Community Clinic Based Primary Health Care Services: A Unique Participatory Approach to Universal Health Coverage (UHC)
Ministry of Health and Family Welfare (MOHFW), Government of the People's Republic of Bangladesh
Bangladesh is committed to ensure ‘Health for All’-a declaration of the Alma-Ata made on Primary Health Care (PHC) that was unanimously adopted by the member states forty years back. In line with the declaration, Bangladesh aims to provide the right to access quality healthcare without facing financial hardship to all citizens to achieve Sustainable Development Goals (SDG) and UHC. As a part of its existing primary health care system, the government of Bangladesh in 1998 started to establish Community Clinics (CC), one CC for 10,000 population in rural Bangladesh. This initiative was highly welcome by the rural population as they enthusiastically donated land for building each CC.
The Community Clinic Project was originally introduced under the MOHFW in 1998 but in its present form, it was mainstreamed in within the Directorate General of Health Service, with implementation through the Community Based Health Care: Operational Plan. The current 4th HPNSP describes the CCs as the basic unit for the Upazila Health System, to act as entry points. Against the target of constructing 14,890 CCs by 2022, construction of 13,812 CCs has been completed and made functional up to June 2020, and 133 CCs are under construction. Also 430 CC/CC corners are to be established at the Upazila Health Complexes for strengthening referral linkages from community to upward. The CC based PHC model is a unique example of Public-Private Partnership (PPP) as the CCs are established in community donated land, and medicines, manpower, and service providers (Community Health Care Providers along with Health Assistants and Family Welfare Assistants) are provided by the Government. Each of the CC activities are managed by a community group (CG) and 2/3 community support groups (CSGs), comprising of community members/landowner/local government representatives. CC is a 'one stop' service outlet for health, family planning, nutrition, focused on prevention and health promotion. In response to the current epidemiological trend of diseases, CC conducts screening of Non-Communicable Diseases (hypertension, diabetes, autism and, club foot etc.) with referral of emergencies and complicated cases to higher level facilities for proper management. In a substantial number of CCs, normal delivery started subjected to the availability of skilled health workers, local demand and dedicated upazila health management with referral facilities whenever necessary.
Mobility of rural people has increased for seeking essential treatment from CCs. Availability of basic healthcare services at their doorsteps and referrals of complicated cases to the higher-level facilities have been possible due to establishment of CCs. Number of CC level service seekers has increased over time gradually and it is estimated that an average of 40 patients/day, receive service from each CC. CC based service provision has led to increasing access of the poor (particularly women) to public health, population and nutrition services and community participation. Health education and counselling through CCs have created mass awareness of many health problems and of the necessity of seeking care from the formal health professionals instead of the quacks and traditional healers. Overall, the CCs have reduced the need for extensive domiciliary services and helped women to go out of home to seek health services, as a groundbreaking step in conservative Muslim society.
It is a unique example of PPP as community engagement is the important pillar of CCs. All CCs are established on community-donated land; service providers, medicines, equipment etc., are of government but management jointly by the community and government. With the SDG for health (SDG3) and aim to achieve Universal Health Coverage (UHC), CC has become a unique instrument for both, however, needs some fine tuning. CCs earned confidence from the community as evidenced by ever increasing utilization, which now need to reposition to deliver comprehensive promotive, preventive, basic curative and to some extent rehabilitative and palliative care.
The country made remarkable progress in improving the health status of its population, supported by the CC initiatives as part of the PHC approach as well as by improvements in the social determinants of health. For long-term sustainability and strengthening community participation, the Government promulgated the “Community Clinic Health Assistance Trust Act 2018” which transferred the government own Community Clinics to legally autonomous Trust to be run by a Trustee Board. consisting of 13 members and an Advisory Board of 8 members none of whom are public servants. The Prime Minister of the country however is the President of the Advisory Board. The Act allows the Trust to raise funds to supplement the financial support provided by the government. This example of best practices can be replicated in other countries as well.
- Official Website of Community Based Health Care, MOHFW http://www.communityclinic.gov.bd/ - Universal Health Coverage and Primary Health Care in Bangladesh, https://www.youtube.com/watch?v=jH3OHBHJQBQ - Community Clinics: Bangladesh Brings Health Care to Doorsteps of Rural People https://www.youtube.com/watch?v=pndal8AWy_I - Independent Evaluation of Community Based Health Services in Bangladesh https://www.who.int/docs/default-source/searo/bangladesh/pdf-reports/20… - Community clinics in Bangladesh: A unique example of public-private partnership https://www.sciencedirect.com/science/article/pii/S2405844020307957
Community Clinics are playing an important role to address COVID 19 involving all its health facilities and supporting staffs along with all necessary logistics (PPE, equipment), organizing community awareness through health education. Its activities include continual vigilance, screening, notification, management, referral, community awareness, follow up, demonstration of social distance, proper hand wash, use of mask etc. These activities restored public confidence in accessing CC services and helped check the slide in service intake which took place since April 2020 and stabilized to pre-pandemic service level by July 2020.
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The main beneficiaries of CCs are the entire community people specially women and children. Key stakeholders engaged in this practice is World Health Organization, other UN agencies, NGOs, Civil Society Organizations, local community and all public health care providers.