Community Participation on Health and Family Planning Programs in Bangladesh: The Role of Education and Knowledge on HFP for Plummeting Pharmaceutical Costing

INTRODUCTION

Bangladesh is one of the most densely populated countries in the world with an estimated population of 150 million (BBS, 2011). Since independence, Bangladesh has been facing challenges to cope with demand of healthcare services required by the local community. However, with some drawbacks and limited capacity, it has invested substantially in the institutionalization and strengthening of health and Family Planning (FP) services with an especial attention to rural community. These significant numbers of projects on healthcare and family planning have made people aware on the use of medical services and medicine. It is thus used as the tool for medical marketing in parallel. Consequently, the country pays her budgets on both medical services and medicines as well as for the projects implemented. Despite intensification of costs through various ways, there has been a significant improvement in the health status of the people over the last three decades. Life expectancy at birth has increased from 55.2 in 1980 to 68.3 years in 2009. Total Fertility Rate (TFR) has decreased from 6.3 in 1971-1975 to 2.7 in 2007 (UN, 2009). The contraceptive prevalence rate has increased significantly from 8 to 56% from 1975 to 2009, with an average of 1.5% increase per year (BDHS, 2007). Notwithstanding some improvements, much still remains to be made especially for the rural community. Particularly, the mortality rates such as infant (38 per 1000 births per year) and maternal (348 per 100,000 live births per year) persist to be unacceptably high in the rural community in Bangladesh (UN, 2011; UNICEF, 2008; Kabir et al., 2011a). Moreover, there is a widening gap between the demand and the available resources for meeting the extensive healthcare that needs by the local and rural people. In addition, the Human Develop Index (HDI) which reflects the quality of life is still low in Bangladesh (which is 0.469) compared to South Asia (which is 0.516) (World Bank, 2010) (The current HDI index of World is 0.624 (WB, 2010)). In addition, low calorie intake continues to result in malnutrition, particularly in women and children. On the other hand, the fundamental knowledge and education of basic healthcare is still limited in rural community (BDHS, 2007).

Considering the existing circumstances, the government’s endeavor is not sufficient to provide quality healthcare services responsive to the needs of the people. Especially, those who are children, women, elderly and poor people are lacking of sufficient healthcare services (UNICEF, 2008; Kabir et al., 2011b). However, the government of Bangladesh has implemented a particular service by the Health Nutrition and Population Sector Program (HNPSP) to relief the drawbacks of the problems. But the HNPSP is not effective due to some complexities and weaknesses of program and lacking of proper implementation (BDHS, 2007). Therefore, principally it is essential to sort out innovative alternatives together with the current system and especial attention must require in strengthening of health and family planning services, including cost-effectiveness of major pharmaceutical services (The major pharmaceuticals service we consider as pills, injectables, female sterilization, male sterilization and condoms as about 80% of people are somehow dependent for anti-contraception), particularly to the majority of population who are living in the rural area. Moreover, the roles of civil society and Non-Government Organizations (NGOs) are important to amplify the quality of healthcare service but their private services are mostly available and which are mostly located in the urban area. In order to improve the complexities and weaknesses of the existing system, alternative service rather than government ones need to be considered prominently. Concerned body must take least substantial alternative initiatives with the existing healthcare as to some alternative policy options that could imply important effects.

As an effective alternative option together with the existing system, the community participation in health and family planning programs nowadays is much uttered in the developing countries. The fruitful outcomes we find from some recent community participation in health and family planning programs such as by Jamkhed Comprehensive Rural Health Project (CHRP), India; Karnataka Project for Community Action in Family Planning, India; Integrated Rural Health Project in Saradidi, Kenya; Mawas diri Community-based Health Care Systems and Training Programme, Indonesia; Mobilization for Nutrition in Tanzania; Community Involvement in Health Development: Caranavi District, Bolivia; Comilla Development Model, Bangladesh and Chakaria Community Health Project of ICDDR, B, Bangladesh. All of the projects scored high in terms of the categories have direct involvement of community people. So it is very much apparent that a successful program on health and family planning needs active participation of community people.

To identify the role of community participation in health and family planning programs together with the cost-effectiveness of pharmaceutical services in the developing countries, an extensive literature is nowadays accessible. Lessons from the country-level experience can be assessable from several countries: Bangladesh, Ecuador, Honduras, Kenya, Madagascar, Nicaragua, Papua New Guinea, the Philippines, Sierra Leone and Swaziland. However, there are some shortcomings in developing of planning and policy implementation in the developing economies but the effective community participation in health and family planning programs are proven to be effective. It may ensure policies and programs that are responsive to local-level needs. It may empower individuals, particularly women, as owners and agents of change in their own sexual and reproductive health. In addition, effective community participation, may made-up women’s groups, Non-Government Organization (NGOs), religious and youth associations and other organized constituencies ensure that the voice of those most in need is heard at all levels of the health care system. Therefore, the key goal of this research task is to search a sound policy option and recommendation that strengthen the existing health and family planning services in Bangladesh.

Following the key research goal this study seeks the possibilities of interaction between service providers and community participation for the efficient and sustainable health and family planning programs mostly focusing in the rural community. However, we must bear in mind that some prerequisite assessments that must in order such as (i) cost-effectiveness of pharmaceutical services (There is the substitution effect between cost on pharmaceuticals service and marinating necessary daily needs), (ii) lacking of basic healthcare knowledge, (iii) assessments of the backdoor problem and rural people’s education level and (iv) problems of implementing actions and effective monitoring and evaluation system. We know that there exists a strong relationship between education level and healthcare perceptions. Education creates awareness about general healthcare such as marriage and child-bearing age, interval between births and other socio-economic factors that responsible for healthcare problems. But, how education facilities can increase healthcare knowledge make available to every doorstep. Therefore, we also feel essential of relevant study to witness the core reason of the raised factors in Bangladesh to support effective policy scope in the way forward. In this study, we placed some sorts of logical grounds before focusing policy scope and recommendation and support of redesign of community participation and family planning programs in Bangladesh.

DATA AND METHODOLOGY

This research document is based on the analysis of the secondary information. The study utilizes information from the reports of Bangladesh Demographic and Health Survey (BDHS, 2007), Health and Demographic Survey (HDS, 2000) and Household Income and Expenditure Survey (HIES, 2005). The BDHS (2007) study is conducted by National Institute for Population Research and Training (NIPORT) and that is a nationally representative survey of 10,996 women age 15-49 and 3,771 men age 15-54 from 10,400 households (BDHS, 2007). The HDS (2000) study is conducted by Bangladesh Bureau of Statistics (BBS) which included information on both the household and individual levels. HDS (2000) is covered a nationally representative sample of 11,219 households constituting 56,118 individuals. The HIES (2005) study is conducted by Bangladesh Bureau of Statistics (BBS) which is also a nationally represented sample of 10,080 households (BBS, 2006). The detailed methodology of the respective database will be found in the survey reports.

SERVICE PROVIDERS AND QUALITY OF SERVICES

Provision of health and family planning services: The healthcare system in Bangladesh is pluralistic with extensive public healthcare programs and services, non-governmental organization (NGO) health services and a growing private sector (BNHA, 2010). The Ministry of Health and Family Welfare (MOHFW) is the largest provider of healthcare services in the country. It operates a nationwide system of facilities and healthcare programs. At the same time, Non-Governmental Organizations (NGOs) play an important role after government. Approximately, 500 NGOs are working in the overall health sector (BNHA, 2010). They are largely funded by the government and development partners. NGOs are very effective in providing healthcare at the grass-root level and complement the efforts of the government.

For earning profit, private sector services, including pharmaceutical outlets, are concentrated in the major cities. Private ambulatory care by qualified modern providers is provided mostly by small clinics and hospitals staffed with private doctors many of who work off-duty or after retirement from government facilities (Rannan-Eliya et al., 2001). In addition, many of the doctors, paramedics both from private and public hospitals or clinics are delivering healthcare services as private practitioners in the afternoons. Pharmacies and pharmaceutical shops are responsible for most of the distribution of pharmaceutical goods. Moreover, traditional unqualified providers including homeopath practitioners, Kabiraj, quacks and others play a significant role in the private healthcare market of Bangladesh, especially in the rural areas (Data International, 2000). In recent years, 589 government hospitals and 2271 non-government hospitals (i.e., registered by DGHS) are working in the health sector. Besides, 18 government medical colleges and 41 private medical colleges have been providing healthcare services in the country (DGHS, 2009). Besides, BIRDEM, DAB Cardiac Centre and other private clinics and hospitals also provide specialized healthcare services mainly in the major cities. A few charitable hospitals provide healthcare services in the country in both rural and urban areas.

Family planning is an important component of reproductive health and knowledge of family planning methods is widespread in Bangladesh. Family planning programs help to reduce the incidence of high-risk birth of the mothers by spacing and limiting number of children. The services are usually provided at all the public healthcare facilities. Furthermore, the Government's policy has been encouraging the participation of NGOs in family planning service in the country. More than 400 NGOs are focusing especially to different aspects of MCH and family planning related activities (BDHS, 2007). Nowadays, most of the NGOs are involved in community distribution of contraceptives, while a few are engaged in clinical services. In addition, there are private providers and increasing number of service sites; those are particularly in urban areas. Moreover, partnership of NGOs with local government bodies is a new dimension for providing health and family planning services in Bangladesh. The collaborative effort provides satisfactory healthcare services in the country.

Clients of existing service provision and pharmaceutical services: In Bangladesh, population reported illness in a particular point in time revealed that same number of people (about 39%) relied on private doctors and pharmacy sources.

Fig. 1:	Distribution of health seeking behavior (Source: BBS, 2006)

The public qualified doctors accounted for only (7.3%) followed by traditional/ unqualified doctors. Besides, the health workers and NGO sources contributed only 1.2 and 0.5%, respectively (Fig. 1). The prevalence of self-treatment from pharmacy as well as choice of traditional/unqualified providers are more evident among the poor people especially who live in rural areas.

The utilization of public facilities at rural areas seems to be pro-rich, while the urban people utilize public facilities at a constant rate throughout the income distribution. On the other side, the most commonly used contraceptive method is the pill. More than 50% of the currently married women who are using some form of contraception relied on pills (Fig. 2). Injections are a distant second, used by only 13% of all currently married contraceptive users, followed by periodic abstinence (9%); female sterilization (9%) and condoms (8%). Pills are the most frequently used method across all wealth quintiles in both rural and urban areas while Injections/injectables are more popular in the first three quintiles and in rural areas. On the other hand, condom use is relatively low in the first three quintiles but increases in upper two quintiles. This trend is more evident especially in urban area. Overall, 17% of currently married women in Bangladesh have an unmet need for family planning services, 7% for spacing and 11% of limiting births. The total demand for family planning in Bangladesh is 73% (BDHS, 2007).

From the existing contraceptive method-mix of Bangladesh (Fig. 2), it is essential to figure out the factors that are accountable of plummeting pharmaceutical service costing. We know that there is the substitution effect between cost on pharmaceuticals service and marinating necessary daily needs for the poor community. It is obvious that why poor should substitute their parts of income for maintaining family planning as they are already fighting for daily necessary needs.

Fig. 2:	Contraceptive method-mix (Source: BDHS, 2007)

Table 1:	The percent distribution of modern contraceptive users of age 15-49
Source: BDHS (2007), aIncludes government hospital, family welfare center, Upazila health complex, satellite clinic or EPI outreach site, maternal and child welfare center, government fieldworker, community clinic and other public sources; b Includes static clinic, satellite clinic, depot holder, fieldworker and other NGO source; c Includes private hospital, qualified doctor, traditional doctor, pharmacy and other private sources; d Includes shops, friends/relatives and other sources

Therefore, the question comes around for the extensive government support as a subsidy in the pharmaceuticals service. If we consider the existing pharmaceutical service figures, the public sector is the largest supplier of contraceptives in Bangladesh which is about 50% (The private sector supplies mostly pills and condoms and account for 38% of total supply. Only 5% of users obtain their contraceptive methods from NGO sources. Other suppliers are relatively insignificant). Eventually, public sector is more popular for poor women in the lower wealth quintiles (Table 1). Therefore, before designing any effective policy and action government should consider the cost effectiveness of the pharmaceutical services to see the effective family planning in Bangladesh, particularly in the rural areas.

Among all users of family planning services in the lowest wealth quintile, 66% procure contraceptives from public sources. As wealth rises, the percentage of women procuring contraceptives from public sources falls to 53% in the third quintile group to 26% among the richest group. The percentage of women procuring contraceptives from commercial sources rises in accordance with wealth level, while the share of NGOs and other sources remains steady across wealth levels. There are significant differences in sources of contraceptives in urban and rural areas. The public sector is a much larger supplier of contraceptives in rural areas compared to urban areas. The education plays an important role for selecting the sources. For instance, the higher the education level the lower the choices of public sector and increases the preferences of private sectors (Table 1).

Accessibility and quality of services: The availability as well as the quality of the services at public provisions makes people to rely on private providers that are obviously more expensive and most of the time that is beyond the capacity level of the poor people in the rural area. Private sector services are usually located in the major cities of the country where the ambulatory care is provided mostly by small clinics and hospitals. Nevertheless, unqualified/traditional providers are cheaper, easily reachable and poor are more familiar with these services. The reasons of the patients for not receiving treatment from public facilities are presented in Table 2. The shortage of medicine seems to be the most critical reason in both rural and urban areas for discouraging people not to visit public facilities. Long distance as well as long waiting time for treatment is also evident among the prominent reasons. Expensive along with non-availability of doctors is also noticeable for not selecting the public facilities.

The accessibility and quality of family planning services have a strong impact on contraceptive use. Quality in family planning programs means extending the choice of contraceptive methods, providing adequate information, increasing the technical competence of providers, improving interpersonal relations between providers and clients and incorporating adequate client support and follow-up. Much of the failure to use existing family planning services is attributable to lack of quality. The trends in current use of contraceptive methods are also attributable to accessibility as well as the quality of contraceptive methods. The contraceptive prevalence rate for married women in Bangladesh has increased from 8% in 1975 to 56% in 2007 which is a sevenfold increase over more than three decades (Fig. 3). Overall, current contraceptive use has declined by two percentage points in the past three years, from 58% in 2004 to 56% in 2007, but the use of modern methods has remained unchanged.

Table 2:	Reasons for not receiving treatment from public facilities
* Multiple responses are considered Source: BBS (2001)

Fig. 3:	Trends in current use of contraceptive methods, 1975-2007 (Source: BDHS, 2007)

In contrast, increase in the use of traditional methods is very slow. Shifting from traditional methods to modern methods indicates an improvement in access and quality of family planning services in the country. Although family planning programs in Bangladesh have a good number of success stories, but the existing system also suffers from lack of adequateness. The following are worth mentioning:

Other major concerns of the existing system are the increasing cost associated with the family planning program in Bangladesh (Islam et al., 2001; Hanifi and Bhuiya, 2001). This is also interesting that the poorest 20% of the population are particularly disadvantaged, receiving only 16% of the public resources devoted to health. In contrast, the richest 20% of the population receive one third of the total public healthcare resources (O’Donnell et al., 2005). Many of the poor do not utilize the public facilities due to lack of accessibility as well as lack of well management. However, those who utilize public healthcare facilities are not getting benefits satisfactorily. This is due to the fact that the rules of public resource allocation across regions are not conducive to delivering health subsides to the poor. Although, fees charged in government facilities do not represent a large burden for poor households, but informal fees required in the same are comparable or even higher than the official ones (World Bank, 2001).

COMMUNITY PARTICIPATION AND RESPONSIBILITY

To make health and family planning programs sustainable, it is imperative to reduce the inequalities that exist in the program. Sustainability and efficiency of these programs also call for strong community participation, consistent administration and political commitment. Moreover, community participation is essential for successful health and family planning programs through transparency and accountability of the service providers. Community participation is a process through which stakeholder’s influence and share control over development initiatives, the decisions and resources which affect them and it has a diversity of definitions (Askew, 1989; Rifkin, 1990; WHO, 1991). The common theme of most definitions of community participation includes population involvement in:

The community participation has been recognized as an important element for sustainability, effectiveness and optimal use of health and family planning programs, particularly among poor and under-served population in developing countries. Both governments and donor agencies in developing countries have become increasingly aware of the importance and need for active local participation to achieve greater success rate in performance of health, family planning and development programs and their limited impact on the welfare of the intended beneficiaries (Stone, 1992). Specifically to Bangladesh, there is a growing realization that the innumerable problems the nation will face in near future that no existing government and non-government mechanisms would not be able to address them adequately without effective participation from the community members (Islam et al., 2001). Participation of stakeholders in healthcare, a major policy theme and a fundamental principle of the Alma-Ata Declaration of 1978 is still considered an essential part of health development (Catino, 1999). The Alma-Ata Declaration stressed people’s right and duty to participate individually and collectively in planning and implementing their healthcare programmes. Other international conferences emphasized on the need of users of health services, especially women and the civil society, to participate in planning, monitoring, and evaluating health services to reorient the services to address their needs and rights and to hold the State accountable to their agreements (Catino, 1999).

Bangladesh has a long tradition of community participation in certain development activities. However, very little is known about community participation in health and family planning activities (Bhuiya and Ribaux 1997). Under the rubric of community participation since 80s aiming at building a partnership between government and people, the use of community-donated space for Expanded Programme on Immunization (EPI) camps, satellite clinics for providing immunizations and reproductive health services to women and children have already shown the way how the community can contribute to their health development in Bangladesh. The village healthcare providers nominated by the community and trained by the government health authorities have been providing services satisfactorily from the village health posts with community resources (Uddin et al., 2001). One good example of community participation in health and family planning programs in Bangladesh is the South Eastern Community Health Project (SECHP) supported by German Red Cross (GRC) and implemented by Bangladesh Red Crescent Society (BDRCS). The project with the purpose of ensuring sustainable healthcare services has developed several mechanisms for contribution of the community that includes cost recovery and cost sharing, fund raising activities and income generating activities through a center management committee. Many of the centers will become self-reliance by the end of the project through active community participation. Under this innovative approach the community members act as the owner of the centers and getting no monetary returns at all.

Although, community participation in health and family planning programs is limited in Bangladesh, there are instances of community involvement to some extent under some innovative programs and some successes have already been achieved through these pilot programs in the country. The benefits of community participation as well as the activities of the committees formed so far in health and family planning programs can be summarized as follows (Islam et al., 2001; Uddin et al., 2001; GRC, 2003).

On the other hand, this innovative approach also suffers from a number of limitations. The committees ensure women’s participation, many of them are housewives inducted just for formalities. As a result, it is important to induct active and committed women capable of breaking social barriers. The present committee members are mainly village leaders and influential people. Moreover, a true representation of the real beneficiary population, which mainly includes, lower middle class and poor sections of the society are not ensured. In many cases the committee members do not understand their role and therefore are unable to contribute even though they are willing to. Sometimes the chairperson of the committee enjoys hidden liberty to select the members (GRC, 2003). Although various committees were formed at different levels of the health system in the past in Bangladesh, most committees remained non-functional due to lack of vision, work plan and action (Uddin et al., 2001).

Role of community leaders: The local community leaders, usually the Chairman and the members of the Union Parishad (UP), local school teacher, social worker, village leader, local businessman/elite and imam (Islamic religious leader) of mosque, have a significant role to play for making the countrywide health and family planning programs successful. To this end, political commitment is essential and program activities should be focused around the grass root level. The local elected Member of the Parliament (MP) could be the chief patron to promote the health and family planning programs successful to his/her locality. The participation of the local leaders helps to increase transparency of the health and family planning programs and hence exposes the weaknesses within and between government and citizens. In addition, local leader’s involvement assists to build the image of the existing system to the mass community people. Nevertheless, local leaders are often accused of commandeering participatory initiatives to further their own connections with local elites for political gains rather than promote any active engagement with the poor (Hulme and Siddique, 1997). The Thana Functional Improvement Pilot Project (TFIPP), a project of the Directorate General of Health Services of the Ministry of Health and Family Welfare (MOHFW), points out that sometimes the Thana managers felt the difficulty in ensuring the continuous participation of community leaders and feared getting involved in local politics. The UP chairmen did not often attend meetings, which negatively influenced the participation of other members. Lack of orientation, motivation and decision-making power and perceived less important role by the community leaders resulted in their low participation (Gazi et al., 2001). These satiations also affect the way local government interacts with community organizations, informal leaders and contractors and so on. But, these cannot be avoided in the process of health sector reform.

CHALLENGES AND POSSIBLE ACTIONS

Although Bangladesh has achieved a significant progress in health and family planning programs but much still remains to be achieved. New challenges to health and family planning programs are emerging. Currently, there is a gap between the demand and the available resources for meeting the extensive health needs in the country. The challenges of existing health and family planning programs as well as possible actions to overcome these shortcomings are discussed below: