Bangladesh is a signatory to the historic Alma Ata Declaration on Primary Health Care (PHC) in 1978. In 1988, in recognition of our roles, responsibilities and commitment to the ideas and principles enshrined in the declaration, GoB adopted the PHC approach as a guiding principle to the health systems development in Bangladesh. Given the country's resource limitations, it was but prudent that a more pragmatic approach to the introduction of PHC be taken. The later commenced with the introduction of selective PHC in districts if only to ensure a broader understanding of the concept. Pursuant to popular demand in 1988, comprehensive PHC was introduced in Gazipur and Tangail Districts. Primary health Care is to-date expanded to cover 12 districts, namely Tangail and Gazipur in the Dhaka Division; Chittagong and Feni in Chittagong Division; Rajshahi, Sirajganj and Gaibandha in the Rajshahi Division; Barisal and Bhola Districts in Barisal Division; Maulvibazar district in Sylhet Division and Bagerhat district in Khulna Division. In the 2004/2005 plan of action, MOHFW requested the inclusion of 8 New Districts in the PHC Intensification scheme. Namely: Comilla, Chandpur, Jessore, Jehnaidah, Joipurhat, Bogra, Sylhet and Kishorganj. PHC Covers 109 Upazillas with a combined 482,68,000 population (estimated). Interventions of operationalizing PHC in Bangladesh were based on 3 pronged strategies i.e.

• Training/ retraining of staff on the elements and principles of PHC;
• Provision of basic essential equipment; and
• Supplies to facilitate effective preventive, curative, promotive and rehabilitative services    to the vulnerable, the disadvantaged and the poor.

Regular monitoring through supportive supervision to ensure acceptable quality of care while simultaneously guaranteeing beneficiary community participation and inter-sectoral collaboration. In Bangladesh the Upazila, Union and Ward levels constitute the operational levels of PHC, while district, divisional and national levels provide managerial support and technical backstopping to the operational levels.

Top

Implementation of PHC:

A. National level:
At national level, the Directorate of Primary Health Care and Line Director of ESP is responsible for the planning and implementation of PHC activities assisted by a deputy director and three assistant directors of PHC.

B. District level:
The Civil Surgeon and the District team provide technical and administrative support by way of periodic supervision to the Upazila Health and Family Planning Officer and team. They also coordinate management of referrals from Upazila level and below.

C. Upazila level:
By sheer reason of population density, Upazila in Bangladesh is the equivalent of district elsewhere. It constitutes the first level of referral in the PHC System. Curative care is provided by specialists in obstetrics and gynaecology, medicine, surgery, a battery of medical officers, and supportive laboratory and supplies personnel. Promotive and preventive services are supported by Health Inspectors, Sanitary Inspectors and Assistant Health Inspectors.

D. Union and Ward levels:
The Upazila health and Family Planning Officer is the overall administrative and technical head of the Upazila Health Complex, as well as all health services up to the community level through the Union level facilities run by field level health and family welfare workers.
Intersectoral action for health has been initiated through intersectoral workshops at District and Upazila levels.

E. Community Participation:
Community participation being one of the pillars of PHC development is established through VHVs nominated by the community people and trained under the intensification project. 8 VHCPs were established in a Ward for providing health services. With the recent reform under HPSP and providing health care through ESP strategy, 15 of the first community clinics were refurbished in 6 Upazilas using own won funds.

Achievement:
Up to December 31, 1999, total 107,412 VHVs were trained of which 15,636 are male, 91,795 are female. Total 13,553 VHCPs and 15 community clinics were established.

Top

In 1998/99 Biennium:
5 Senior staff participated in study tours in Regional and Extra regional countries. 1 PHC staff at national level completed a short course (3 months) in planning in a regional country. 1000 traners of VHVs were trained. 12,560 Village Health Volunteers were trained. 2000 Village Health Volunteers had refresher training. 200 Women groups participated in awareness workshops on PHC.

In the 2000/2001 biennium
4 Senior PHC staff participated in package study tour to observe PHC development in Thailand, Sir Lanka and Indonesia. 1 senior PHC staff participated in a short course in planning in a regional institution. 2143 participated in intersectoral workshop on PHC at Upazilla and idstrict levels. 610 Trainers of VHVs were trained. 17,218 VHVs received basic and refresher training.

As of 31 December 2003 during the 2002-2003 biennium 2624Upazila level managers (UHFPOs, FPOs HIs. MOs. Sr. FWVs) tained in management; 856 MOs, MAs, FWVs, AHIs at Union level were given inservice training in basic management; 1 national level manager 1 Civil Surgeon and 2 UHFPO under fellowships were trained to improve technical skills and capacity building in management of Community Health Service Delivery. 5331 community groups members were given awareness orientation training on community health care. 5717 VHVs were given training on concept of community clinics and perceived roles and responsibilities. 2124 sector representatives ere given awareness training on community clinics concept and the importance of intersectoral collaboration in functioning, acceptance and utilization of ESP services. Developed guidelines for planning and setting up referral system from community level to union and Upazila levels. Dsigned and procured 15 Rickshows (local tricycle) fitted with ambulatory facilities. Survey on "Pre-training assessment of awareness of community group members and others
conducted.

Upazila Manager Union level Manager Fellowship Community Members VHVs Sector Representatives

Research:

A. To develop guidelines for planning and setting up sound referral system two tire pilot intervention     studies were contracted to the London School of Hygiene and Tropical Medicine. The studies are:

(1) Bridging the Access GAP (BAG): A pilot intervention for setting up and operationalizing a referral      system at the community level and
(2) A cost sharing on package of services and referrals at the community level under the BAG pilot       intervention. The studies are being conducted.

B. Study on enhancing health system performance using procurement and supply of goods under Health     and Population Sector Programme (HPSP)
C. Methodology to formulation of strategic vision for next phase sector programme (2002-2003)
D. Study to assess implementation of HPSP using essential service package (ESP)
E. Study on the impact of training in management on the output of Upazila Level Manager.

Top