
45 What is the most prevalent disease in your area?
1.
2. Don’t know
55
If 2 skip to ans. 47
46 Is there any activity from the UHC to prevent this disease?
1. Yes
2. No
3. Don’t know
4. Not applicable
1
2
3
66
47 How do you rate the standard of treatment of common diseases and injuries in the UHC?
1. Very good
2. Good
3. Moderate
4. Bad
5. Very bad
1
2
3
4
5
48 What is the condition of availability of essential drugs in the UHC?
1. Always available
2. Sometimes available
3. Rarely available
4. Not available
1
2
3
4
49 Are there any forum/ seminar/ meeting/ committee for decision making on services of the UHC in the village/ union/
1. Yes
2. No
3. Don’t know
1
2
3
If ans. 2 or 3 skip to ques. 52
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upazila?
50 Have you ever participated in any forum/ seminar/ meeting/ committee for decision making on services of the UHC in the village/ union/ upazila?
1. Yes
2. No
3. Not applicable
1
2
66
If ans. 2 skip to ques. 52
51 Do you think your participation/ opinion was useful?
1. Yes
2. No
3. Don’t know
4. Not applicable
1
2
3
66
52 Is there any scope to work in collaboration with the UHC concerning health?
1. Yes
2. No
3. Don’t know
1
2
55
If ans. 2 or 3 skip to ques. 54
53 Have you ever worked in collaboration with the UHC concerning health?
1. Yes
2. No
3. Not applicable
1
2
66
54 Is there any client feedback mechanism in the health center?
1. Yes
2. No
3. Don’t know
1
2
3
55 Is your feedback taken into sincere consideration?
1. Yes
2. No
3. Don’t know
1
2
3
56 What kind of client feedback mechanism is suitable for the UHC?
