Fazilat Begum, a resident of Charkaona village in Pakundia upazila of Kishoreganj district, is in her 60s and frequently suffers from various ailments due to her age. Previously, when she fell ill, she would rely on her sons and grandsons to purchase medicine from the local market. However, she now visits the nearby community clinic for free consultations and medicine. According to her, the clinic is conveniently located and provides excellent services. Shefali Khatun, who is pregnant, also visited the clinic to consult with health workers. She expressed her gratitude for the accessible and affordable healthcare services provided by the clinic, as she previously had to travel to the city hospital, which was expensive and time-consuming.
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The community clinic initiative is a major success story in the health sector of Bangladesh. More than 400,000 people receive primary health care, family planning services, and nutrition services every day from community clinics. Patients can receive free essential medicines from the clinics, which has made them an important healthcare provider for rural communities where hospitals and good medicine shops are often far away. The community clinics have become a lifeline for the poor and marginalized people of Bangladesh, providing them with basic healthcare facilities at their doorsteps.
The community clinic initiative is a brainchild of Prime Minister Sheikh Hasina, who introduced the idea to deliver health services to the grassroots level. The community clinic model has been emulated by many other countries, and has gained recognition from world leaders and the World Health Organization (WHO). The community clinic program is considered a crucial component of the government’s healthcare framework, and is helping to achieve the Sustainable Development Goals. Community clinics are not only providing health services but are also playing an active role in planning, monitoring, coordinating, and ensuring accountability in health, population, and nutrition programs. The community clinic program is an essential part of the Bangladesh government’s human resource development plans and health service expansion initiatives.
WHAT SERVICES ARE THERE?
The Community Clinic offers a range of services that include maternal and child health care, reproductive health, family planning, vaccination programs, nutrition, health education, and counseling. As a single health care unit, the following services are provided in detail at the Community Clinic:
1. Maternal and Child Health Services, Neonatal Health Services, and Integrated Management of Child Health Services.
2. Provides Fertility and Family Planning Services and
3. Facilitates the registration of newly married couples, expectant mothers, births, and deaths, among other events.
4. Provides nutrition education, information, and nutrition support vitamins.
5. Providing advice on health and family planning
6. Identifying fatal diseases and dangerous pregnancies, and makes referrals with recommendations for improved services.
7. Identifies the possibility of new disease transmission and sends cases for service at the upazila level.
8. In line with the Health Policy of the Government of Bangladesh, the Community Clinic provides other health services and maintains a linkage with upazila level health service centers.
9. Common health problems, such as fever, stomach ache, and diarrhea, are treated at the clinic.
10. Additionally, in special cases and taking into account the delivery condition, the clinic arranges child birth in the general process. 11. Immunizations for tuberculosis, diphtheria, whooping cough, polio, measles, hepatitis-B, pneumonia, and other essential health care for children and adolescents are also provided at the clinic.
In the beginning, community clinics did not offer delivery services, but now nearly 4,000 clinics across the country provide normal delivery services. The clinics also offer 32 types of medicines and medical supplies for free, including insulin for indigent and poor diabetic patients. An objective of establishing community clinics was to serve as a link point between the clinics and government health service centers at the upazila level, enabling referrals for urgent and critical health services. In 2009- 10, 25,000 patients were referred from community clinics to upazila level services, and by 2014-15, this number had increased to 307,000. The success of the Community Health Project indicates that community clinics have achieved their goal of ensuring primary healthcare availability and adequacy for the rural population.
COMMUNITY CLINIC IN BANGLADESH: BEHIND THE SCENE
The success of the community clinic system was not achieved overnight. Bangladesh is a signatory to the 1978 ‘Alma Ata’ declaration, which committed to providing “health for all” by the year 2000 through the provision of primary healthcare. However, a review in 1996 revealed that the health sector was far behind in achieving the desired targets against various indicators due to the inadequacy and inaccessibility of primary healthcare for rural populations. To address this issue, in 1996, the Bangladeshi government initiated a plan to establish one community clinic for every 6,000 people to ensure access to primary healthcare for rural communities across the country.
The community clinic project was taken up by Prime Minister Sheikh Hasina after forming her government in her first term as Prime Minister, and construction of the clinics began in 1998. The Gimadanga Community Clinic in Patgati Union of Tungipara Upazila of Gopalganj was inaugurated by Prime Minister Sheikh Hasina on April 26, 2000. Between 1998 and 2001, 10,723 community clinics were established, and approximately 8,000 began providing services. Unfortunately, after a change of government, the community clinic program was closed from 2001 to 2008. However, after the 2009 election, the community clinic program was revived under the leadership of the Awami League government. The program was relaunched in 2009 under the title of “Revitalization of Community Health Care Initiatives in Bangladesh.
LEGAL FRAMEWORK, FINANCING AND SUPPORT
In 2018, Prime Minister Sheikh Hasina took a step to institutionalize the community clinic system and bring it under a legal framework. To this end, the ‘Community Clinic Health Care Trust Act-2018’ was passed by Parliament on October 8, 2018. Following the enactment of the act, a 16-member Board of Trustees was formed.
The government also provides Tk 250 crore worth of medicines every year for free distribution.
The creation of this act and the board provides a means of raising funds to ensure the continued operation and financial sustainability of the clinics, including salaries and allowances for the workforce.
The Community Based Healthcare Scheme of the government provides necessary financial support to the trust. The government also provides Tk 250 crore worth of medicines every year for free distribution. Local government institutions are also sponsoring community clinic activities.
In addition, international organizations such as the United Nations, World Bank, JICA, and UNICEF are supporting the implementation of community clinic activities through financial, technical, and logistical supplies. Various NGOs are also working to improve the quality of services provided by the community clinics.
HOW THEY LOOK
Community clinics are typically located along rural roads, and their small buildings have a similar design. The ratio is one clinic per 6,000 people in rural townships, with the goal of ensuring that clinics are within a 20- to 30-minute walking distance from health services. Initially, clinics were established in only 5 decimals of areas, but due to increasing demand, a new model clinic is being constructed on 8 decimals of land.
Each building has four rooms: two for health workers, one for a patient waiting room, and one for a delivery room. Additionally, there are two bathrooms.
The latest design of these clinics has been approved by Prime Minister, and their architecture is both aesthetically pleasing and attractive.
As a result, these clinics are becoming modern quality facilities even in remote villages.
THE WAY THE CLINICS OPERATE
Community clinics are an exemplary model of the government’s public-private partnership, where the local people donate land, and the government bears the cost of establishment and provides medicines and supplies. The service providers are appointed by the government, and the management responsibility is jointly entrusted to the local people’s representatives and government officials. The community clinics are operated by local staff. Each clinic is staffed with three workers. Community Health Care Provider (CJCP) is the main responsible person.
The government has prioritized hiring women and locals for this role. CHCP works six days a week at the clinic, and they are assisted by Department of Health field workers, who serve for three days at the clinic. Additionally, health field workers, family welfare field workers, and family welfare assistants from the Directorate of Family Planning also serve at the clinic for three days. The clinic is open every day from 9 am to 3 pm, except for weekends and public holidays. The management of each community clinic is overseen by a community group consisting of 13 to 17 members, with at least four female members representing the local community.
Additionally, a community support group of 13 to 17 members is established to assist the community group in informing the local population about the basic healthcare services available at the clinic and to raise health awareness through informal discussions. The involvement of local people in the management of healthcare has empowered them, and these groups ensure some form of accountability in the clinics. The Vice chair of Public Health Foundation, Bangladesh, Taufik Joardar said, “The unique aspect of community clinics is community groups and community support groups. Local people feel empowered to be involved in the management of healthcare.
The monitoring of these two groups ensured some form of accountability in the community clinic. As a result, people think of clinics as their institutions.” A pilot program focusing on community clinics has started, with one Multipurpose Health Volunteer nominated for 250 to 300 households in the vicinity of each clinic, and the government plans to provide 70,000 volunteers across the country.
BENEFICIARIES & BRODER OUTCOME
Community clinics have become a popular choice among rural residents as they offer easy, reliable, and free healthcare services close to their homes, essentially acting as family hospitals. Each clinic provides over 1 lakh 70 thousand taka worth of free medicines every year, with a total of 106,353,729 visits made to these clinics from July 2021 to June 2022. Over 10 crore people have benefitted from these free healthcare services, with an average of 70-80 people visiting each clinic daily, 80% of whom are women and children.
These clinics have facilitated safe normal delivery for around 1 lakh mothers across 4000 clinics, while more than 3.7 million patients have been referred to various hospitals for urgent and complex primary care. Truly, the introduction of community clinics has sparked a quiet but impactful revolution in the country’s healthcare system, particularly for marginalized communities.
During the last 10 years, the infant mortality rate in Bangladesh decreased by 29%, and the birth rate dropped to 2.3. The rate of breastfeeding has increased to 55%, and 64% of babies now receive care from skilled health workers in the womb. The number of low birth weight babies has dropped to 33%, while 42% of women now have access to trained health workers during delivery. The contraceptive use rate is 62%, and 86% of children have received the measles vaccination. The uptake of all basic vaccines by 23 months is 84%.
These improvements have also led to an increase in the average life expectancy of people in the country in recent years. After gaining independence, Bangladesh struggled in almost all indicators in the health sector.
However, the country has made significant progress in recent years, surpassing India, Pakistan, Nepal, and many other countries in health services.
The community clinics have played a significant role in improving overall healthcare service in the country. Rural communities are benefiting from the services provided by these clinics, which continue to expand day by day.
In the future, community clinics will serve as repositories of health care information in rural areas, making it easier for people to access the services they need. The community clinic program has been identified as an example for other developing countries to follow.
The Bangladeshi government is taking various initiatives to expand this program to all parts of the country, ensuring that every citizen has access to healthcare.
This will help to guarantee the fundamental right of every human being to access healthcare, and we will hope that this progress will continue.
