Urban Dispensaries and Primary Healthcare in Dhaka

Written by: Umme Salma Anee, Masroor Salauddin, Sadika Afrin, Faiaz Chowdhury, Nabila Binte Jahan, Deepa Barua, Rumana Huque, Helen Elsey

Urban regions in Bangladesh are now more densely populated as a result of migration and industrialization. With a population rise of 3.26% from 2022 to 2023, Dhaka, the country’s largest metropolis that is growing day by day, now has 23,210,000 residents 1. There are a variety of urban primary health care providers within urban areas, including2

Figure: A table displaying the list of urban primary health care facilities

* Primary health care is provided by urban dispensaries (UDs) in urban environments and by Upazilla Health Complex (UHCs) in rural ones 3. Throughout the entire city of Dhaka, there is solely one UHC that also serves few more services than the UDs including the cervical screening, breast feeding, diarrhea, and baby-friendly Anti-Natal Care (ANC) corners, as well as the Integrated Management of Childhood Illness (IMCI) corner 4. These are crucial for strengthening the urban health system in terms of giving the urban population primary healthcare services.

 

History: Urban dispensaries (UDs) in Bangladesh have played a crucial role in providing healthcare services to the population in urban areas. While the concept of dispensaries has a long history in Bangladesh, the establishment and development of urban dispensaries have evolved over time. Dispensaries were first used in Bangladesh during the colonial era, when the British offered basic medical services 5. The British colonial authorities and the local elites were the main customers of hese early dispensaries. They were mostly found in large cities like Kolkata (then a part of British India), Chittagong, and Dhaka. The newly formed East Pakistan (which eventually became Bangladesh) experienced several difficulties in providing adequate healthcare to its expanding population after gaining independence from British authority in 1947 and then from Pakistan in 1972. To meet the healthcare demands of the urban population, Bangladesh government established dispensaries in urban sittings since 2000 6.

As a consequence of the establishment and administration of dispensaries in various urban areas throughout the country, the government has continued to collaborate with non-governmental organizations (NGOs) and private healthcare providers to strengthen urban dispensaries and provide health care services to all urban residents. Several regional and global non-governmental organizations (NGOs) have frequently backed the provision of healthcare services in urban dispensaries (UDs) through programs with varying lengths of time. The system’s health initiatives work to promote all primary healthcare, including basic diagnostics, preventive care, common illness, and non-communicable disease (NCD) services, as being accessible, affordable, and readily available to all levels of the population.

This information was obtained from the health facility assessment survey on preparedness of Non-Communicable Diseases (NCD) services management in urban primary health care facilities entire Dhaka city. The survey was conducted as part of the CHORUS research project on Strengthening urban primary health care system to deliver essential Non-Communicable Diseases (NCD) care to urban poor at the ARK foundation for the CHORUS urban health initiative.

Location: Government Outdoor Dispensary (GOD) is another name of Urban Dispensaries (UDs). Currently, there are (19) Urban Dispensaries (UDs) in the entire city of Dhaka, which are overseen by the Dhaka Civil Surgeon in the Ministry of Health and Family Welfare (MOHFW). In Dhaka city, One, known as a maternal dispensary, offers services for women’s and children’s health along with other services. Other UDs run school health clinics in various regions of schools.  Additionally, some UDs work in primarily for government officials of their official zones, while other UDs tend to ordinary urban dwellers of various catchment areas in the entire city. In accordance with the region of UD, all are shown in a list that is given below:

Figure: UDs in several areas in the entire Dhaka city

Services Delivery 7: During the health facility assessment survey period, it was observed that all UDs at different tiers were capable of providing a variety of services, such as the early detection of conditions (Seasonal Fever, Diarrhea, Skin diseases-scabies), reproductive health, counseling, vaccinations, screening, diagnostic, and referral to other centers, in addition to the comprehensive service delivery package of maternity issues, child care and adolescent health. All of the previously listed services are offered to clients at no cost, in contrast to other primary healthcare settings like NGO clinics or private practices. Regarding those patients come here to obtain their medications for free who have previously been diagnosed with NCDs such as hypertension or diabetes from outside diagnostic centers.

As all UDs are only equipped for primary healthcare services, the UD providers refer the most serious cases to adjacent government tertiary institutions such Kurmitola Medical Hospital, Shaheed Suhrawardy Medical College or Dhaka Medical College and so forth.

 

 

 

 

Figure: Maternity clinic and dispensary in catchment area

Additionally, a few particular health services such as leprosy treatment or NCD care or Tuberculosis (TB) is obtainable in UDs in co-ordination with NGOs like the Damien Foundation, Marie-stopes, ARK foundation, ICDDRB. For example, a small team (from Damien Foundation) working on leprosy care at the UDs for two days a week has taken samples, diagnosed and treated patients, and given counseling and medication door-to-door.  As well, monthly mobile medical campaigns are also organized by UD around the city of Dhaka in an array of congested regions, including the bus or train station, school premises, roadside, and local fish and vegetable market.

 

Health Workforce 7: Each UD has a medical team that includes a doctor, senior nurses, a Sub Assistant Community Medical Officer (SACMO), Medical Lower Subordinate Staff (MLSS) and a pharmacist. However, existing healthcare professionals require additional training on a variety of aspects, including NCD, to enhance their skill sets.

Along with their tasks at UDs, the government frequently dispatches health care personnel on short notice for special assignments regarding school exams, medical camps for national job exams, and health inspections for Cabinet members or foreign guests. As a consequence of this, there is a scarcity of personnel to manage the UDs, and at the same time, client access to UD health care has altered. When a client come to UDs for health service, he/she follows the care pathway according to the availability of the health care providers shown below:

 

Figure: The patient’s path to receiving care in UD is determined by the availability of health care providers.

 

Health Information System 7: Together with a pharmacist, a SACMO maintains records and reports for all monitoring paperwork, including client information, staff attendance logs, medication inventory forms, and requisition for supplies and equipment. These are kept in a number of register books such as patient registration books, medicine stock register books, medicine supply register books, and others for all services. Along with explaining how they update the register books every day, they also gave us a demonstration.

 

Medication and Equipment 7: Additionally, UDs have a modest amount of medications as a plenty of patients come here to especially get treatment for several health issues such as common cold, skin issues, hypertension.  The patients often become rude with UD medical teams when they do not get their desire medicines as they have an affinity to come frequently in their adjacent urban dispensaries (UDs). There are also available essential functioning equipment’s such as sphygmomanometer, manual blood pressure machine, adult weight and height scale, thermometer, glucometer and glucose test strips.

 

Figure: Urban dispensary in the government staff quarter

 

Leadership and Governance 7: In the interim, government officials such as the civil surgeon of Dhaka City (CS), a team from the Ministry of Health and Family Welfare (MOHFW), a team of Non-Government Organisations (NGOs) and International Non-Government Organisations (INGOs) among others, have often surveilled UDs.

Figure: School health clinic

 

Challenges: The UD medical team shared their experiences about providing health services to numerous clients (80 to 100) each day through a shortage of medical professionals and staffs.  The UD team has met several difficulties due to the high number of patients using their services, particularly when staff members are absent due to illness or family issues or leave. To ignore their problems and strive to make their clients happy, the UD team nevertheless carried on offering healthcare services every day. However, the majority of clients are resident of nearby slum and non-slum regions including the transgender population. People who live in Bihari camps, workers, and residents of adjacent government staff quarters are very often afflicted with scabies and fungal infections as a results of having to live informal settlements that have no or limited access to clean water, sanitation and waste clearance and are overcrowded. Bihari are the Indians, or Pakistani people, who remained in various parts of Dhaka city following Bangladesh’s independence. They reside in what are known as the Bihari camps, a slum8. In addition, the majority of maternity services such as anti-natal care (ANC), normal delivery, with the exception of Post Natal Care (PNC), were unavailable during the COVID situation at the maternity UD clinics. The government announced that this service will be made available promptly, yet there is only one maternity UD in the entire city of Dhaka. Even though most UDs have inadequate space to provide services and have fewer personnel in many fields, they have managed to provide all services from one or two rooms.

 

Conclusion and Recommendation: The government of Bangladesh has made significant contributions with its urban dispensaries, which should be strengthened to advance the urban health system. If a part of the responsibilities the outdoor departments of tertiary govt. hospitals are shifted to the government UDs, it will lessen the burden on the government tertiary hospitals in Dhaka city. To fulfill their respective assigned responsibilities in a sustained and efficient way, the two Ministries (Ministry of Health and Family Welfare (MOHFW); Ministry of Local Government, Rural and Development Cooperatives (MOLGRDC)) need to build a sustainable coordinating mechanism through a consultative approach. Additionally, MOHFW has been addressing this challenge in order to collectively assess, map, project, and plan Health, Population and Nutrition (HPN) services in urban areas. Overall, urban dispensaries in Bangladesh have evolved from their infancy to become vital healthcare facilities that will significantly expand urban residents’ access to primary healthcare.

 

This blog has also been published on CHORUS website. Read Here

 

Reference:

  1. Dhaka, Bangladesh Metro Area Population 1950-2023; https://www.macrotrends.net/cities/20119/dhaka/population
  2. Bangladesh Health Facility Survey, 2017, https://dhsprogram.com/pubs/pdf/SPA28/SPA28.pdf
  3. Urban Health, Community based health care, DGHS, Ministry of Health and Family Welfare, http://www.communityclinic.gov.bd/urban-health-page.php
  4. DGHS, Tejgaon Health Complex, Dhaka, physical structure; http://facilityregistry.dghs.gov.bd/org_profile.php?org_code=10000057
  5. Public Health in British India: A Brief Account of the History of Medical Services and Disease Prevention in Colonial India, Muhammad Umair Mushtaq, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763662/pdf/IJCM-34-6.pdf
  6. Primary Health Care Systems (Primasys): Case study from Bangladesh. WHO-HIS-HSR-17.12-eng.pdf
  7. Monitoring the building blocks of health system: A handbook of indicators and their measurement strategies. World Health Organization (WHO), 2010. https://apps.who.int/iris/bitstream/handle/10665/258734/9789241564052-eng.pdf
  8. Altaf Parvez, what is to be done with ‘stranded Pakistanis’? 2021, prothom alo English. https://en.prothomalo.com/opinion/what-is-to-be-done-with-stranded-pakistanis

Celebrating 10 Years of Dedication Excellence and Impact: Journey of ARK Foundation

In the crisp and vibrant air of November 2013, a promising initiative emerged – the ARK Foundation. Committed to enriching the landscape of research-based knowledge and making invaluable contributions to the health sector of Bangladesh, the organisation embarked on a remarkable journey. Fast forward to the 14th of October 2023, and ARK Foundation proudly celebrated a decade of unwavering commitment and dedication. This milestone was not just an occasion for merriment but a profound reflection on the substantial impact we’ve made towards achieving sustainable development goals and shaping effective policy development in public health systems.

Guests from our Policy Dialogue session (Addressing Non-Communicable Diseases (NCDs) to Achieve Sustainable Development Goals (SDGs)) seated on the podium for the 1st half of the program.

The program unfolded in two distinct sessions, each bearing its own unique significance. In the first session, the focus was a critical policy discussion, revolving around “Addressing Non-Communicable Diseases (NCDs) to Achieve Sustainable Development Goals (SDGs).” Dr. Khaleda Islam, a renowned public health expert, a mentor to us and the former Director of the Primary Health Care, MoHFW, skilfully moderated the session, while the main program was led by Hossain Ali Khandkar, Additional Secretary-MoHFW and Coordinator of the National Tobacco Control Cell.

In addition, as a panellist, Professor Dr. Ahmedul Kabir, Additional Director General, DGHS, MOHFW and Mr. Md. Abdur Rahman Khan, Additional Secretary, Ministry of Finance.

The speakers of this session are Prof. Dr. Mohammad Robed Amin, Line Director, NCDC, DGHS, MOHFW,  Mr. AHM Noman Khan, Executive Director, Centre for Disability in Development, Dr. Rashid Zaman, Health Adviser, British High Commission in Dhaka and Dr. Halida Hanum Akhter, Reproductive Health Epidemiologist, Johns Hopkins University, USA

 

Prof. Dr. Mohammad Robed Amin, Line Director, NCDC, DGHS, MOHFW and Mr. Md. Abdur Rahman Khan, Additional Secretary, Ministry of Finance during the presentation of the policy dialogue session.

The first session laid a solid foundation for the program by highlighting the importance of informed policy decisions in achieving sustainable development and improving public health. The speakers all applauded the ARK Foundation’s contribution to the control of NCDs and discussed how faster progress can be made by connecting different sectors in this way forward. In this discussion, the budget in the health sector, the extent and severity of non-communicable diseases in women, ensuring health care for disabled people, etc. were highlighted. Addressing the NDC for women, Dr. Halida Hanum Akhter said,

NCDs cause two in three deaths among women annually, which is alarming”.

Mr. AHM Noman Khan highlighted the disability and said,

“For disabled people to get the necessary NCD services, the policies that have been developed should be implemented at the field level.”

This diverse and knowledgeable panel contributed to a robust discussion, addressing the complexities of NCDs and their alignment with the SDGs. Prof. Dr. Mohammad Robed Amin, Line Director, NCDC, DGHS, MOHFW thanked ARK during his presentation on ‘Addressing Non-Communicable Diseases (NCD) for achieving Sustainable development Goal (SDG)’ and said,

I want to give thanks to the ARK Foundation for working with several social determinants. They are working with Government Research Grants for exploring several ways of approaches to mitigate the gaps in the health sector, which demands different sectoral alignment along with coordination”.

Dr. Rashid Zaman, the Health Adviser at the British High Commission in Dhaka, highlighted the impact of Non-Communicable Diseases (NCDs) on Sustainable Development Goals, specifically SDG Goal 1 (No Poverty), SDG Goal 11 (Sustainable Cities and Communities), and SDG Goal 12 (Responsible Consumption and Production). He also said,

I want to congratulate the ARK Foundation for their wonderful journey of the last 10 years. We are very proud to be partners. In a few cases we have worked together and it was such a wonderful journey.”

At the end of this session our chief guest Hon’ble Minister of Planning Ministry of People’s Republic of Bangladesh, Mr. MA Mannan, MP and special guest Bangladesh Diabetic Association (BADAS) President – Professor Mr. AK Azad Khan handed over some greetings of appreciation to the speakers from the policy brief session.

Dr. Halida Hanum Akhter, Reproductive Health Epidemiologist, Johns Hopkins University, USA receiving greetings from the Hon’ble Minister of Planning Ministry of People’s Republic of Bangladesh Mr. MA Mannan, MP as a token of appreciation for her presentation on the occasion of 10 years celebration of ARK Foundation.

The distinguished Vice Chancellor of Sylhet Medical University and Technical Consultant of the ARK Foundation, Prof. Dr. AHM Enayet Hussain, presided over the inaugural ceremony of the second and final session of the program. To commence this session, Professor Dr. Rumana Huque, Executive Director of the ARK Foundation, and Professor Dr. A H M Enayet Hussain extended a warm welcome to our esteemed Chief Guest and Special Guest, presenting them with traditional Northern clothing (উত্তরীয়). Dr. Rumana Huque delivered an insightful speech, providing an overview of the ARK Foundation’s remarkable 10-year journey, accompanied by an impressive video presentation.

Thanking everyone for having our backs and being strong advocates, she mentioned,

In this journey of our 10 years, your support and advice are always our way forward”.

During this session we were also delighted to have honourable Additional Director General of the Department of Health of the Ministry of Health and Family Welfare Dr. Ahmedul Kabir sir.

Professor Dr. Rumana Huque, Executive Director of the ARK Foundation, and Professor Dr. A H M Enayet Hussain extended a warm welcome to our esteemed Chief Guest Hon’ble Minister of Planning Ministry of People’s Republic of Bangladesh Mr. MA Mannan, MP and Special Guest Bangladesh Diabetic Association (BADAS) President – Professor Mr. AK Azad Khan, presenting them with traditional Northern clothing (উত্তরীয়).

Our honourable chief guest and special guest have recognised ARK’s participation for research in the health sector. For guiding us with more diverse issues, Bangladesh Diabetic Association (BADAS) President – Professor Mr. AK Azad Khan mentioned,

“We have to take care of digitization of the Health Care System. Also, to reduce NCD we have to take initiative to ban Tobacco Cultivation.”

We were delighted to have the esteemed Minister of the Planning Ministry in the People’s Republic of Bangladesh, Mr. MA Mannan, MP, whose visionary leadership has been instrumental in propelling Bangladesh’s development towards the goal of a Smart Bangladesh. It was an honour to have the Honourable Minister as our Chief Guest at this event. The presence of Mr. MA Mannan, MP, and Professor Mr. AK Azad Khan among us brought immense joy to everyone in attendance. In recognition of their presence, Dr. Rumana Huque, the Executive Director of ARK Foundation, conveyed our deep appreciation through a heartfelt gesture. She presented a souvenir representing our beloved country – a traditional rickshaw, as a token of our affection to the Chief and special guest. During this program, the Honourable Minister graciously extended greetings to those in attendance and also had the privilege of unveiling the New Logo of the ARK Foundation. In a celebratory spirit, the Honourable Minister, along with everyone present, came together to cut the cake, marking this significant moment.

Dr. Rumana Huque, the Executive Director of ARK Foundation, presented a souvenir representing our beloved country – a traditional rickshaw to the Chief and special guest of the 10 years celebration program, appreciating their presence with ARK Foundation.

As we celebrate this remarkable 10-year milestone, we are pleased to announce the publication of a comprehensive booklet. This booklet includes a Message from the Executive Director, as well as messages from our valued Partners, Collaborators, Supervisors, and Mentors. It provides a concise yet informative overview of our journey thus far.

Within the pages of this booklet, you will find selected studies covering a wide range of critical health topics, including Non-communicable Diseases, Communicable Diseases, Reproductive, Maternal, Neonatal, Child, and Adolescent Health, Health System Strengthening, as well as the pressing issue of Climate Change and our other Multi-sectoral Projects. Furthermore, it highlights our efforts in Capacity Development and Research Uptake.

We invite you to explore this publication, which encapsulates a decade of dedication and progress in the field of health and research. (To read the booklet, please click this link.)

Guests who were present with ARK Foundation on the occasion of our 10-year celebration

The recent ceremony served as a significant milestone of the ARK Foundation’s remarkable 10-year milestone celebration. But let’s not close the curtain just yet. Following a sumptuous buffet lunch extended to all the esteemed event guests, it was time for a heartfelt gathering. The dedicated individuals who have tirelessly worked for the foundation, along with their steadfast companions on this remarkable journey, came together to exchange personal greetings. It was a touching moment as we concluded this eventful day with a final cultural program, highlighting the strong sense of community and shared experiences that have fuelled our journey thus far. The ARK Foundation’s journey continues, and we’re excited to see what the future holds.

Dr. Rumana Huque, ARK Foundation’s Executive Director, joins the Chief Guest, Delegates, Well-Wishers, and Team Members in celebrating a decade of Dedication, Excellence, and Impact with a cake-cutting ceremony!

 

Author: Prema Nath

Research and Communication Officer, ARK Foundation Bangladesh.

Author


Stakeholder Workshop on the physical health of people living with severe mental illness including effect of COVID-19 pandemic and its responses in Bangladesh: What has been done so far and way forward

 

ARK Foundation in partnership with National Institute of Mental Health (NIMH) and with the technical support of Department of Health Science, University of York is implementing IMPACT SMI and IMPASS research study targeting people living with severe mental illness (SMI). As part of these research studies a stakeholder workshop was organized as on Monday, June 20, 2022, at NIMH. The workshop aimed to share and discuss overview of the IMPASS and IMPACT SMI study for raising awareness on the physical health of people living with severe mental illness (SMI) including effect of COVID-19 pandemic and its responses on SMI and their family members.

Workshop Participants

A diverse group of potential stakeholders attended the workshop from Government, Non-Government and Development Partner organizations.

From Government Organization:

Specifically, the following honorable dignitary stakeholders attended: Joint Secretary and Chief Coordinator of NDD (Neuro-developmental disorder) and Autism Cell under Health Services Division, Programme Manager – Mental health of Non-Communicable Disease Control (NCDC) Programme under Directorate General of Health Services, Chairman, Dept. of Psychiatry, BSMMU, Director, National Institute of Mental Health (NIMH), General Secretary Bangladesh Association of Psychiatry[1], Former Director Primary Health Care, DGHS.

Other Stakeholders from Government Organization: Associate Professor, Registrar from NIMH, National Institute of Neuroscience Hospital, Programme Manager from Community Based Healthcare Programme, Assistant Health Officer and Programme Officer of Dhaka North City Corporation, Psychiatrists from NIMH.

From Development partner and Non-Government Organization: National Mental Health Consultant of WHO, representative from development partner Civil Society Organizations Sajida Foundation.

Presentation

Prof. Dr. Rumana Huque, Executive Director ARK Foundation and Dr. Helal Uddin, Associate Professor, National Institute of Mental Health (NIMH) gave an introduction to the workshop and shared overview including aims, methods, key findings and way forward of the IMPASS and IMPACT SMI study respectively.

Summary of IMPACT SMI study

People with SMI are vulnerable as, on average, they die earlier than the general population, primarily due to physical disorders. There is limited information on physical illnesses and health risk behaviours in people with SMI in low and middle-income South Asian countries and the IMPACT SMI study addressed this by conducting a survey to investigate the physical health and health risk behaviours of this population in Bangladesh, India and Pakistan. Randomly selected in and outpatients with an SMI  diagnosis (i.e. schizophrenia, bipolar disorder, major depressive disorder with psychotic feature) were interviewed (1500 SMI patients) followed by anthropometric measurements and blood sample collection among those who consented. Key findings from IMPACT SMI baseline survey are as follows:

  • Nine percent had diabetes, 16.1% hypertension, 36.8% were overweight or obese, and 46% had hypercholesterolemia.
  • Most participants (84%) with diabetes, hypertension and hypercholesterolemia were previously undiagnosed; of those diagnosed only around half were receiving treatment.
  • Fifty percent of men and 19.1% of women used tobacco;
  • 3% and 84.1% did not meet WHO recommendations for physical activity and fruit and vegetable intake respectively.
  • Compared with the general population (data from the WHO STEPS survey), people with SMI were more likely to have diabetes (Odds ratio (OR)=1.7), hypercholesterolemia (OR=2.5) and to be overweight or obese (OR=2.0) in the country. They were less likely to receive tobacco cessation (OR=0.11), and weight management (OR=0.48) advice than the general population.

Summary of IMPASS study

The COVID-19 pandemic has adversely affected lives and challenged healthcare provision. Those with SMI are likely to be disproportionately affected. The IMPASS study explored the effect of COVID-19 and its response (e.g. lockdown) on people living with SMI majorly in terms of income earning, food security, financial management, access to healthcare, mental and physical health problem, vaccine uptake and hesitancy. Consented SMI patients who were recruited in IMPACT SMI survey were followed up through 5 rounds of telephone surveys (first three rounds were at the beginning of COVID-19 pandemic between May to October 2020 while fourth and fifth rounds were during June-Aug 2021 and Jan-Mar 2022 respectively when severity of pandemic quite reduced than beginning). Key findings from IMPASS survey are as follows:

  • In round 1 survey, it was found that Television (80%), family and friends (77%), and religious leaders (38%) were the major source of information about COVID-19. Overall, participants reported good knowledge and that they were following government advice for limiting its spread.
  • Finances (47.8%), employment (9%), and physical health (27.6%) were the most frequently mentioned concerns during COVID-19 pandemic.
  • In round 1 survey, main earning member of the family of SMI patients generally were employed or running business (64%) pre-pandemic, but reported not currently working (43%) at the time of COVID-19 pandemic and related measures, this scenario was more evident at the beginning of COVID-19 pandemic which was gradually decreased (At round 5 survey 89% reported main earning member generally employed/running business and of them only 1.2% reported of not currently working) with the improvement from COVID-19 pandemic situation.
  • Treatment for mental health was affected by COVID-19 pandemic and its response; this rate was also higher (54% in round 1) at the beginning of COVID-19 pandemic which was gradually reduced (5% in round 5 or round 6) with the improvement from COVID-19 pandemic situation.
  • IMPASS survey (Jan-Mar 2022) findings revealed vaccine uptake rate as 64% among SMI people while Dr. Helal Uddin opined that at the time of conducting workshop, the rate increased to 72%.

Key points from discussion

The following are the key discussion points and suggestions from workshop participants:

Participants reflected that under IMPACT and IMPASS studies, two amazing research studies have been conducted, which investigated many issues and some of which can be of use for different types of research in future. Findings of these research studies will be of use as primary data for Bangladesh or International perspective.

Lack of screening at primary care and patient load at NIMH

National Institute of Mental Health (NIMH) was the study site in Bangladesh for the IMPACT SMI research study. Participants opined that even though NIMH is considered to be the tertiary level healthcare facility, in reality all types of patients from all over Bangladesh visit here as there is no screening process to identify mental health problem at primary health care facility. The ideal process should follow referral from primary or secondary health facilities to tertiary level.

Attitude of Government officials to work with mental health issues

Programme Manager, Mental health of Non-Communicable Disease Control (NCDC) Programme under Directorate General of Health Services mentioned in his speech about favorable attitude of NCDC office to work with mental health. He quoted “Office of Line Director, NCDC are very much cordial about the mental health issue. There is no problem from NCDC office side to work with this issue. If any planned activities from mental health act/strategic plan/policy are provided to NCDC office along with action plan then they will facilitate to implement this”.

Advocacy for ensuring mental health drugs at primary health care

Programme Manager, Mental health of NCDC informed that he raised the issue in drug list finalization meeting to include 6 essential drugs of mental health treatment in the revised list of drugs of Upazila Health Complex (UzHC) because if these are not included in the drug list of UzHC, procured and supplied, then UzHC personnel will not be able to provide those drugs to patients.

Neurodevelopmental disorders (NDD) and Autism cell and plans to achieve SDG3

Joint Secretary and Chief Coordinator NDD and Autism cell, Ministry of Health and Family Welfare stated that “Specific laws, acts, policies and strategic plans were developed to ensure rights and for protection of people living with NDD (e.g. schizophrenia, bipolar disorder) and Autism. NDD and Autism cell was formed to maintain coordination among Ministry of Health and Family Welfare which provide Diagnosis and treatment of people living with NDD and Autism and Social Welfare and other Ministries which do rehabilitation of such people. To achieve Sustainable Development Goals (SDG3) by 2030, we have added mental health and health insurance along with primary health care.’’

Lack of mental health professionals

  • In Primary Healthcare facility (Upazila Health Complex) there is no psychiatrist, while in eight old Medical Colleges, the psychiatry units are not strong enough.
  • According to earlier study findings, there are social stigma towards mental health issues, not only in community, but also among doctors.
  • Lack of skilled human resources and crisis of mental health professionals is one of the challenges of implementation of mental health strategic plan.

Plans to address shortage of mental health professionals

Joint Secretary and Chief Coordinator NDD and Autism cell, Ministry of Health and Family Welfare informed that there are plans in implementation process to increase the number of psychiatrists through training and retraining option within psychiatry departments in Bangabandhu Sheikh Mujib Medical University (BSMMU), Pabna Mental health hospital, District Sadar Hospital and new medical colleges. Plans to address mental health are outlined in detail in the 8th five year plan, the 4th Health, Nutrition and Population Sector Programme (HNPSP), and the mental health policy. As a long term goal NDD and Autism cell have taken initiative to create large number of posts for Psychiatry considering to achieve the target of SDG3.

Strengthen Mental Health service in Primary Health Care

  • It was suggested to strengthen mental health services in primary care: e.g. preliminary screening using the mhGAP (mental health gap action programme) tool in NCD corners to understand mental health conditions and then refer to specialist services (NIMH) based on severity found from preliminary diagnosis. This reduces pressure on NIMH to screen out patients who do not need mental health care.
  • As a short term goal at union level 64,000 Para Counsellors are being prepared for mental health by training family welfare visitor who earlier advised pregnant mother for diet, antenatal care only. Those Para Counselors are doing para counseling for mental health also at village level.

Mental and physical comorbidities and service strategy

  • Participants opined that through research, we may look into which medication or drug adjustment can be done for SMI patients with comorbidity (NCD or NCD risk factors).
  • The participant concurred that, for complete management of psychiatric treatment, preventive measures should be given importance in strategic plan. Along with curative measures, this will help to prevent occurrence of new physical disease or aggravated physical condition (including NCD or NCD risk factors) due to antipsychotic medication and/or lifestyle health risk behavior through people’s and community participation. These are covered broadly in the mental health act/policy/strategic plan. This is now important to implement the plans to address physical health needs of SMI patients.
  • It was mentioned that due to mental health problems, physical health is hampered, and also due to acute or chronic physical health problems mental health problems occur. Hence, mental and physical health are interrelated and cannot be separated from each other.
  • It was suggested that it would be helpful to know segregated results of outcome variables regarding mental and physical comorbidity, lifestyle health risk behavior, lifestyle modification advice by gender and socio-economic group so that specific intervention/services can be designed for target population.

COVID-19 testing at mental health facility

Psychiatrists from NIMH opined that at the beginning of COVID-19 pandemic there was no testing facility of COVID-19 for patients. But with the change of time now COVID-19 testing facility is available for patients at NIMH.

COVID-19 vaccination at mental health facility

At NIMH there is COVID-19 vaccination centre from where any adult citizen irrespective of SMI people who did the registration and receive message for receiving vaccination can get vaccinated here. There is no priority option for getting COVID-19 vaccine among people living with SMI.

Health insurance for mental health

Joint Secretary and Chief Coordinator NDD and Autism cell informed that in Dhaka North and South City Corporation, Government health insurance scheme (known as Sasthyo Suroksha Karmasuchi-SSK) will be started within next two months. There will be a booth for SSK health insurance pilot programme at NIMH. All mental health treatment (medicine, tests) of SSK card holders will be borne by Government. If any required tests is/are to be done by SMI patients which are unavailable at NIMH then cost of those tests will be reimbursed.

Participants of Stakeholder Workshop agreed towards a consensus statement regarding vulnerability and needs of SMI patients which is as follows:

Consensus Statement from participants of IMPASS Stakeholder Workshop

“We, the participants at the IMPASS workshop, acknowledge that people with severe mental illness are disproportionately (regarding education, gender, place of residence, socioeconomic status etc.) vulnerable to physical as well as mental ill-health, and that they face multiple challenges in accessing care particularly during pandemics such as COVID-19 and related measures (lockdown, social distancing etc.)”

Findings from the workshop participants’ discussion and suggestions and insights of this research study will be helpful to design recovery-centric intervention programmes for SMI patients, increase capacity, quality of life, and develop skills on different activities. As there is limited information on physical illnesses and health risk behaviors in people with SMI in low and middle-income countries, these studies are very crucial to determine the actual scenario of physical health along with mental health within these countries and take measures accordingly.

Further Information:  

  • “The IMPACT SMI research study is implemented in Bangladesh, Pakistan and India and was funded by the National Institute for Health Research (NIHR) (17/63/130) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.”
  • “The IMPASS research study is implemented in Bangladesh and Pakistan and was funded by the “Global effort on COVID-19 health research (GECO) UK Research and Innovation, Medical Research Council (UKRI-MRC) (Grant reference: R23204)” Co funders National Institute for Health Research (NIHR) (Grant reference: 17/63/130) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the UKRI-MRC or NIHR or the UK government.”

To know more information about the study please visit: https://www.impactsouthasia.com/

The Policy Brief is prepared by –

Prof. Rumana Huque, Asiful Haidar Chowdhury, Fariha Islam Munia on behalf of IMPASS study Research Team in Bangladesh

 


The Transgender Community and Disparities of Urban Health Care System: The Untold Stories

A transgender named Sumaiya (pseudonym) became sick while collecting money for a long time under the scorching heat of summer. She went to buy medicine from a road side drug store. While buying medicine, she heard many witticisms saying, ‘You also get sick!’

the drug sellers generally compel the transgenders to leave quickly as the other customers scorn or fear them. Facing discrimination in hospitals are also not uncommon. Seventeen -year-old Oishi (pseudonym) went to hospital with high fever. After standing in the queue for a long time, the hospital staff told her to ‘come last’. While seeking treatment for Corona, Maria (pseudonym) was deprived of treatment from a clinic and returned without treatment. She also went to a private hospital in Dhaka with her sick sister. She was denied to be admitted in the hospital by the hospital authorities and warned not to create any “trouble” and spread panic among the other patients.

The living of the third gender community, locally known as “Hijra’’ in Dhaka is said to be temporary. According to Department of Social Welfare, there are more than 10 thousand members of the third gender community living in Dhaka. Though equal rights for this community have been declared, the reality is different. They are still underprivileged, socially unacceptable, economically neglected and considered as an extremely marginalized group, as social prejudice and stigma have left them sidelined in every sphere of life. Consequently, they are facing various barriers to access primary healthcare.

The real scenario of the quality of their lives has been revealed through various research projects. As a part of the CHORUS research project, we have included some representatives from the third gender community for interviews, along with participants from binary gender identities. “CHORUS” is a research consortium that brings together the health researchers from Africa, South Asia and the UK. As rapid and uncontrolled urbanization continues across low- and middle-income countries, health systems are struggling to keep up, and the needs of poor urban communities are often not met. This is especially true for those experiencing exclusion due to intersections with gender, caste, ethnicity, religion and disability. The core objective of the CHORUS project is to address these challenges while helping to build resilience in the city’s health system and strengthen urban primary health care to provide primary care for non-communicable diseases, particularly hypertension, diabetes and heart disease among the poor. ARK Foundation is working on the implementation of the project in Bangladesh.

The health seeking behavior of the transgender community has been captured through the qualitative interviews with the transgender section, as a part of the need assessment phase of CHORUS project. The urban poor of Bangladesh seldom visit clinics/ hospitals until they feel the absolute necessity- when they miss a day’s work. In occurrence like that, they seek medicine suggestions from the people nearby (neighbors, friends, families, coworkers). If that doesn’t help, they go to nearby pharmacies/ drugstores to ask for medicine from the seller without any doctor’s consultation. If that also doesn’t work, they go to government hospitals or NGO clinics. If they can afford, they may go to private hospitals, which is highly unlikely. The scenario is more miserable for transgender people as they are the always looked down upon with contempt.

Being excluded from the family and society, the transgenders are compelled to live undignified lives with strong negative attitude from the society. The lack of respect and recognition make them undergo hatred, scorn and negligence, being victims of various types of ridicule and harassment. Social stigma precludes them from participating in education and any economic activities. Finding no other way, they are forced to collect money from people to make a living. Often they are  seen in various poses on the busy streets of the city collecting money, adorning themselves in various attires, wearing a pair of sandals; being ridiculed or even sometimes become victims of physical abuse. They also face discriminations while seeking health care facilities.

A transgender, named Samia (pseudonym) says “If we ever enter a hospital or clinic, the behavior of the doctors, nurses and other staffs become very uncomfortable. We are often asked in harsh, unwelcoming tone to wait saying, “Why have you come here’ or ‘come last of all’’. These stories unfold the saddening truth about the trans community and health service sector.

In the capital city Dhaka, the government has made provision of providing health services for everyone (especially for the marginalized population) at a low cost or free of cost through urban primary health care centers under the auspices of the city corporation. But the systematic discrimination has prevented them from visiting public health facilities by their fear of being stigmatized and ridiculed, which puts them at increased health risks. Their poor economic conditions do not allow them to seek healthcare services from the private sector. Since there are barriers for the transgender community to enter the tertiary hospitals in the city, they are bound to go to small pharmacies near their residences to measure hypertension, blood sugar etc.

On November 11, 2013, a cabinet meeting presided over by the Honorable Prime Minister decided to recognize the Hijra community. In 2014, the Ministry of Social Welfare recognized the Hijra community through a gazette notification. This legal recognition is certainly a progressive policy change. But stronger steps and policies are required to ensure their rights to health care. Initiatives from the government and social organizations can play a significant role to remove these barriers and contribute to a more equitable health care system across the country.

Blog Written by-

Umme Salma Anee, Nondita Hassan, Fariha Islam Munia, Maisha Ahsan Momo, Tahmid Hasan, Deepa Barua, Rumana Huque.


Antimicrobial Resistance: An Overlooked Pandemic Threatening Our Economic Future

 

Have you ever wondered what would happen if no medicine were effective to treat illnesses, caused by bacteria, fungi, viruses, and parasites? I am sure you have never thought about it. But it could happen because of a process known as “Antimicrobial Resistance or AMR”.

We will discuss about AMR later. First, let us familiarize ourselves with a new term that I have come to know a few days ago.

 “A Tragedy of the Commons.”

Tragedy of the Commons occurs when the shared, limited resources of a community are exhausted, depleted, and exploited by its people due to their personal gain, even though the depletion of that very resource would eventually bring loss to the community in the longer term. In short, people neglect the greater well-being of the community in order to achieve personal gain. Overfishing without thinking the loss of reproduction of aquaculture would be the classic example of the Tragedy of the Commons.

But how is this term relevant to Antimicrobial Resistance (AMR)?

Antimicrobial Resistance (AMR) occurs when antimicrobials such as antibiotics, antifungals, and antiviral are no longer effective against the disease-causing microbes and bacteria. These microbes have evolved (changed) in order to find ways of surviving antimicrobial treatments. When this happens, we say that the microbes are resistant to antimicrobials. In biology we call these changes mutations. They happen naturally and gradually over time but anything that is stressful to a microbe can force it to change or mutate more quickly. The use of antimicrobials is incredibly stressful for a microbe. Drugs like antibiotics are designed to kill microbes like bacteria and so the microbe will do anything it can to protect itself. The more antimicrobials are used the more microbes will fight back and find ways to survive the medicines – this is AMR.

Antimicrobial Resistance is fast become a new example of the ‘Tragedy of the Commons. This is because many people use antibiotics and other antimicrobials to treat common illnesses, they don’t follow health professional’s advice on dosage, or they use them in the livestock farming to increase the growth and productivity of animals. However, this ‘misuse’ of antibiotics could result in fatal consequences in the future because of AMR. We might soon be faced with an era where antimicrobials are no longer able to treat our illnesses because many microbes have become resistant to them.

As several studies suggest, people often utilize antibiotics and other antimicrobials without following the usage guidelines created by professionals such as the World Health Organization. This means microbes are being exposed to antimicrobials regularly but often not long enough to kill them. This in turn means microbes can find ways to change (mutate) to survive the medicine. This trend of AMR is increasing at a concerning rate worldwide.

Because microbes can move around in our soil, water and pass between human and animal bodies, resistant microbes can quickly spread from human to human, human to animal, animal to human and across geographic areas. This is therefore the right time to focus on tackling Antimicrobial Resistance from the ‘One Health’ perspective which includes humans, animals and the environments.

Antimicrobial Resistance not only regresses us to a pre-antimicrobial era (Antibiotics /antimicrobials like antimalarials were only commonly used since the 1940s) when people died of infections now treatable with antibiotics, but also will have a devastating effect on the world’s economy.

According to a recent report “Drug-Resistant Infections: A Threat to Our Economic Future (2017)” by the World Bank, Global GDP may be reduced by 3.8 percent if AMR is high, whereas in the optimistic case scenario, the global economic output might shrink by 1 percent by 2030 and 1.1 by 2050. If uncontrolled, the AMR could cause the world GDP to fall lower than the figures we saw in the 2008-2009 financial crisis. This cost is due to an increased spending on health care infrastructure and response to drug resistant infections in human health and food producing animals.

Bangladesh as a country might face both the direct and indirect costs of diseases as a result of Antimicrobial Resistance. Direct costs include the resources used to treat the disease, such as prolonged or multiple hospitalizations and medication costs for multiple courses, or more expensive drugs. Bangladesh has already suffered from the escalated burden of out-of-pocket expenditure for healthcare with nearly no existence of any social safety net or insurance. According to the BNHA (1997-2015), a large share of out-of-pocket health expenditure of people goes on medicines. Many people are forced into impoverishment due to catastrophic health expenditures every year in the country. With the efficacy of antibiotics and other antimicrobials declining, both the medication cost and the extended hospital stays will contribute to the increased cost of healthcare, pushing more people towards impoverishment. Moreover, drug-resistant infections will require more and more advanced diagnostic tests to identify and treat diseases resulting in a further cost burden to the general population.

In the case of indirect cost, people will suffer from higher morbidity in the longer term which would lessen the overall production of the country.

Unregulated, misuse and overuse of antibiotics and other antimicrobials in livestock production, animal health and agricultural processes will have similar consequences. Animal disease will be harder to treat, require more veterinary attention and potentially more expensive courses of medication. If drug resistant infections in food producing animals are fatal, we could also face a decreased supply of livestock and thus increased prices of major sources of protein such as meat, milk and eggs.

There are other costs associated with AMR as well. We still do not know about these costs with certainty. There is a risk that those costs could be far higher than the current best estimates by the economists. Assume that there is a 1% increase in resistance to a certain drug, then it would be very important for us to know what pathogen is exhibiting that resistance, what type of infection the pathogen causes, the current and future health burden of that infection, how transmissible the resistance gene and infection are, and whether alternative treatments are available and how costly they are. Because the cost of increased resistance and the threat it poses is uncertain. Thus, it is complex to measure the actual economic impact of AMR.

This grim situation posed by AMR calls for immediate global action. Over-the-counter dispensing and selling of antibiotics remain a major problem in Bangladesh. This action contributes to making the AMR situation worse because people can access antimicrobials without health professional’s advice on usage. The Directorate General of Drug Administration has already suggested a couple of actions to contain the problem. Additionally, strengthening the monitoring framework and proper implementation of the law from the supply side (Provider aspect) coupled with strong community awareness among general people (Consumer aspect) could help to tackle this overlooked pandemic.

It is not too late to invest in tackling AMR to protect the future generation from untreatable infections. Otherwise, interventions that we are using for a long time and get comfortable with such as major surgery, management of injuries and efficient food production might get much more expensive and challenging for us.

Author- Md Badruddin Saify, Research Assistant, ARK Foundation

 


Midwifery education in Bangladesh is improving women’s access to safe childbirth

From British High Commission Dhaka

Published: 1 June 2022

In association with the British High Commission in Bangladesh, the Directorate General of Nursing and Midwifery (DGNM) and the United Nations Population Fund (UNFPA) organised a dissemination seminar on Wednesday 1 June 2022, at the auditorium of DGNM in Dhaka, to share findings of two studies on midwifery in Bangladesh.

ARK Foundation conducted one of the studies titled ‘Strengthening Midwifery in Bangladesh – Lessons learnt’  with the support of FCDO’s South Asia Research Hub at the seminar. The study was presented at the seminar by Professor Rumana Huque, PhD, Executive Director, ARK Foundation.
Mr. Md. Saiful Hassan Badal, the Honorable Secretary of the Medical Education and Family Welfare Division of the Ministry of Health and Family Welfare graced the occasion as Chief Guest. HE Mr. Robert Chatterton Dickson, the British High Commissioner to Bangladesh, Dr. Vibhavendra Raghuyamshi, the Chief of Health, UNFPA, Bangladesh, Dr. Daniel Novac, First Secretary, Embassy of Sweden in Bangladesh attended the seminar with over hundred representatives from different ministries, development partners, implementing agencies,midwifery institutions, and student midwives.

The two independent studies focused on the lessons learnt while strengthening midwifery in Bangladesh, and pathways to women’s empowerment through midwifery education. The findings indicate that the UK Government’s support helped the Government of Bangladesh increase deployment and utilize the diploma holder midwives which greatly improved women’s access to safe childbirth, over the last three years. In 2021, the midwives, deployed in 403 Upazila Health Complexes (UzHCs), conducted 87 per cent of the total deliveries at those UzHCs. In 2018, the percentage was only 24.

 

The studies also found that the existing midwifery education in Bangladesh is effective and contributing to sharpen the social and counselling skills, and improve interpersonal communications of midwives while attending any service recipients. In contrast to the traditional birth attendants, the trained midwives are able to provide more institutional support to use technology-based tools for child delivery, which makes midwifery in Bangladesh more trustworthy to service recipients.

Md. Saiful Hassan Badal, the Honorable Secretary of the Medical Education and Family Welfare Division of the Ministry of Health and Family Welfare (MoHFW), said:

The national midwifery programme has greatly contributed to the reduction of maternal and newborn deaths, as well as caesarean section rates in Bangladesh. The Ministry of Health and Family Welfare has initiated development of a cadre of international standard professional midwives. It was possible due to the strong commitment and support of our honourable Prime Minister. Government has opened the door to higher education for midwives. I believe that the midwives will play significant role in enabling us to achieve the SDGs by 2030.

In his remarks, British High Commissioner HE Robert Chatterton Dickson said:

The UK has been a close development partner to Bangladesh since independence. Our joint effort to strengthen midwifery in Bangladesh adds to the five-decade long Brit Bangla Bondhon for development.

Today almost 3,000 midwives are working in the public health system and have helped deliver over 300,000 children over the last five years. Almost 500 midwives are serving in the Rohingya camps and others in the private sector, enabling safer childbirth for women and their babies across Bangladesh.

During his speech, the British High Commissioner highlighted the importance of empowering young women through midwifery education, which helps women to realise their potential and contribute to a healthy society. He reiterated the UK Government’s prioritisation of women and girls in its new International Development Strategy.

He added:

I thank the Government of Bangladesh and hope that the Government will consider those recommendations the UK supported studies have proposed to further strengthen midwifery in Bangladesh.

The Chair of the seminar, Ms Siddika Akter, the Director General of the Directorate General of Nursing and Midwifery (DGNM), the Ministry of Health and Family Welfare (MoHFW), said:

Midwives play a critical role in saving the lives of both mothers and newborns. Bangladesh’s National Midwifery Programme has successfully enabled thousands of mothers to give birth normally. Considering the need for their services across the country, more than 20,000 midwives need to be deployed to different health facilities including district and medical college hospitals in the near future. To continue these promising developments, the Government has created 5000 new midwifery posts.

For one decade, UNFPA Bangladesh has been a committed implementing partner of the UK who is playing a significant role in advancing the midwifery in Bangladesh. Dr. Vibhavendra Raghuyamshi, the Chief of Health, UNFPA, stated:

It has been an immense pleasure for UNFPA to take part in conducting these studies, the findings of which are highly valuable. Professional midwives do not just play a critical role in preventing maternal and newborn deaths, but also providing family planning and gender-based violence response services to vulnerable women and girls. We look forward to continuing our partnership with the Government of Bangladesh, as well as our generous donors the United Kingdom, Sweden and Canada to ensure the life-saving services of midwives will become as widely in available Bangladesh as possible.

Further information

  • The UK is a leading bilateral donor and develop partner to Bangladesh. The UK provides financial and technical assistance to the Forth Health Sector Programme of the Government of Bangladesh which aims to strengthen Bangladeshi health system to combat issues related to global health insecurity including COVID-19, ensure Sexual and Reproductive Health and Rights (SRHR) to end preventable deaths of mothers and newborns.
  • At the global level, the UK is the champion of the Sustainable Development Goals (SDGs) and an important contributor to the Global Alliance for Vaccine and Immunisation (Gavi), Global Funds for AIDS, Tuberculosis and Malaria (GFATM) and the Global Financing Facility (GFF). The UK is also a major contributor to the COVAX facility that helped millions of people around the world get vaccinated against COVID-19.
  • The study titled ‘Strengthening Midwifery in Bangladesh – Lessons learnt’ was conducted by ARK Foundation, funded by FCDO’s South Asia Research Hub, with the objectives to:
    • investigate the role that the educated midwives can play in improving the maternal/ new-born health care services in the country
    • generate insights on the effectiveness of the midwifery services and its long-term impact on maternal health
    • provide suggestions on the future direction of the midwifery programme by, inter alia, identifying possible scale-up options, opportunities and challenges, through involving/linking private/NGO sectors for training more midwives as per the needs of the country
  • The study ‘Pathways to Women Empowerment through Midwifery Education’ was prepared by Disaster Management Watch (DM WATCH) as part of the UK Government supported ‘Better Health in Bangladesh (BHB)’ programme. The study shows the impacts of midwifery education programme on the empowerment of young women in Bangladesh.

 


Health Economics Research Network-HERN launched in Bangladesh

ARK Foundation Bangladesh with the support from Centre from Health Economics, University of York, UK has launched Health Economics Research Network (HERN) in Bangladesh. A number of students complete undergraduate degrees in economics and health economics each year from different public and private universities of Bangladesh. However, they still require the practical experience of applying the theory into practice.

The demand of skilled health economists who can carry out cost-effective analysis of trials, modeling, and forecasting is also ever growing. HERN has been initiated with the aim of bringing together academics in the field of health economics across Bangladesh.
The launching event of the network was held on April 19, 2022 at the Six Seasons Hotel in Dhaka. Professor Dr Rumana Huque, Executive Director, ARK Foundation; Professor Dr Zahidul Quayyum, Director of Research, BRAC James P Grant School of Public Health (JPGSPH); Professor Dr Atonu Rabbani, Mushtaque Chowdhury Chair in Health and Poverty, BRAC JPGSPH; and Professor Dr Syed Abdul Hamid, Institute of Health Economics, University of Dhaka launched the HERN by inaugurating the website and logo of the organization.

The event was also attended by policymakers, health experts, researchers, academicians, and youths from Bangladesh and around the world.
Professor Rumana Huque said that the network has been inaugurated with the purpose of conducting high quality research in the field of health economics and hoped that the research would play an effective role in informing policies to improve population health. She also said that the network would work to bridge the knowledge gap and create a platform for local researchers to carry out context-specific research in the field of health economics.

For more information please visit: https://bdhern.org/

 


Men’s Health in Urban Bangladesh: Is the Urban Primary Healthcare System Leaving Men Behind?

Abdur Rahim (67) lazily passes his days at his shabby little home in Duwaripara slum. Being a retired day-laborer, he is now financially dependent on his wife’s and daughter’s income, both of whom work as part-time maids for several families in Pallabi, Dhaka. Rahim, sitting at a tea-stall with a bunch of his contemporaries, expresses how irrelevant a visit to an Urban Primary Healthcare Center (UPHCC) is to his life – in fact, he is not even sure if there is a healthcare facility as such nearby.

When asked where he goes to seek healthcare, he reluctantly replies that he “never needs to go to a doctor”, and that the compounder at the nearby drug store gives him all the medicines he needs for minor ailments like a headache or a stomach flu. Rahim has neither felt the necessity to measure his blood pressure, nor has he ever checked his blood glucose level. For him, even though he has not engaged in any productive activity for years, visiting a UPHCC for a general health check-up is a tedious use of his time.

After all, why would he? “I am not in any pain, and I don’t have any difficulty in doing what I do every day,” explains Rahim.

On the other hand, Foyez’s (35) family has been enlisted as “extreme poor” during a survey conducted a few years ago by the UPHCC health workers, and they now have a “Red Card” as a ticket to free healthcare for the whole family.

He gladly described that he didn’t have to pay for his wife’s ANC check-ups, vitamins and supplements; the delivery was also conducted at “Nagar Matrisadan” (Delivery care center under the urban primary healthcare service delivery project) absolutely free of cost, otherwise a rikshawpuller like himself would have to suffer very much to manage the medical cost.

When asked how many times he himself has taken free services from the UPHCC using the Red Card, he smiled and said that the center is mostly for pregnant women and newborns. Although he had brief episodes of illness in past few months – a fever, a headache that expanded to his neck and shoulders, restlessness and discomfort in his chest; he either bought himself some paracetamol from a local drug-store, or did nothing about his ill health. If he goes to visit a doctor, he would have to wait for a long time in the queue.

A long waiting time means lost income, and not everyone can afford it. Especially a rikshawpuller with 3 children to look after.

Men’s health as an issue has begun to attract more specific attention as growing evidence emerges of differential epidemiological trends between men and women, particularly with respect to men’s premature mortality from non-communicable diseases (NCDs) and morbidity linked to poor health-seeking behaviors, mental health and violence.

Several global public health research bodies have stated that in almost every country of the world, men are more likely than women to die before age 70, and data from the World Health Organization (WHO) suggest that approximately 52% of all NCD deaths worldwide (2018) occurred among men.

The probability of men dying from cardiac ischemic diseases is 75% higher compared with women. However, 36% of deaths in men are preventable, compared with 19% in women. Why then are men underutilizing the available healthcare services?

Research suggests that gender and society’s perception of masculinity and men’s role in a family and community have big roles to play in men’s health. Nevertheless, the pattern of urban poor men’s health seeking and priorities of the urban healthcare service delivery projects in Bangladesh do leave questions about the inclusiveness of the system.

 

Men’s health in a system that prioritizes women

Bangladesh has a rather complicated urban health system. Considering the inadequate health workforce of the Local Government Division (LGD), the Ministry of Local Government (MoLGRD), who is responsible of providing primary healthcare to the urban population, has launched several healthcare delivery projects, mostly through contracting out service delivery to NGOs.

The ADB funded Urban Primary Healthcare Service Delivery Project (UPHCP) was launched in 1998, in order to provide general healthcare and comprehensive reproductive healthcare to the urban population, with special emphasis on the urban poor.

Although UPHCP, along with most other healthcare projects under MoLGRD, are bound to provide primary care to the entire urban population irrespective of their socio-demographic traits, maternal and child health (MCH) and sexual and reproductive health (SRH) services have traditionally been the main focus of the projects.

For needs assessment of CHORUS Bangladesh, a project which is designed around strengthening UPHCP for providing NCD care, we had to explore not only the project documents that define the priorities of this project, but also the approach and activities of the healthcare managers and providers.

The NGOs are given certain service delivery targets that they are bound to meet in order to remain in the role of providers; targets that are mostly revolving around MCH and SRH – number of ANC visits, number of deliveries, number of family planning methods implemented per annum, etc.

There are no targets that prioritize adult men’s health per se, unless a female counterpart’s reproductive health is linked to the health outcome of the man. Literature suggest that the high rate of maternal and child mortality and morbidity related to reproductive health before and during the MDG period might have influenced funders and the government to focus on MCH and SRH.

Consequently, the field workers and paramedics running the satellite clinics in each project area direct their services and community engagement towards increased utilization of services by women and adolescent females. However, healthcare managers state that they have always kept their doors open for men. “We have even hung banners to invite men to the primary healthcare centers. Yet, we only get less than 20% male patients at the facilities,” said the Project Manager of one of the NGOs implementing UPHCP under Dhaka North City Corporation (DNCC).

To provide insight about why the trend has been set like that, project manager of another NGO said, “I think since the Comprehensive Reproductive Healthcare Centers (CRHCC) and Primary Healthcare Centers (PHCC) in each area are run by the same NGO, men have this presumption that the NGO clinics are for women.”

She further stated, “Almost all of our healthcare providers, including the health counsellors, are female. The men in our target population might not be comfortable consulting with female providers, as the urban poor communities still hold prejudices.” From interviews of healthcare providers and clients, we know that the community health workers play a big role in bringing ANC and family planning clients to the clinics, but they do not engage as such with adult men (or women) to bring potential or diagnosed NCD patients to the PHCCs.

Our experience says that urban primary healthcare system at present is not prioritizing men’s health. On the other hand, research has shown that healthcare utilization by men increase at each higher level of care (from primary to secondary, and tertiary hospitals), which suggests that men seek care when the severity of their health issues require advanced interventions.

To improve men’s healthcare-seeking behaviors, researchers and practitioners will need to consider individual, economic, and social determinants of men’s healthcare-seeking behaviors and pertinent barriers toward improvement.

The urban health system in Bangladesh needs to be sensitized to the healthcare seeking patterns and difficulties of men so that the system can be made more acceptable for men in need.

Community health workers and primary care providers need to be trained and equipped to not only recognize the needs of adult men, but to also provide preventive care, i.e. screening, counselling and health education about risk factors, to improve health seeking behavior of this vulnerable group.

Author: Maisha Ahsan Momo, Research Assistant, ARK Foundation

 


Public Private Partnership in Improving Access and Utilization of Health Care Services: Scopes, Opportunities and Challenges

Improved quality and access to healthcare services are essential for a country’s development. Private sectors like NGOs, for-profit and non-profit organizations have significantly contributed to health by financing and managing healthcare services in different ways. Private sector, similar to other countries, brings technology, innovation, financing, and most importantly, additional health workforce – areas that public sector has always been struggling.

In developing countries, the private sector becomes more critical because, with limited resources, such countries struggle to ensure proper health care for everybody. Private sector, similar to other countries, brings technology, innovation, financing, and most importantly, additional health workforce – areas that public sector has always been struggling.

However, issues including high cost and centralized/urban location raised concerns regarding equity in access to private healthcare services by the poor and
underprivileged service recipients in the country.

That is why, the public-private partnership can offer new opportunities by sharing risks, resources and finance to provide healthcare services under certain conditions. A combination of the positive aspects of both private and public sector could address the situation by expanding the service coverage and increasing equity, which could be brought in through approaches like Public PPP.

In spite of being one of the most populous countries in the World, the improvement of Bangladesh in Health, Population and Nutrition (HPN) sector is quite remarkable.

The country achieved its Millennium Development Goals (MDGs) related to HNP well ahead of the stipulated time and now aiming towards achieving Universal Health Coverage (UHC) by 2030. Under 5 child mortality dropped from 49.4 in 2010 to 34.2 in 2016 (per 1,000) and infant mortality reduced from 37.4 percent to 30.5 percent in the same period.

Two third of the total health expenditure in the country still comes from the recipients as Out of Pocket Expenditure, with government contribution is only one third. Only 2.64 percent of GDP is spent for healthcare, which is one of the lowest in South Asia. Under this scenario, the contribution of private sector in terms of increasing coverage of health services is commendable, as evident from the fact that availability of hospitals beds in private sector (87,610 in 2017) is almost twice than that of public sector (49,414 in 2017), as specified in Health Bulletin, 2018.

ARK Foundation condcuted a study to find out the possibilities, scopes and challenges of public-private partnership (PPP) which will inform a guideline to design and implement such collaboration to improve access to and quality of health.

A mixed-method approach was followed for the study combining desk review, case studies and qualitative data analysis.The findings in this report are generated from shreds of global, regional and local evidence obtained from the desk reviews, observations from the case study and qualitative data from the interviews and group discussions.

Also, feedback from the technical and dissemination workshops are incorporated in the report. All of these informed a policy matrix for publicprivate partnership in health. Potential scopes of PPP in health lies in terms of extending the time of public healthcare services, minimizing the cost of the overall treatment and enhancing the capacity of healthcare providers and managers.

For the health sector, the government can implement PPP either by hiring private organizations, purchasing services or outsourcing or contracting doctors.Contracting out the underutilized health facilities (such as 10/20 bedded hospitals) and robust referral system (such as through general practitioners recruited by the government) can help expand health service coverage in the country.

Partnering with private entities to provide healthcare services to hard-to-reach areas, generic drug production and introducing health insurance can increase equity in health. PPP can also be introduced in case of the ambulance, security, laundry, cleaning and waste management service in the public healthcare facilities, diagnostics, dialysis, imaging, emergency services and capacity development of service providers.

Proper implementation of PPP in health requires to have an enabling environment at the policy level. Such an enabling environment can be facilitated by having a PPP guideline for health sector and a legal framework for private partners considering the alignment of values between the public and private sector. Also, institutional capacities in the form of training or guideline in the relevant sectors for the key actors are essential.

In the whole process of implementing PPP in health, conflicts of interests must also be carefully considered to not only ensure transparency but also make it scalable and sustainable. Furthermore, PPP must not lead to any market distortion because of the collaboration instead encourage competitive health market in the country.

The findings in the study brought out a series of recommendations and strategies that needs to be taken into account for considering successful PPP in the health sector in Bangladesh. Firstly, the formation of a technical committee with relevant stakeholders in the ministries, its involvement, leadership and guidance will ensure coordination in the process which is currently missing.

A comprehensive guideline for PPP in health needs to be developed by the ministry of
health that can guide both the technical committee and key stakeholders. With the existence of a leading entity and a guideline, relevant stakeholders in both public and private sector can be sensitized through workshops.

These workshops can then help to prioritize the service domains where PPP should be considered and explored. Rest of the steps from identifying potential private entities to implement and monitor the PPP projects should be followed as per the guideline and recommendations from the technical committee.

Achieving universal health coverage by 2030 requires a positive transformation in the health sector. New, innovative, successful and evidence-based approaches through public-private partnerships can pave the way towards achieving the short-term and long-term goals in the health sector and ensure health for all.

Authors: Rumana Huque, PhD, Sushama Kanan, Zunayed Al Azdi


Strengthening primary healthcare to achieve universal health coverage

 Rumana Huque |  December 08, 2021 00:00:00

The World Health Organisation (WHO) strongly promotes the primary care principles enshrined in the 1978 Alma Ata declaration which emphasises equity, inter-sectoral collaboration, access to essential drugs, appropriate health technology, and comprehensive care. A Primary Health Care (PHC) approach from a services delivery perspective can be characterised as primary care: the continuum of first contact promotive, preventive, diagnostic, curative, rehabilitative and palliative care services delivered across the life-course. It is also important that PHC has close liaison with secondary and tertiary cares in coordinating care across health sectors.

According to WHO European Health Report 2018, in spite of progress made in strengthening PHC, widening inequities and gender differences, especially for non-communicable disease (NCD) outcomes, population ageing, increasing vulnerable groups, quality deficiencies, increased burden of mental illness, the global threat of antimicrobial resistance, and high out-of-pocket payments are critical challenges globally for providing PHC for all. With the 2030 Sustainable Development Goals (SDGs) on the horizon there is renewed drive and political commitment globally for PHC strengthening as an accelerator towards Universal Health Coverage.

Since independence, successive health plans of Bangladesh have emphasised primary healthcare (PHC) as the key approach to improving the health status of the population, particularly the vulnerable groups. However, before the health- sector reforms in 1996/97, the share of the Ministry of Health and Family Welfare (MOHFW) in resources going to primary and tertiary-level care was nearly the same, 38 per cent and 37 per cent of total healthcare expenditure respectively. Under the reforms in 1998, an Essential Service Package (ESP) was designed, with the aim to allocate 60-65 per cent of total healthcare resources to the primary level (upazila and lower level).

The ESP in Bangladesh was planned to be delivered through different levels of the primary healthcare system (community, union, upazila, and district levels). A set of the most cost-effective interventions was selected for the package. Within ESP, government gave the highest priorities to those interventions that have a merit-good character (that is have important externalities), and that were related to maternal and child health. In 1999/00, the proportion of MOHFW expenditure incurred at the upazila and lower-level health facilities to total MOHFW expenditure increased to 62 per cent, while the share to district and upper level declined to only 19 per cent. However, since 2001/02 the healthcare expenditure at upazila and lower levels(i.e. the primary care level), as a proportion to total healthcare expenditure, started to decline, and the MOHFW could not meet the target of channeling 60-65 per cent of healthcare resources to the primary-level facilities. Public Expenditure Review 2015 states that in 2012, 49 per cent of the total healthcare expenditure was incurred at upazila and lower-level facilities, while the proportion has gone down in recent years.

It is, therefore, important to increase investment in primary health services, which would help reduce the burden on secondary and tertiary healthcare.

Non-communicable diseases are a major public-health challenge accounting for 67 per cent of adult deaths in Bangladesh. Studies have found 12 million people, 32 per cent of women and 19 per cent of men, aged 35 years or older having hypertension, while 7 million individuals aged 15 and above having diabetes. The MOHFW while implementing the 4th Health, Population and Nutrition Sector Programme (HPNSP) from 2017-2022 emphasized strengthening PHC to address NCDs. Preventing risk factors, screening for early diagnosis and management at PHC level has been identified as a priority under the 4th health-sector programme. It is recommended that integrated PHC with expansion of ESP and healthcare financing as a crucial component of health systems are vital for achieving universal health coverage (UHC).

Hence, strengthening PHC for providing preventive and promotive care, especially for NCD control, should receive high priority in budgetary allocation. However, the Public Expenditure Review 2015 showed that the proportion of government spending on curative care is increasing over time while that of preventive care is in a declining trend, which needs attention of policymakers. It was evident during the COVID-19 pandemic that allocation under public health, specially for water and sanitation and hygiene programme, is insufficient in the country. Government needs to take the responsibility of these interventions, need to put it in budget and ensure efficient utilisation of the resources.

Primary healthcare in Bangladesh is very diverse — both public and private (not for profit and for profit) sectors provide primary healthcare. A variety of healthcare providers, including “allopathic”, ayurveda, unani, homeopathic, and traditional healers (without any form of training) deliver care. The government needs to put emphasis on regulating the diverse actors in ensuring quality primary healthcare.

Inadequate human resources and retention of health personnel in rural areas are also major challenges. Evidence suggests that improved living and working conditions, better salaries, use of disruptive technology, co-operative arrangements with other rural health facilities, and continued training help the doctors and nurses to provide high-quality care in rural areas. In the absence of adequate training, improvement in living and working conditions, and career progression, merely making it mandatory for nurses and doctors to work in rural areas does not work. Bangladesh needs to develop career path of the doctors and health workforce and ensure other facilities to retain them in the rural areas. In addition, given the shortage of physicians to work in rural areas, many countries have engaged non-physician providers to deliver primary healthcare in rural areas. It is evident that non-physician providers, when well-skilled, supported, and supervised, can deliver good-quality healthcare for a range of conditions. The Ministry of Health and Family Welfare of Bangladesh has sub-assistant community medical officer, community healthcare providers, health assistants and family-welfare assistants to provide preventive and promotive care in rural areas. It is important to ensure that they have adequate skill in providing quality primary healthcare. They should be supported through regular training, incentives, and supervision.

Although urbanisation has been on the run in the nation, urban primary healthcare system remains weak. Providing urban primary healthcare services is the responsibility of the Ministry of Local Government, Rural Development and Cooperatives. However, due to the limited resources of City Corporations (CCs) and Municipalities, primary healthcare facilities and services for the urban population are inadequate and private sector remains the major sources of care. Since the Ministry of Local Government, Rural Development and Cooperatives is also responsible for maintaining transport systems, water, sanitation, planning and development, there is yet to develop a system for accountability in terms of the urban health system.

In addition, the plurality of providers at the primary healthcare level in the urban health system creates heterogeneity in service delivery with diverse service coverage, quality of care, and service fee. According to the National Urban Health Strategy 2020, rapid influx of the rural population into the cities in search of employment opportunities and a better lifestyle has made the challenges in delivering quality urban healthcare services more complex. It is crucial to strengthen primary healthcare services focusing on the vulnerable group of urban population, and the government needs to invest in improving urban primary healthcare system.

Out-of-pocket health expenditure is high in Bangladesh — 74 per cent of current health expenditure — and most of this is spent on outpatient treatment, mainly medicines and diagnostic tests. Healthcare expenditure is a common reason for families to be forced into poverty. In the absence of structured referral pathways, people can seek care from tertiary level bypassing the primary care, which increases the healthcare expenditure manifold.

Purchase of medicines including antibiotics over the counter without prescription is another challenge which poses the serious threat of antibiotic resistance. The World Bank report 2018 estimated that low-income countries could lose more than 5.0 per cent of their Gross Domestic Product in a high-impact scenario if antibiotics and other antimicrobial drugs lose their effectiveness due to inappropriate use of antibiotics. Measures should be taken for appropriate drug dispensing, including training of pharmacists and regulation.

The WHO also places great emphasis on local community involvement, delivering care locally, without requiring people to travel long distances, patient-centred care, good local governance, and empowerment of people to take responsibility for their own health. There is no “one-size-fits-all” type of methodology for delivering primary care. However, local ownerships are common features of successful PHC models. Bangladesh should also strive to engage community in strengthening PHC.

Dr Rumana Huque is a Professor of Economics, the University of Dhaka, and Executive Director,

ARK Foundation, Bangladesh.

[email protected]

Originally published in The Financial Express