CPD-UNFPA
Programme on Population and Sustainable
Development
Paper 16 (Summary)
Effectiveness of
Recent Policy for Unification of
Health and Family Planning Service
at Upazilla Level and Below: Case
Study of Two Upazillas
Haripada Bhattacharjee, Swapan
K. Bala, Manik Lal Bose
INTRODUCTION
Every
human being has the basic right
to enjoy the highest possible standard
of health. Despite having limited
financial resources, traditional
cultural values and a high level of
illiteracy, Bangladesh has made
considerable progress in slowing
population growth during the past three
decades, improving the health of
the population and strengthening
Primary Health Care Services. Progress was satisfactory
in the
reduction of fertility and child
mortality but with respect to maternal
mortality and morbidity, the improvement
is unsatisfactory. Inadequate inter-project
linkages, duplication of efforts,
lack of institutional coordination,
overall poor utilisation of government
services, and the cost-effectiveness,
sustainability, and quality of services
are other issues of concern.
In view of the current level of
achievements and shortfalls in
the health and family planning sector,
the Government of Bangladesh planned
to address the key health issues
of the population through an unified
and customer-centred approach.
To achieve this purpose,
the Government
undertook the project of implementing
the Health and Population Sector
Program (HPSP) in July 1998. The
primary aim of the project was to
provide quality health care and
family planning services to all
the people of the country and to
facilitate easy access to health
services for the community. The implementation of the
new reform process started
on 27th December 1998 and it was too
early to evaluate the "Effectiveness
of The Recent Policy for Unification
of Health and Family Planning Services
at Upazilla Level and Below".
But to generate hypotheses for further
improvement, CPD conducted the study
on the aforementioned theme, exploring
the achievements and problems faced
by the health centres at Upazilla
and below Upazilla level.
OBJECTIVES
The
main objectives of the study were
to -
a)
Examine the extent of unification
already achieved.
b) Identify the barriers to realisation
of the planned level of unification.
c) Assess the effect of unification
on service delivery and program
performance.
d) Find out whether unification
has reduced the
average cost of service
provision, and
e) Make recommendations for further
improvement of unification.
METHODOLOGY
The
study was conducted in two
upazillas,
namely, Baliakandi of Rajbari district
and Sarail of Brahmanbaria district.
Upazillas were selected according
to four years of high and low cumulative
average outdoor attendance rate.
Two unions from each Upazilla were
also selected by applying judgemental
sampling technique. A total of 120
married women of
reproductive
age (MWRAs) were selected for interviews.
An "exit survey" was conducted
in two upazilla health complexes
and four family welfare centres
to understand the provider-client
interaction and physical conditions
of the facilities. The study was
implemented in three broad steps
i.e. pre-data collection activities,
activities during data collection
and post-data collection activities.
MAJOR FINDINGS OF THE STUDY
Characteristics
of the study area
It
was found that Baliakandi Upazilla
was better compared to Sarail in
terms of literacy rates (especially
among women), communication networks,
financial condition of the inhabitants,
availability of outside health facilities
and mortality rates.
Description of married women
of reproductive age (MWRAs)
The
social, economic and demographic
characteristics of the respondents
of Baliakandi Upazilla were found
to be moderately better then those
of Sarail upazilla. The mean age
at marriage of the respondents of
Baliakandi was 21.50 and Sarail
was 20.40 years. The monthly income
of the respondents' family was also
higher in Baliakandi than in Sarail.
The number of children per family,
average years of children's schooling,
social affiliation and mobility
of the respondents were more favourable
in Baliakandi than in Sarail.
Disease Pattern
The
disease pattern in both the
upazillas broadly followed the national pattern.
It was reported that diarrhoea, respiratory
problems and fevers of all types
accounted for 70 per
cent of the
sickness in Baliakandi and 65 per
cent
of the sickness in Sarail. The children-specific diseases like measles,
whooping cough and worms were common
in both upazillas. Poor environmental
and sanitary conditions were reported
to be the major cause of
Diarrhoeal
diseases in both the upazillas.
Family Planning Related Information
from MWRAs
The
study observed that 61 per
cent of
the respondents in Baliakandi and
53 per cent of the respondents in Sarail were using family planning
methods. Field workers of the family
welfare centre (FWC) were the most
predominant source of supplies
in both the upazillas followed by
the pharmacy. More than 90 per
cent
of respondents from both the
upazillas expressed their desire
to use the FP method in future and
all of them preferred oral pills
as contraceptives. The restricted
mobility of the respondents
makes it difficult to continue any FP
method with the discontinuation
of the home visit program as stated
in the HPSP, and if that happen
in near future, one out of every
ten respondents would stop using
contraceptives.
Knowledge about Unification
The
study found that 63 per
cent of the
respondents, in average, from both
the upazillas were not aware of the
unification program. 80 per
cent
of them were not aware about community
clinic (CC) and 90 per
cent of the
respondents from both upazillas did
not have any idea of the essential
service packages (ESP), which is
the major component of HPSP. About
68 per cent of the MWRAs in Sarail
and 52 per
cent in Baliakandi
did not observe any qualitative
changes in the service delivery
of FWCs over the last two years.
But when the respondents were being
informed about the ongoing unification
program, 84.2 per
cent of them from
both upazillas found it necessary
and according to 79 per
cent of respondents CC was a good
concept.
Knowledge about the Services Offered
at FWC
According
to the study, 88 per
cent of the
respondents in Baliakandi and 76
per cent of the respondents in Sarail
knew about the curative services
and over 74 per
cent of them in Baliakandi
and 68 per
cent of them in Sarail
were aware of FP and child care
services offered at FWCs. According
to 56 per
cent of the respondents
from Baliakandi and 69 per
cent from Sarail were satisfied with provided
services. However, a large number
of respondents were not happy about
the clinical examination and about
33.5 per cent of the respondents,
in average, from both the
upazillas,
identified the drug supply provision
as the weakest point of FWCs. No
significant differences in knowledge
were found among the respondents
with different education levels.
Information about Unification in
Two Upazillas
The
unification program was officially
started from January 2000 in Sarail
and from July 2000 in Baliakandi.
When started none of
the officials
or the lower level staffs had any
comprehensive and clear-cut idea
about the new reform of health and
FP program. FP personnel in both
the upazillas were not satisfied
with the ongoing unification program
as they did not receive any training
on HPSP, ESP or
other aspects of
the process from Upazilla Health
and Family Planning Officers (UHFPO).
There was no development of any
specific mechanism in any upazilla
to deliver the services under ESP.
The government's guidelines for
the site selection, construction
and maintenance of the CC were not
properly followed in either
of the
two upazillas because of the manipulation
of influential political leaders
in their respective localities.
That is why the construction of only
2 out of 39 CC in Sarail and 4 out
of 24 CC in Baliakandi have been
completed so far, and delivering
ESP services had not
commenced until recently. Female field workers
of the FP wing were happy with the
new reform process, as their door-to-door
visits would be limited. Not a single
appointment of health assistants
(HA) or family welfare assistants
(FWA) was made in either of the
two upazillas till the completion
of the study, though they would
be trained in delivery of ESP and
running the CC according to the
government guidelines. UHFPOs in
both upazillas had no control over
the providers of various departments,
because there was no system to foster
coordination among the providers
in Sarail and a lack of proper coordination
in Baliakandi. The Government usually
plays the dominant role in continuing
the activities of the program in
both the upazillas even if there
are provisions for involvement for
NGO and local leaders in the HPSP.
Extent of Unification Achieved by
Upazillas
Functional
integration of health and FP services
in Upazilla and below Upazilla level,
distribution of job responsibility
between the
medical officer in-charge
and the FP officer in-charge, decentralisation
of power to monitor and control
the activities of the staff, site
selection and construction for setting
up CCs, and formation of
a coordination
committee were some of the achievements
of the program.
Problems of Unification
According
to the service providers there were
several problems regarding unification
and proper implementation of the
program. The shortcomings such as
poor facilities, poor equipment, lack
of quality medicine, bad staff attitude,
lack of staff accommodation, lack
of trained and specialist doctors,
lack of female doctors, lack of
skilled staff, unhappy relations
among colleagues, unwanted interference
by local representatives, ambiguity
about ESP, poor financial autonomy
to use funds, lack of
a clearly defined
job description, and lack of incentives
for extra work were the crucial
factors adversely affecting the
proper implementation of HPSP.
Focus Group Discussion (FGD) and
Exit Survey Results
It was found
that most of the local leaders in
both upazillas were
fully aware of the unification of
health and FP services. However,
among 40 community leaders, more
than 80 per
cent of
respondents in Baliakandi
and over 90 per
cent in Sarail informed
that the CCs were not being set up
as per the rules of the government.
The respondents complained about
the absence of linking roads to
and from the villages, which made
access to
the centres
difficult,
particularly for women and children.
Only
6 out of 30 beneficiaries were aware
about the unification of health
and FP services in their respective
upazillas but none could provide
any information regarding the nature
of unification. The majority of respondents did not notice any
significant
differences in facilities and services
in both UHCs and FWCs following
the unification process.
To
fulfil the objective of assessing
the average cost of service provision,
the only information collected from
UHFPOs was
the total yearly health
and FP expenditure received from
the concerned authority. Considering
the three years allocation pattern
of health and FP services in two UHCs,
it may be explained that the cost
implication of the unification
process is minimal and therefore,
it would be unwise to draw any
inference from it.
POLICY RECOMMENDATIONS
o
The providers need to be trained
how to deliver the services according
to the standardised management protocols.
o
To ensure offering of quality services
and expand the range of services.
o
Adequate and appropriate logistic
support and supplies should be made
available to the providers. Efforts
should also be made to ensure the
use of available tools.
o
Precise responsibilities of each
provider need to be determined.
o
Coordination among the service providers
at the upazilla and below upazilla
level should be strengthened for
effectiveness of the activities.
o
Community mobilisation programs should
be strengthened to create awareness
about ESP services in the CC areas.
o
Job security of staff should
be ensured and job descriptions should
be defined to increase their morality
and efficiency in order for them
to provide quality services.
o
Strong partnerships between Ministry
of Health and Family Welfare (MOHFW)
staff and NGO staff need to be developed
in order to deliver ESP services
more effectively.
o
Upazillas should be identified according
to high quality service delivery,
which then can become 'model'
upazillas
where new policies can be implemented
and monitored closely.
o
Steps should be taken to encourage
private practitioners to work as
formal members of the health care
system in Bangladesh for successful
implementation of the on-going reform
process.
o
An independent assessment of the
key performance indicators such
as EPI coverage, coverage of FP
services, and
utilisation of health
services should be made on an annual
basis to evaluate the program performance
at upazilla and below level.
o
A need-assessment study in each
upazilla should be made to bring
into operation the cost-effective
delivery of the ESP.
o
Frequent transfer of trained medical
officers should be stopped immediately.
o
Information, education and communication
posters should be included in the
efforts.
o
More authority for decision-making
should be provided to the providers
to develop client-centred services.
To
obtain the full text of this report
please contact:
Centre for Policy Dialogue
Dialogue
and Communication Division
House No 40/C, Road No 11,
Dhanmondi R/A, Dhaka-1209
GPO Box 2129, Dhaka-1000, Bangladesh
Tel: (+880 2) 8124770,9141734,9141703; Fax: (+880 2) 8130951
E-mail: cpd@bdonline.com
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not include postal charges)
Pages: 130
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