Role of Primary Health Care
In Health System Development in Bangladesh
Background
Bangladesh is a signatory to the historic Alma Ata Declaration on Primary
Health Care (PHC) in 1978. In 1988, in recognition of our roles,
responsibilities and commitment to the ideas and principles enshrined in the
declaration, GoB adopted the PHC approach as a guiding principle to the
health systems development in Bangladesh. Given the country's resource
limitations, it was but prudent that a more pragmatic approach to the
introduction of PHC be taken. The later commenced with the introduction of
selective PHC in districts if only to ensure a broader understanding of the
concept. Pursuant to popular demand in 1988, comprehensive PHC was
introduced in Gazipur and Tangail Districts. Primary health Care is to-date
expanded to cover 12 districts, namely Tangail and Gazipur in the Dhaka
Division; Chittagong and Feni in Chittagong Division; Rajshahi, Sirajganj
and Gaibandha in the Rajshahi Division; Barisal and Bhola Districts in
Barisal Division; Maulvibazar district in Sylhet Division and Bagerhat
district in Khulna Division. In the 2004/2005 plan of action, MOHFW
requested the inclusion of 8 New Districts in the PHC Intensification
scheme. Namely: Comilla, Chandpur, Jessore, Jehnaidah, Joipurhat, Bogra,
Sylhet and Kishorganj. PHC Covers 109 Upazillas with a combined 482,68,000
population (estimated). Interventions of operationalizing PHC in Bangladesh
were based on 3 pronged strategies i.e.
Training/ retraining of staff on the elements and principles of PHC;
Provision of basic essential equipment; and
Supplies to facilitate effective preventive, curative, promotive and
rehabilitative services to the vulnerable, the disadvantaged and the poor.
Regular monitoring through supportive supervision to ensure acceptable
quality of care while simultaneously guaranteeing beneficiary community
participation and inter-sectoral collaboration. In Bangladesh the Upazila,
Union and Ward levels constitute the operational levels of PHC, while
district, divisional and national levels provide managerial support and
technical backstopping to the operational levels. Top
Implementation of PHC:
A. National level:
At national level, the Directorate of Primary Health Care and Line Director
of ESP is responsible for the planning and implementation of PHC activities
assisted by a deputy director and three assistant directors of PHC.
B. District level:
The Civil Surgeon and the District team provide technical and
administrative support by way of periodic supervision to the Upazila Health
and Family Planning Officer and team. They also coordinate management of
referrals from Upazila level and below.
C. Upazila level:
By sheer reason of population density, Upazila in Bangladesh is the
equivalent of district elsewhere. It constitutes the first level of referral
in the PHC System. Curative care is provided by specialists in obstetrics
and gynaecology, medicine, surgery, a battery of medical officers, and
supportive laboratory and supplies personnel. Promotive and preventive
services are supported by Health Inspectors, Sanitary Inspectors and
Assistant Health Inspectors.
D. Union and Ward levels:
The Upazila health and Family Planning Officer is the overall
administrative and technical head of the Upazila Health Complex, as well as
all health services up to the community level through the Union level
facilities run by field level health and family welfare workers.
Intersectoral action for health has been initiated through intersectoral
workshops at District and Upazila levels.
E. Community Participation:
Community participation being one of the pillars of PHC development is
established through VHVs nominated by the community people and trained under
the intensification project. 8 VHCPs were established in a Ward for
providing health services. With the recent reform under HPSP and providing
health care through ESP strategy, 15 of the first community clinics were
refurbished in 6 Upazilas using own won funds.
Achievement:
Up to December 31, 1999, total 107,412 VHVs were trained of which 15,636
are male, 91,795 are female. Total 13,553 VHCPs and 15 community clinics
were established.
VHCP Established 13,553
Pilot Community Clinics Established 15
Change of Health Status in PHC Intensified Areas.
SL No. Indicators 1991 1997
01. Crude birth rate 31.6 23.6
02. Crude dea
In 1998/99 Biennium:
5 Senior staff participated in study tours in Regional and Extra regional
countries. 1 PHC staff at national level completed a short course (3 months)
in planning in a regional country. 1000 traners of VHVs were trained. 12,560
Village Health Volunteers were trained. 2000 Village Health Volunteers had
refresher training. 200 Women groups participated in awareness workshops on
PHC.
In the 2000/2001
biennium
4 Senior PHC staff participated in package study tour to observe PHC
development in Thailand, Sir Lanka and Indonesia. 1 senior PHC staff
participated in a short course in planning in a regional institution. 2143
participated in intersectoral workshop on PHC at Upazilla and idstrict
levels. 610 Trainers of VHVs were trained. 17,218 VHVs received basic and
refresher training.
As of 31 December 2003 during the 2002-2003 biennium 2624Upazila level
managers (UHFPOs, FPOs HIs. MOs. Sr. FWVs) tained in management; 856 MOs,
MAs, FWVs, AHIs at Union level were given inservice training in basic
management; 1 national level manager 1 Civil Surgeon and 2 UHFPO under
fellowships were trained to improve technical skills and capacity building
in management of Community Health Service Delivery. 5331 community groups
members were given awareness orientation training on community health care.
5717 VHVs were given training on concept of community clinics and perceived
roles and responsibilities. 2124 sector representatives ere given awareness
training on community clinics concept and the importance of intersectoral
collaboration in functioning, acceptance and utilization of ESP services.
Developed guidelines for planning and setting up referral system from
community level to union and Upazila levels. Dsigned and procured 15
Rickshows (local tricycle) fitted with ambulatory facilities. Survey on
"Pre-training assessment of awareness of community group members and others
conducted.
Upazila
Manager Union level
Manager Fellowship Community
Members VHVs Sector
Representatives
Research:
A. To develop guidelines for planning and setting up sound referral system
two tire pilot intervention studies were contracted to the London School of
Hygiene and Tropical Medicine. The studies are:
(1) Bridging the Access GAP (BAG): A pilot intervention for setting up and
operationalizing a referral system at the community level and
(2) A cost sharing on package of services and referrals at the community
level under the BAG pilot intervention. The studies are being conducted.
B. Study on enhancing health system performance using procurement and
supply of goods under Health and Population Sector Programme (HPSP)
C. Methodology to formulation of strategic vision for next phase sector
programme (2002-2003)
D. Study to assess implementation of HPSP using essential service package
(ESP)
E. Study on the impact of training in management on the output of Upazila
Level Manager.
