PHC in Bangladesh—Too much to ask?

0277-9536/83 $3.00 + 0.00 Pergamon Press Ltd

Sm. Sci. Med. Vol. 17, No. 19, pp. 1463-1466, 1983 Printed in Great Britain

PHC IN BANGLADESH-TOO KAMAL

Sreepur

Gonosasthaya

Kendra,

ISLAM

and

MUCH

SALLY

Village Tengra,

TO ASK?

BACHMAN

Thana

Sreepur,

Dacca,

Bangladesh

Abstract-In Bangladesh where the number of those without land is increasing; 30% of the budget (national) goes for ‘maintaining law and order’; there is massive illiteracy; the common people and, more specifically, women, are not involved in decision-making. It is unrealistic to think that PHC has a chance to survive or succeed. Should Government (with all good intentions) try to run a PHC while socio-economic and political factors remain unchanged, it (PHC) will not succeed. Its fate is either a collision, in which PHC will be the victim, or a compromise of some type. In most Third World countries, it is a compromised PHC that one sees. In spite of this, we still believe that community-oriented health care can help to bring about social, economic and political changes, provided such changes are accompanied by structural reform in the political economy of the country.

INTRODUCTION So

much has been written about primary health care that it is difficult to add something new. However, ironically enough, although much has been written in an international context, very few articles have been writen on PHC, per se, in Bangladesh. A search through government institutions, including the Planning Commission (usually a reposite for all important government papers) revealed only one document: the ‘Country Paper on Health for All by the Year 2000’. This document was read carefully and although the paper expresses high hopes for providing PHC to all by the year 2000, it will be argued in this paper that this goal is not attainable-at least not if the prevailing system of health care together with high levels of poverty, unemployment and inequality continue uninterrupted until then. (PHC)

BACKGROUND

Political and economic condition of Bangladesh Bangladesh is presently ruled by a military government, the third in the country’s 10 year history of independence. Despite changes in rulers however, the ruling ‘class’ has never changed. An Clite, educated, moneyed and well-placed urban population, with links to upper classes at the village level, control and exploit the vast majority of Bangladeshis who live in scarcity and poverty in their villages and, to a limited extent, those of the urban bustee (slum) life. The condition of the country’s health care system has a direct bearing on its quality of life standard and all measurements of the quality of life in Bangladesh show that it is quite poor. A glance at statistics for education, health, distribution of income, distribution of agricultural land (vital in this predominantly agrarian society) and the GNP per capita shows: (A) Education [l]: literacy: less than 20% of the population is literate. Enrollment in primary schools is 55-60% of age groups and drop out rates are extremely high. (B) Health [2, 31: Doctor/population ratio: 1/lO,OOO; crude birth rate = f 44 per thousand; crude death rate = f 17 per thousand; infant mortality

rate = 150/thousand live births; maternal mortality rate = 30/thousand live births; life expectancy at birth = 47 years; 1st degree malnutrition among children = 36.1%; 2nd degree malnutrition among children = 8.3%; Average caloric intake = 93% of the requirement, but 59% of the households are deficient. (C) Distribution of income [4]: 20% (highest income groups) make 40% of the national income; 20% (lowest income groups) make 7% of the national income. (D) Distribution of agricultural land (1977) [5]: 10% largest landowners own 45x, 10% smallest landowners own l”/,, rural households owning no or less than 0.5 acres of agricultural land (1977) = 48%. (E) Economy [6]: GNP/capita = US$90.00. Evidence of the consequences of the inequalities in Bangladesh’s economy can be found in figures showing that consumption of all major food nutrients by the average Bangladeshi declined significantly during a recent 13 year period [7]. Half the rural families in the country eat fewer calories than what is considered the desired amount [8]. Another indicator of ‘quality of life’ is the general status of a country’s female population. Bangladeshi women have two major functions--child bearing and care and food production. Neither occupation is recognized for its value, time consumption and/or wear and tear on the woman herself, but both are the ‘expected’ role of woman. According to UN statistics, only 11.8% of the rural female population work outside their homes [lo]. Painting a broad-stroked picture of the political economy of this country, one sees a vast rural population, a majority of whom have no land, security or regular employment. Politically, both on the m%ro and micro levels, the country is dominated by the well-off, most of whom are residents of, or have connections to, the cities.

EXPERIENCES FROM SRI LANKA AND KERALA

In desperation, many health professionals look for success stories among other under developed countries with similar GNP/capita ratios. One immedi-

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ately focuses on Sri Lanka and Kerala who have a GNP/capita of 130 and $110 respectively [l I]. In Sri Lanka, during most of the Bandaranaike administration, each citizen over 1 year of age was entitled to a free ration of two pounds of rice per week. A further two pounds was provided at a subsidized rate. Also included in subsidized foods was wheat flour, sugar and a range of less important items [12]. The food subsidy, coupled with similar subsidies in education, health, transport and a progressive tax structure, resulted in a major redistribution of income. Similarly, in Kerala, subsidized food distribution through fair price shops covering virtually the entire population with a subsidy as high as 60% (though offering no free rice), coupled with land reforms and other policy actions, improved the well-being of the poor. Wage rates and employment policies brought higher wages, increased bargaining power by landless workers and resulted in higher employment in the State. Agricultural labourers are now provided with virtually unprecedented employment security and pension benefits [ 131. THE BANGLADESH SCENE A subsidized rationing system exists in Bangladesh, but by contrast it reaches at best, only 25% of the total population and less than 15% of the country’s rural population. Seventy per cent of the food distributed through the ration system goes to urban consumers. Even for the few poor who own ration cards, only half can afford to purchase rationed rice even at the subsidized prices [14]. Education is equally urban oriented. More money is spent on university and college education than on primary. The health system is based on curative care and is biased towards the urban population, with the bulk of health budgets being spent on training doctors and equipping city hospitals or building health edifices in rural towns. No emphasis is placed on training workers in primary and village health care 1151. Clearly, the socio-political and economic systems of Bangladesh are oriented not towards the basic needs of the poor, but rather towards the politically pivotal middle class [16]. A number of authors have previously reviewed available evidence from developing countries and been unable to find reasons to believe that either preventive or curative efforts contributed significantly to the rapid decline in death rates since about 1930. Improvements are generally ascribed to political and social stability, economic growth and some improvements in equity, all of which in their turn contributed to improving nutritional standards [17]. It is interesting to note that in some States (again notably Kerala and Sri lanka), generous health budgets have coincided with low budgets for the military and law enforcement agencies. The direct correlation between the two, if there is one, would prove interesting subject matter for a social scientist. It must be emphasized however, that more money for health budgets makes little sense if that money is not wisely spent. Injections of currency alone will not cure a sick health care system.

Despite the overwhelming impact of external factors on the health of any population, it certainly cannot be said that health programmes have no role to play. On the one hand, health professionals should not have to take excessive blame for a nation’s ill-health. Many factors in addition to germs contribute to any illness. “If our goal is truly to get to the root of human ills, must we not recognize that health projects and health workers are likewise appropriate only if they help bring about healthier distribution of wealth and power?” [18]. On the other hand, health professionals can justifiably be blamed for helping to perpetuate a hierarchial system and for not paying enough attention to changing the socio-economic factors of health. Health programmes, both private and government run, CAN tackle these problems given appropriate attitudes, expectations, evaluation and training. PHC IN BANGLADESH:

THE CURRENT

STATE

When discussing PHC in the Bangladesh context, one MUST talk about a fundamental redistribution of wealth and power. As in redistribution of land, such a shift of power and resources is bound to cause social conflicts. Many are still under the delusion that redistribution of health care through a PHC system can be achieved without rocking the social boat. It is utopian to dream that the curative-oriented, urban based majority of health care workers currently concerned primarily with private practice, secondary and tertiary patient care in larger hospitals can be easily converted to taking part in predominently rural PHC programmes. Considering the above, it is hereby suggested that a serious indicator of the success of any PHC programme is the degree of social change it arouses. The health professional, despite the limitations of his/her effectiveness described earlier, should be part of a health programme fitting into an overall development strategy with social justice as a primary objective. If previous patterns are any indication, the ‘urban bias’ which plagues almost all other sectors of the economy will continue to also dominate the provision of health care facilities. despite the assurance to provide minimum health care for all by past and present governments, the country has yet to see a shift from ‘urban bias’ to ‘rural bias’. In past budgets, an average of 7Oyi has gone to urban services, and the majority of that amount to funding medical colleges and hospitals [19]. Not only are major public and private hospitals located in urban areas, but of the 8500 qualified allopathic doctors in the country, less than 100: work in rural areas where the majority of the population resides. Here is a brief outline of the proposed plan by which PHC is to be delivered to rural Bangladesh. PHC will be delivered through the FWC (Family Welfare Centre), one in each Union (several Unions of approximately 20,000 population each, make up a Thana, the lowest administrative level of government). They will be staffed by a Medical Assistant, one Family Welfare Visitor and other auxiliary staff and will provide preventive and curative medical care together with MCH and family planning services. At

PHC in Bangladesh-too

the village level, services (health education, immunization, MCH and family planning activities) will be performed by Family Welfare Workers (male: l/4000 population) and Family Welfare Assistants (female: l/6000-7000 population). One Thana Health Complex (THC) will be constructed in each thana. this centre will be staffed by four doctors, nurses and many auxiliary staff (laboratory technician, compounder, etc) and will provide both in-patient (3 1 beds) and out-patient facilities. In addition, it will also coordinate and provide back-up services for the Union Welfare Centres. District hospitals with 100 beds each will provide secondary health care, along with 50 bed subdivisional hospitals which will be gradually upgraded to include 100 beds (thana population averages 250,000 with several thanas making up a subdivision and several subdivisions making a district). Tertiary care will be available at the medical college hospitals, each having 25&500 beds. Super-specialized care will be provided through specialized institutions [20]. The Second Five Year Plan (1980-1985) described the condition of rural health care facilities in the following way: The utilization of even the existing health facilities in rural areas is very poor. The bed utilization rate in Thana Health Complex is only 30 as against 100% or more in the urban areas. This is not due to less morbidity in the rural areas, rather it reflects generally the poor quality of services arising out of poor management and technical inefficiency coupled with gross inadequacy of supply of drugs, medical and surgical requisites. Consequently. the rural health institutions do not enjoy complete confidence of the local people leading to the phenomenon of bypassing such institutions and overcrowding the urban hospitals [21].

We can see now that the planners have not ignored the provision of health care facilities to the masses. Recently, the government has instituted a law requiring newly graduated doctors to serve in rural areas for 5 years before receiving licences for other practice. Decreeing change does not, however, automatically create it. A number of problems with the government’s approach can be seen.

TEAMWORK AND

COORDINATION

For any PHC programme to function effectively, the approach has to be through a cohesive group. There are 16 different types of health workers delivering PHC at the thana level. They are all trained in different institutions, with different curricula, in different places. Even though family planning programmes have been integrated at the thana level, they still function separate!y, dealing with contraception as a problem of persuasion and sales technique [22]. Our own experience with the training programme at Gonoshasthaya Kendra have been very encouraging, especially concerning the formation of a team and building in atmosphere of cooperation. We have recruited both boys and girls (but predominently girls), training them for a period of a year in preventive and curative medicine and family planning. Our paramedics have subsequently moved up to more senior positions after gaining experience and are now managing inpatient, outpatient and operating theatre

much

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to ask?

departments in addition to providing domiciliary care at the village level [23]. We did not train paramedics in each department separately and as a consequence the paramedics have a strong community feeling about themselves. Staff hierarchies should be broken down in the government’s programme and the types of worker at the thana level reduced from 16 to 3 or 4. Government health workers are now segregated according to the kind of service they render (in/out-patient care, etc.). Differentials between the salaries and responsibilities of male and female workers also should be entirely eliminated. TRAINING/RESPONSIBILITY Health workers’ responsibilities will definitely have to be upgraded and increased in order to improve their status in the eyes of village people and to increase their credibility. Training should be carried out locally and preferably ‘on-the-job’ so that the health worker can build up a sense of belonging and responsibility for the area in which he/she will be working. This is particularly important for new recruits. We would argue very strongly for including more women in PHC programmes to encourage their personal growth and independence. In general, women are more sensitive, hard-working and caring for mothers and children who should be the prime target group of any PHC programme. Trainers must be aware that training women presents some particular challenges. In order to fulfill their potential, at least in Bangladesh, we have found women may have to be given special attention and encouragement and should even be favoured over male workers in many ways to help them advance. TRAINING IN

PRODUCTION POLITICAL ECONOMY

AND

Bangladesh is a rural, agricultural society, yet most of its health workers, as hinted earlier in the discussion on urban bias, hold themselves superior to the work that the majority of their countryfolk do. At Gonoshasthaya Kendra we have found that involving health workers in production by requiring them to work for an hour each morning in the fields has helped them to have more empathy with the people to whom they are delivering health care. Many health workers have left or have failed to turn up for training for fear of doing this agricultural work, but most workers who get through their initial uncomfortable period, learn to like growing their own vegetables and rice. Most government curricular contain nothing on the current political economy of the country. I (Kamal) confess that throughout my formal education, I never read anything on my country’s then current condition. What I was forced to read, however, was ancient history. Every paramedic, if they are to be an agent of change, must have more knowledge of the present rather than such a thorough knowledge of the past. Here then, are specific improvements which could be made in the structure and content of PHC training in Bangladesh. The principles, in general, apply to

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ISLAM and SALLY BACHMAN

both private and government run programmes although we have been specifically examining the latter. To sum up and return to a more general level, it can be pointed out that two types of health workers exist, one of which will predominate in any country given the local politics, culture and economy: Type I Health Worker is: taught a limited range of skills; trained not to think but to follow special directions; subjugated to restrictive supervision and rigidly predefined limitations. Type II Health Worker is: taught a respectable range of skills; encouraged to think, take initiative and keep learning on his/her own; is limited only by what he/she knows, not by instructions from superiors alone; watched carefully, but not overbearingly, by supportive and educational supervision [24]. The health worker of Type I will have a limited impact on a population’s health and even less on the growth of the community, whereas Type II, with more freedom and responsibility, can become an integral agent of change. The principles listed above defining the Type II health worker-obviously the prefereable type-are admittedly vague. They mention nothing of the constraints which trainers face in trying to produce this type of health worker. First, trainers must themselves be convinced that paramedics can and should be able to take on the responsibility and knowledge for which we are calling, and since most trainers have themselves been taught under the old system (which produces mostly Type I workers) changing their own attitudes poses an initial challenge. In addition, there are some constraints specific to this country and culture which must be taken into account. Although we have found that some traditions, e.g. segregation of women, can be overcome by first eliminating them in our own institution and then encouraging others to follow our example, other problems have proven larger and more difficult. Specifically, we have not yet found the road leading to successful ‘community-based’ health care in a large part because ‘community’ is very difficult to define in Bangladesh. Years of class involution/evolution have fragmented village ‘communities’, normally defined along geographical lines, into not only economic classes, but groups distinguished by religion, regional background, family ties, etc. Hierarchies in all these groups are well-defined and yet there are so many links among different groups and hierarchies in different places that isolated attempts at social change inevitably run into the homogeneity of social injustice in the society at large. In other words, one or two committed and well-trained health workers will not, in the long run, make much difference if workers in all sectors of society are not similarly encouraged. Social change cannot come about through health care alone, or only in the field of health. It will come only if all sectors of society are moving forward simultaneously.

CONCLUSION

Under existing constraints, it is unrealistic to ask the government health care system to run a successful community based programme. More realistically, we can ask them to change policies to create a community oriented system as opposed to presently centrebased programmes. Community based programmes can be taken up after passing through this intermediate stage, when time and conditions are ripe.

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Vylder S. and Asplund D. Contradictions

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and DisThe Case of Bangladesh,

p. iii. Sida Utredningsbyrin, 1979. 2. Streefland P., Chowdhury S. A., Ashraf A., Khan A. H., Nabi N., Quanine J. and Delmonte S. Health, 3.

4. 5. 6. 7. 8.

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IO.

11.

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16. 17. 18. 19. 20. 21. 22. 23. 24.

Disease, Care and Cure in Rural Bangladesh-A Study of Three Villages in the Tangail District, p. 4, 1981. Ahmad K. (Ed.) Nutrition Survey of Rural Bangladesh 1975-1976 1). 130. Institute of Nutrition and Food Science, Umversity of Dacca, 1977. de Vylder S. and Asplund D. op. cit. de Vylder S. and Asplund D. op. cit. Streefland P. et al., op cit., p. 4. Islam K. In search of relevant health care. Holiday 7, 10. 12 January, 1982. Khan M. R. Nutrition Situation of the Child and Mother-Causes and Policy Issues Involved. (Dacca, 1979). McCord C. Medical technology in developing countries: useful, useless, or harmful? Am. J. c/in. Nutr. 31, 2301-2313, 1978. UNDP, quoted in “Third World Women-a Major Factor in Rural Workforce”, The New Nation, 10 July, 1982. 1982 World Population Data Sheet, Population Reference Bureau, Inc., Washington, DC, and Ratcliff J. W. Poverty, politics and fertility: the anomaly of Kerala. Hastings Center Rep. 34-41, 1977, and Levinson F. J. Incorporating nutrition in agricultural, food and health policies and programs in South Asia. Paper presented at the Regional Seminar on an Integrated Approach to Population, Food and Nutrition Policies and Progress for National Development, Bangkok, 1979. Levinson F. J. op. cit., p. 9. Ratcliff J. W. op. cit., pp. 3637. Levinson F. J. op. cit., pp. 13-14. de Vylder S. cited in Urban Bias in Bangladesh: How Much Too Much? Community Development Library, Dacca, 1981. ibid. McCord C. op. cit., p. 2302. Werner D. The village health worker: lackey or liberator? Wld Hlth For. 2, 4678, 1981. Streefland P. et al. op. cit. p. 6. Planning Commission, Health for All by the Year 2000. Dacca, 1980. The Second Five Year Plan, 198g-1985, cited in Streefland P. et al. op. cit., p. 8. Planning Commission, op. cit. Gonoshasthaya Kendra, Progress Report, 1978, Dacca. Werner D. op. cit.