by Dr. Syed Jahangeer Haider
Prior to inception of Bangladesh, institution-based health programmes existed only at the district level. Health programmes at that time meant predominantly curative health services dispensed through large hospitals at the national level and medium-sized hospitals at the district level with a few vertical projects attempting to reach the people at the grassroots, such as Malaria Control, Small Pox Eradication and Family Planning. Exactly health service programmes with institutions to assure availability and access to health services by the people at the thana level were absent.
Early seventies (1972-75) ushered the concept of people-based health programmes at the community level with the first institutional health care starting at thana level in the Thana Health Complex (THC). During the same period, a few emerging health programmes trying to reach the people, like malaria control, small pox eradication and family planning were also strengthened at the grassroots levels with creation of a permanent cadre of health workers (Health Assistants), which was further strengthened by creation of a permanent cadre of Family Planning Field Workers (FWAs and FPIs). A few global events, such as the Alama Ata Conference on Health For All' and the Conference in Bucharest on Population and Development' reinforced hitherto unknown concepts of integrating both Health and Family Planning (FP) with socio-economic development stimulating broad-based community participation to such programmes.
These two international events subsequently accelerated the process of extending health services to the people.The period following 1975 in Bangladesh witnessed concerted efforts to push health services from mere institution-based programmes to community-participated activities gradually releasing health services from the monopoly control of medical graduates to paramedics and ultimately to community-level health workers. These movements were further reinforced with emergence of programmes addressed to the needs of the most predominant target audience, i.e., the disadvantaged population, the women and children.Programmes on Mother and Child Health emerged also during the period following 1976-1985. The concept of integrating health care needs for the poor was yet to emerge. During this period health care services were pushed institutionally to reach upto the union level, a tier below the thana through establishment and operationalising the rural dispensaries and FWCs. This process ultimately culminated in the establishment and operationalisation of the Satellite Clinic, a community-based health services programmes (combining dispensation of EPI and FP from a single structure) from non-permanent but static structures owned by individuals in the community. Till mid-eighties, health care services remained within full control of the health care service providers. During mid-eighties and nineties, especially with enormous movements and mobilisation augured by EPI programmes, broad based community participated activities started to take place. Commitment to the success of EPI was massive as it addressed the needs of the children, especially emphasising the need of the poor children. This movement opened the eyes of many thinkers in health programmes regarding the effectiveness of collaborative efforts of grass root level field workers and the community. The success of EPI is also an eye-opener in the perspective that any mass level programme addressing the priority needs of the community and especially the needs of the poor is likely to succeed, as it usually draws the support and participation of the community. This lesson although demonstrated the massive success of the EPI programmes, it is yet to be accepted as the main principle in the current health programmes of the country. Often deviations are made from this learning and misguided principles are put at the forefront of a programme and people remain passive and indifferent to accept such concepts, as these do not directly affect their life style. One such example is the current Health and Population Sector Programmes (HPSP), wherein the strategies pronouncedly advocate for services for the poor, and especially the women and children. The programme strategies, due to insistence of a few bureaucrats, turned into health professionals, have been insisting to propagate achievement of a bureaucratic goal, i.e., achieving the targets of putting all health and population services under one health sector program, i.e., under one unified management'. One does not understand that the broad-based community participation augured by the success of past programmes in health could be disguised in the slogan of establishing a unified (Single System Managed) health sector programme. After all having unified health sector programme can not be the goal of a health programme; it is merely a bureaucratic convenience; instead the philosophy should have been a Unified People Centred Health Programme'. Now that this philosophy is mired in the in-fighting of the departmental giants (health professionals and bureaucrats), the success of the HPSP has become an issue of grave concern. There is still time to redirect the program and introduce the operational concepts of Unified Community Participated Health Programmes at the grassroots level. In which the issues of supremacy of one cadre over the other will become secondary to the emerging demands of gradual control and ownership of the people in the health programs of the country.The goal of achieving Unified Services' for the people is certainly a laudable endeavour as it attempts to reduce sufferings of the people from seeking different services from different sources. But the same goal when equated with Unified Services through Unified Managements may not remain a priority of the people. Instead the concept of satellite clinic, functioning in private homes, has already demonstrated success, as it stimulated people's ownership in the services, even though the structure providing such services was not always as ideal as one would recommend.BINP is another example where without creating a Unified Management the services are being rendered through participation of community efficiently and also effectively.
The concept of Community Clinic certainly substantiates the principle of community participation but it is short of community ownership as the establishment of the clinics predominantly is entangled in the bureaucratic processes and decisions and that also is quite centralised. One is not sure when these clinics could be operationalised even in fifty per cent in the targeted areas; as by the end of almost third year of HPSP even a dozen could not be made functional, while the target was by this time to operationalise at least 6500. The critical issue remains to be considered whether a bureaucratic goal of achieving unified management mired in peoples goal of achieving unified services is a feasible and cost-effective strategy. The field workers of both health and FP belonging to both the government (MOHFW) and NGOs were successful in the past in stimulating active and genuine people's participation in the health services. This movement has now been stifled by bureaucratic conflict between conflicting and confusing concepts of whether or not to achieve Unified Services for the People or to establish Unified Management for the health and population services in the country. Resolution of this issue is urgent and to do so the direct intervention of the political leadership is essential. Politicians will gain only when people would receive benefits, i.e., effective services.
Source: The Independent, 24 May 2000