Since the late 90s, it has been claimed that Bangladesh is witnessing myriad development in various sectors, and among them, accessibility to healthcare system for all the citizens is one of them. While we are glorifying nation's economic strides, the question ofwhy the lack of equity, transparency, and good governance in the health sector remains unanswered. The uneven equation of healthcare professionals, an unsatisfactory budgetary allowance for all, and not a visible primary health care services to many of the citizens" are also some issues we need to ponder.
Let's revisit the history. Back in 1978, the Bangladesh government recognised the importance of formulating a national healthcare policy for rural citizens. Then, Bangladesh became a signatory of the historic Alma Ata Declaration on Primary Health Care (PHC). In 1988, Bangladesh adopted the PHC approach as a guiding principle for the development of health systems. The government put emphasis on healthcare following a given model supporting reduction of infant mortality rate as well as EPI drives. Later the ruling party, Awami League came to power in 2008 and instituted a more pragmatic innovation in the health sector. And the pragmatic innovation is none other than establishing 'Community Clinics'. Not to mention that this flagship programme of the current government; with the help of public-private partnerships, primary healthcare services are being taken to rural and marginalized populations in the country.
The Community Clinic model has a connection with section (VII) of the Alma Ata Declaration. Section (VII) says,"maximum community and individual self-reliance and participation in the planning, organisation, operation, and control of primary health care"-which is encouraging the empowerment of local populations in primary healthcare services.
In 1998, Bangladesh instituted a new public health strategy: a community clinic for every 6,000 people. The Government has been able to establish more than 13,200 of these clinics all over the country. Community clinics have now become one of the important strategies of the Government for achieving Universal Health Coverage (UHC).
The Community Clinic model is indeed an innovative example of a public-private partnership. According to a study in 2021, the country has about 148,000 community health workers of which about 60,000 are supported by the Government: the rest being in BRAC and other non-government organizations.
Community Clinics operate through the involvement and donations of local stakeholders. For establishing a community clinic, a wealthy man from the locality donates land. The government provides structural services, medicines, service providers, and other logistical support to local communities. Importantly, the owners of these clinics are the people residing in the community. According to different media reports, over 130,000 Community Clinics receive constant support from the government.However, the media also reports about the awful condition of Community Clinics where service providers do not have the minimal facility.In 2018, the government ensured the CHCPs that their job would be taken to the revenue sector soon but that didn't happen and about 14,000 workers of Bangladesh Community Health Providers are seriously frustrated about their job. Many of them didn't even have one taka increment over the last 10 years. Also, it is also disheartening to note that, around ten thousand community clinics had to shut down in last two decades.
Community Clinics are undeniably a positive way to get rural communities involved in healthcare systems.Over the years many people have understood that 'health is an asset'. Hence, I get a clearer picture in my recent visit to Manikganj'sRatanpurcommunity clinic, I have seen how people are cautious about their health. It was a day of "National Safe MotherhoodDay" observance where I found most of the people were wearing masks, which is not a common scenario even in Dhaka.
Rahima Begum, 85-year-old women come to visit the community clinic alone tocheck her blood sugar on the day of "National Safe Motherhood Day". The event was organized by Bangladesh Health Watch, a multistakeholder civil society platform working with the vision that all citizens of Bangladesh enjoy universal health coverage. There were around 200 people gathered at the event and took the opportunity to avail of primary health care services. Around 50 pregnant mothers participated in the event to takeprimary health care facilities, and other elderly women came for basic health check-ups. Civil surgeon,upazilahealth and family planning officer, and other local administrators were present at the event.
Along with Brac, Bangladesh Health Watchis sincerely working to make the healthcare system more participatory and getting it more accessible to the marginalized population.
As I said previously, Community Clinics have their challenges as well. The lack of skilled healthcare professionals in rural Bangladesh is a major issue. The 85-year-old Rahima Begum said, "We expect that apart from CHCPs at least one MBBS doctor from nearby Upazila Health Complex must visit the place twice a week." This is an expectation from most of the people who reside in Ratanpur.
Quality healthcare service is a bumpy road and thus the journey is difficult, and tiresome.However,the question is, what can be done to ensure effective service delivery in the face of these existing crises in community clinics?The answer is to ensure quality services, we need to make service providers more efficient and trained. Also, we need to mobilize community clinic management committees effectively through public participation, build a strong infrastructure, and above all ensure good health at the institutional level.
Last but not the least,some integrated efforts from NGOs, government, communities, and localities are needed. Theirsupport and integration of health services at the local government level, andstrengtheningthe participation of communities can bring changes in the health sector. Also, we need broader healthcare systems through the training, education, and growth of healthcare professionals in rural Bangladesh.
The writer is a development worker.
