Community Participation and Health: An innovative national intervention in Bangladesh

December 16, 2012 1:36 am 1,305 comments __
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By Prof. Dr. Sheikh Md. Nazmul Hassan

The first International Conference on Health Promotion, meeting was held in Ottawa on 21st day of November 1986 and declared a charter for action to achieve Health for All by the year 2000 and beyond. It was built on the progress made through the Declaration on Primary Health Care at Alma-Ata, the World Health Organization’s targets for Health for all document, and the then time debate at the World Health Assembly on intersectoral action for health. The Alma-Ata conference held on 12th September, 1978. One of the most important outcomes of that conference was the definition of Primary Health Care (PHC). It was defined that Primary Health Care is the essential care based on practical, scientifically sound and socially acceptable method and technology made universally accessible to individuals and families in the community through their full participation and at a cost they and the country can afford to maintain in the spirit of self reliance and self determination. Through the conference, eight elements were set for PHC, out of them number four was ‘the people have the right and duty to participate individually and collectively in the planning and implementation of their health care’. Five basic principles were also set for PHC, those include; community participation, intersectoral collaboration, integration of health care programs, equity and self-reliance.

Community participation is a process by which individuals and family assume responsibility for their own health and develop the capacity to contribute to the community development. Participation can be in the area of identification of health needs to the whole cycle of the health planning and implementation. Through the conference, it was diagnosed that community participation is the hallmarks of primary health care, without which it will not be succeeded. The community needs to participate at village, ward, district or local government level. This participation addresses the felt health needs of the people in different ways like; it ensures social responsibility among the community, ensures sustainability, cost sharing, enhancement of knowledge and encourages intersectoral collaboration.

In the Ottawa charter some health promotion means were undertaken those included; Build healthy public policy as health promotion goes beyond health care. Create supportive environments as our societies are complex and interrelated. Health cannot be separated from other goals. The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. Strengthen community actions; health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the core of this process is the empowerment of communities – their ownership and control of their own endeavours and destinies. Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation in and direction of health matters. This requires full and continuous access to information, learning opportunities for health, as well as funding support. Develop personal skills; health promotion supports personal and social development through providing information, education for health, and enhancing life skills. By so doing, it increases the options available for the people to exercise more control over their own health and over their environments, and to make choices conducive to health. Enabling people to learn, throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries are essential. This has to be facilitated in school, home, work and community settings. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves. Reorient health services; the responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Moving into the future; health is created and harbored by people within the settings of their everyday life; where they learn, work, play and love.

Though Bangladesh was one of the signatories of those two charters but it failed to reach the target as country’s health indicators expressed. It was assumed that the country’s health policy was not community friendly and failed to ensure community’s participation anyway in the health system. Taking the fact into account, during 1996-2001 government of Bangladesh decided to extend primary health care facilities at the door step of rural people to improve the overall health status of the rural community by providing health, family planning and nutritional services with special emphasis to the poor and planned to establish 18000 Community Clinics (CC) all over the country. It was decided then that out of 18000 CCs, 13500 will be newly constructed to provide limited health care services and the same services will be provided by establishing CC units in 4500 existing health facilities. GoB believes that active participation & ownership of the community is most essential for successful implementation & sustainability of CC activities and meaningfully involved the community people to the CC initiative. As per plan, community people donated land for the CCs and Govt. constructed the CCs in the donated lands. To ensure sustainability of the health services government facilitated to establish a Community Group (CG) for each clinic comprising of 9-13 members with diverse representation from community people and 3 Community Support Groups (CSG) for each CC catchment area with the representation of 10-15 community peoples in each CSG. The role of CG is to plan, implement, coordinate, monitor and resources mobilization both for smooth CC operation and supporting poor & vulnerable people. Government also took initiative to build capacity of the CGs, CSGs and local government representatives (LGR) through GO-NGO collaboration and follow up the progress to carry out their responsibilities.

 

Due to change of govt. CC activity was stopped during 2001-2008. Considering the people’s health and wellbeing at grass root level, the present Govt. has given top most priority to revitalize the CCs through “Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB)” project which is going on since July 2009. Through this project 11816 CCs out of 13500 CCs already have started functioning, the rest 1684 CCs will be functioning soon. Community Clinics are providing health services 6 days a week through a Family Welfare Assistant (FWA), working 3 days and a Health Assistant (HA) working other 3 days with a full time service provider designated as Community Health Care Provider (CHCP). Out of 13500 Community Health Care Providers (CHCP), 13133 CHCPs have been appointed. The process is ongoing to appoint the rest 367 CHCPs. 28 types of enlisted medicines for the CCs are being supplied continuously from the project office situated at Dhaka and monitor to the rationale use of the supplied medicines. Huge numbers of community people of all age groups including aged people are coming to CCs for getting their health services. The average number of service seekers per year is increasing in the community clinics as statistics says. Service seekers were 1,46,27,416, 2,36,91,306, 3,72,99,744 and 2,37,94,811 in the year 2009, 2010, 2011 and up to June, 2012. Patients are being referred in the higher health centers as well.

Policy was set to institutionalize all community clinics under an integrated Upazila Health System (UHS) and District Health System (DHS) and channelizing effective referral linkage from Community Clinic to Union & Upazila facility for proper management of the cases. A public private partnership strategy was taken where Community will donate land for CC construction and construction works including service providers, medicine and other inputs will be providing by the government. The management of the CC will be jointly by the government and the community people. Government believes that active participation and ownership of the community is most essential for successful implementation & sustainability of CC activities. Through this one stop service centre at the door step of community people, government has highest commitment to ensure universal coverage of Essential Primary Health Care for the rural population.

Through Community Group (CG) 121500 to 175500 community peoples and through Community Support Group (CSG) 526500 to 607500 community peoples have got opportunity to take part directly to the health system. The CHCPs were recruited from the local community and provided 3 months long training by dividing the duration into two parts, 1.5 months theoretical and 1.5 months practical where they were attached with sub-district hospitals. The HA and FWA were also from the local community so, CC initiative has created huge opportunity for mobilizing local human resources. Monitoring and direct observation reports reflect the satisfaction of the community people about this health service provision which also supported by some research findings. This is the first time, a web health system database is going to be established extending up to the CC level to get exact health related data, information and reports. Once the system would have been established and functional then it will help to make exact health planning at national and local levels. Finally, it can be concluded with a comment that the CC initiative is an epoch-making step of the government to truly ensure the previously unachieved national targets Health for all and to fulfill currently set MDG’s targets by 2015.

 (Prof. Dr. Sheikh Md. Nazmul Hassan; Is Public Health Expert (HRD), Ministry of Health & Family Welfare, RCHCIB, Bangladesh, Visiting professor of Public health, Atish Dipankar University of Science & Technology and State university of Bangladesh, Author of 15 different types of books, Among them books on Arsenic issues, Adolescent health, Emergency management of sickness, scientific novel on psychophysical issues, Poetry are notable.  Mentionable experiences in public health research. Some of the researches have been published in veteran international journal, working as a consultant in the field of public health including research at the national and international level. ) 

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