Healthcare Services for All: the Bangladesh Story

Healthcare Services for All: the Bangladesh Story

Bangladesh is doing extremely well (on health services). I am really very impressed on community clinics. I happened to visit the community clinics. Not only that I saw women sitting and waiting for consultation with doctors. Television is giving extremely good messages on how they should take care of children, what nutrition given to their children. Time is being utilized so well that it is not seen in many parts of the region. –Dr. Poonam Khetrapal Singh, the Regional Director of WHO South-East Asia Region, 14 September 2014, the Daily Observer

In recent times Bangladesh has made important gains in health outcomes. In terms of providing primary health care the country has made important strides and most of the health indicators show steady gains and the health status of the population has improved. Presently, number of steps has been taken by the government to improve its leadership and regulatory role to improve equity and quality of services, especially to reach the poor and the disadvantaged. Initiatives for development of new health policy, revitalization of primary health care by making all community clinics functional with required human resource, supplies and logistics, recruitment and appropriate deployment of human resource for health and gradual extension of e-health services to the rural areas are some of the examples for health development in the country (WHO).

An Intricate countrywide healthcare network

The public healthcare network of Bangladesh is an intricate web of public health departments, NGOs, and private institutions constitutes. Responsibilities and functions range from policy planning, regulation, implementation, and healthcare delivery to medical education. The Ministry of Health and Family Welfare (MOHFW) is responsible for formulating national-level policy, planning, and decision-making in the provision of healthcare and education. The healthcare infrastructure under the DGHS comprises six tiers: national, divisional, district, upazila (subdistrict), union, and ward.

Figure: Types of facilities from national to the ward level, with managerial hierarchy

Improvement of primary healthcare

Among countries that provide free medical services to the people at the community level through various public health facilities, Bangladesh has a top-ranking position in this regard. The primary healthcare is provided through an extensive network of health facilities extended down to the community level with upward referral linkage and a set of government funded permanent community healthcare workers.

The community clinics are the lowest-level static health facilities located at the ward level. These have upward referral linkages with health facilities located at the union and upazila levels. There are 467 government hospitals at the upazila level and below, which altogether have 18,791 hospital beds. At the upazila level, there are 436 hospitals with 18,301 beds. At the union level, there are 31 hospitals with 490 beds and 1,362 health facilities for outpatient services only. So, at the union level, there are 1,393 health facilities. At the ward level, there are 12,584 community clinics in operation till date.

Figure: Primary healthcare centers run by DGHS at the upazila level and below (2013)

Community clinics: healthcare services at people’s doorsteps

The community clinics provide the basic healthcare package to the community people, viz. maternal and child healthcare, reproductive health and family-planning services, immunization, nutrition education, micronutrient supplementation, health education and counseling, communicable disease control, treatment for minor ailments and first-aid, and referral to higher-level health centers. The community clinics are managed by a 15 to 17-member management committee selected from the respective communities. At least 4 members must be female. There are also three community support groups each comprising 15-17 members to work as community health volunteers (non-paid) to assist the management committee and community clinic. The local government representatives are included in the management committee. By April 2014, all community clinics received Internet connection through a laptop and wireless modem to help collection of local health-related data, provide telemedicine service, community health education, and certain other ICT-based health solutions.

Community clinic is certainly a pro-people health initiative led by the Government. If quality health services can be ensured near doorsteps even at the remotest corner of the country, people will spontaneously seek necessary service from the well-trained care providers at the health facilities, instead of the untrained traditional healers.

Grassroots covered by telemedicine

Honorable Prime Minister of Bangladesh Sheikh Hasina formally inaugurated the telemedicine service on 6 July 2011 from the National Digital Innovation Fair held in Bangabandhu Novotheater.

Current number of telemedicine centers is 43. These telemedicine centers are equipped with high Internet bandwidth, large screen display, good-quality telemedicine camera, and telemedicine peripherals.

All functioning community clinics and union health centers have been brought under coverage of Internet connectivity through provision of one laptop and one broadband wireless Internet modem in each. These ICT gadgets are exploring a new horizon of expanding medical consultation by qualified physicians to patients visiting community clinics and union health centers. About 13,000 community clinics are functioning, while writing this report, all over the rural areas of Bangladesh–one for about 6,000 to 10,000 people. There are about 4,500 unions, each having an outpatient health center.


Maternal healthcare

The Ministry of Health and Family Welfare of Bangladesh, in collaboration with UNICEF, is undertaking facility-based Emergency Obstetric Care (EOC) Program in all the districts of Bangladesh to improve the maternal health situation, targeting to achieve the Millennium Development Goal 5. All the government medical college hospitals, district hospitals, upazila hospitals, and maternal and child welfare centers (MCWCs) provide obstetric care service, inclusive of emergency obstetric care.

Obstetric care is classified into two categories in this program, viz. Comprehensive Emergency Obstetric Care (CEmOC) and Basic Emergency Obstetric Care (BEOC). Currently, all medical college hospitals, 59 district hospitals, 3 general hospitals, 132 upazila health complexes, and 63 MCWCs provide CEmOC, and rest of the upazila health complexes provide BEOC.

Voucher scheme for maternal health

The Ministry of Health and Family Welfare, in collaboration with WHO, introduced in 2007 an innovative maternal health voucher scheme, a demand-side financing (DSF) initiative, to improve access to and use of quality maternal health services. Currently, the program is being implemented in 46 upazilas of 41 districts and 7 upazilas of 4 MNHI (maternal and newborn health initiative) districts. Poor women defined by specific criteria (roughly 50% of the pregnant women) and validated by local government representatives are eligible for the voucher.

mHealth for safe pregnancy and childcare

The MIS-DGHS, in coordination with the Ministry of Health and Family Welfare, is carrying out a partnership program with D.Net to provide a mHealth service called MAMA (Mobile Alliance for Maternal Action). MAMA Bangladesh uses a short code ‘16227’, provides lifesaving information for pregnant women and new mothers, including also advice for their newborn babies and children through SMS and IVRs. This program is supported by USAID, partnered by Smiling Sun Clinic and Save the Children and coordinated by Abt Associates and D.Net.

Maternal and Newborn Health Initiative (MNHI)

The Maternal and Newborn Health Initiative is being implemented by the Director of Primary Healthcare of DGHS in four districts of Bangladesh, with the assistance of UNFPA, UNICEF, and WHO and funded by EC and DFID. The districts are Thakurgaon, Jamalpur, Narail, and Maulvibazar. All the upazilas under these four districts are included. The program focuses on saving maternal and newborn lives through creating need-based demand and priority-based actions. The broad principle of this program is Local-level Planning (LLP) and decentralization.

Tetanus Toxoid (TT) for women of childbearing age

The country is maintaining the maternal and neonatal tetanus-free status since 2008. The immunization program of Bangladesh aims to immunize the women of childbearing age by administering Tetanus Toxoid vaccine (TT) before the age of 18 years. A period of 2 years and 7 months is required to complete all the 5 doses of TT vaccines. If a woman starts TT vaccination at the age of 15 years and maintains the exact interval, she would be able to complete all the doses before she reaches the age of marriage, ensuring protection for her entire reproductive life.

Table: Tetanus Toxoid coverage (%) in Bangladesh among women of childbearing age (2013), Source: MOHFW Report, 2014

Community-based skilled birth attendants and midwives

Shortage of skilled manpower in the remote areas to extend obstetric care is one of the major barriers to improving maternal health. The Ministry of Health and Family Welfare undertook a short term measure to tackle the problem by producing trained manpower for fulfilling the gap in the interim period. Young medical doctors were given 6 months’ training on obstetrics and anesthesiology.

The Directorate General of Health Services is also implementing community-based skilled birth attendant (CSBA) training program since 2003, with the goal to train and educate the family welfare assistants/female health assistants and similar health workers in NGOs and private sector, with midwifery skills. The CSBAs are trained to conduct the normal safe deliveries at home and to identify the risks and complicated cases so that they can motivate the women and their family members to refer to the nearby health facilities where comprehensive EOC services are available. The CSBA training program is now organized in 342 upazilas of 60 districts. The Government introduced midwifery course and created posts for 3,000 midwives.

Cervical and breast cancer screening program

The cervical and breast cancers are significant disease burdens in Bangladesh. The United Nations Population Fund has been assisting the Ministry of Health and Family Welfare to run cervical and breast cancer screening program. About 320 centers have been established throughout the country to conduct the cervical and breast cancer screening program and 1,228 service providers from 64 districts were trained within 2013 on cervical and breast cancer screening, based on visual inspection with acetic acid (VIA) and clinical breast examination (CBE).

Child healthcare

This report on child healthcare in Bangladesh covers information on universal routine child immunization, integrated management of childhood illness (IMCI), scaling up of newborn health interventions, and special-care newborn unit (SCANU), school health and adolescent health programs.

WHO completed necessary scientific observations on the polio situation in South-Asia Region, including Bangladesh, and we obtained the polio-free certification in February 2014.

Table 1: Valid full vaccination coverage differentials by sex, area of residence, and division as found in EPICES

Public health nutrition program under MOHFW

Through this program MOHFW has planned mainstreaming nutrition intervention into the health and family planning services, along with scaling up of the provision of community-based nutrition services throughout the country under the OP−National Nutrition Services (NNS). Through NNS, the Government of Bangladesh plans to accelerate the reduction of persistently high rates of maternal and child under nutrition by mainstreaming and scaling-up the implementation of proven nutrition interventions into health (DGHS) and family planning (DGFP) services.

Four hundred and eighty-two medical officers of the upazila health complexes are already designated as Medical Officer (Public Health Nutrition) who is responsible for coordinating all activities of NNS at the upazila level. The component NNS services include: (i) training; (ii) facility-based services; (iii) community/area based nutrition activities; (iv) human resource development; (v) providing micronutrients to people; (vi) operational research and surveys; (vii) monitoring and evaluation; and (viii) nutrition information system.


National eHealth Policy and Strategy

There is a growing international effort to develop long-term country-specific vision, goal, policy, and strategy for eHealth. To keep pace with global trend, MIS-DGHS completed preparation of drafts of the National eHealth policy and strategy with technical assistance from DFID. It is expected that by the end of 2014, these drafts will be finalized.

Looking Ahead

The current Bangladesh government has now embarked on the plan of designing and implementing a universal health insurance scheme. The plan envisages quality healthcare for all without financial hardship to any. The first target will be people below the poverty line, some 48 million now. The government will pay their premiums as subsidy. For this programme, the government has designed the Healthcare Finance Strategy 2012-2032 and currently a law is being drafted. Before the formal launch of the programme, a four-year pilot scheme will be run as a test case in three Upazilas of Tangail from the end of 2014. Under the scheme, free health cards will be issued to around 100,000 households living below the poverty line.

Additionally, the human resources in the health sector have also been revamped. In the largest recruitment drive in the public healthcare sector, the government has newly appointed 6,221 new doctors to ensure health services at everyone’s door. The Prime minister has personally instructed the Health Ministry to appoint 10,000 new nurses for dynamic healthcare services. Another 4,133 assistant surgeons are to be appointed on ad-hoc basis too. To reduce the maternal mortality rate and to achieve MDG-5, government has taken several initiatives, one of which is to provide 24/7 service for the pregnant women around the country. According to Family and Health Welfare Ministry, government is to enable 4,000 family welfare centres (FWC) to provide assistance and service round-the-clock. Government is also planning on developing a national electronic database titled “Civil Registration and Vital Statistics (CRVS)” from next year to record and document vital health information of people.

This report has been developed based on the Health Bulletin 2014, Government of the People’s Republic of Bangladesh Ministry of Health and Family Welfare.

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