Community Clinic (CC) as a new horizon in ensuring primary healthcare in Bangladesh has been working astoundingly since its inception. Reportedly, some of the CCs are not working effectively that’s why the beneficiaries, the villagers, are seeking care from other professionals. To address the underlying reasons of ineffectiveness of the CC in the site was the key objective of this study. Lack of work in that particular context motivates to pursue this study. Due to the financial constraint, the sampling site, Naogaon district, was purposively selected. Then the randomly selected upazila, Raninagar, was undertaken. Applying multi-stage random sampling technique, primary data of 100 household of two villages, as per the secondary data, were collected. From the empirical investigation, it is addressed that the key determinants of demand for health care from the CC; the level of education and level of income; are not playing a robust role. Instead of those, the problem of comparative low use rate of the CC lies on the determinants of supply-side; the unavailability of the CHCP and the drugs, which ultimately strengthens the traditional outlook towards the CC by the villagers. Once the provision of drugs is ended, the CC becomes literally meaningless except few responsibilities conducted by the health workers. Along with the government’s strong commitment, some reforms; formation of Village Solidarity Group’ keeping educational institute at the centre; can transform the scenario drastically.
Research Article
The Reality Check of Community Clinic in Bangladesh: A Case Study of Two Selected Villages of Naogaon District
https://doi.org/10.21203/rs.3.rs-2109715/v1
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Community Clinic
Bangladesh
Demand for Healthcare
Primary Health Care
Health, like education, is among the basic capabilities that gives value to human life (Sen,1999). It indeed, contributes to both social and economic prosperity (Ahmed, 2005). Mostly, health systems are ineffective in reaching the poor people generate less benefit for the poor than the rich and impose regressive cost burden on poor household (Fabricant et al., 1999). Neglect, abuse, and marginalization are the issues of their normal experiences (WHO, 2001). Based on experience, it can be said that poor people will be effectively excluded unless the services are geographically accessible, of decent quality, fairly financed, and responsive (Narayan et al., 2000). The government of Bangladesh is committed to deliver basic health care services to all of its citizens irrespective of income, race, gender, community, religion etc. as per the constitutional obligation stated in the article 15(A). In response to that obligation, government has enormously built health infrastructure across the country through an intricate web of health care network from tertiary to secondary to primary level in line with the administrative tier of the local government. In that healthcare network, community clinic is an instrumental part which is designed for the poor village people across the country.
Community Clinic (CC) was introduced as a project in 1998 which was renamed in 2009 as “Revitalization of Community Healthcare Initiatives in Bangladesh” (RCHCIB), targeting about 6000 population at the lowest administrative tier, ward level. Currently, (as of September 2017), 13,442 CCs are operational. From July 2015, all the activities of CCs were being carried out under an Operational Plan of the DGHS, namely Community-based Healthcare (CBHC) which is now being accomplished under the activities of the 4th HPNSP (Health Population and Nutrition Sector Program) 2017–2022. Hundreds of thousands of villagers, particularly the poor and the underprivileged mothers and children, are the beneficiaries of the services from the nearby CCs. Average estimation reveals that about 9.5–10 million patient-visits take place nationwide each month in the CCs (Health Bulletin, 2017). It is a matter of irony that despite the existence of impressive infrastructural development, particularly in building CCs, the ineffectiveness of healthcare provision is vividly demonstrated in some of those facilities across the country. One of the foremost factors contributing to this situation is the under-utilization of community clinic services (CCS). Reasons for under-utilization of CCS have been attributed to distance of the facility from home, lack of awareness on the value of services, perceived poor quality of care, cultural and social belief systems, discrimination against those of low socio-economic status and perceived high access costs (Yaya et al., 2017). A significant range of impediments prevails at the side of demand for seeking care from those public facilities which is evidenced as the use of formal health care is incredibly low (40%); about two-thirds (65%) of which is private health care and only one-fourth utilizes public sector facilities (Hamid et al., 2014). It was addressed that only 34.1% percent of rural people are participating on health services (Islam et al., 2009). The causes of this low participation in health services mentioned by previously mentioned study are lack of financial and technical support, mismanagement, malpractice of doctors, lack of coordination among the provider, absenteeism of doctors etc. In another study, researchers identified three reasons such as, inadequate financial coverage cultural attributes of the poor and the system barriers for low use of discretionary health care services by the poor (Dutton, 1978). A study considered population factors (socio-economic condition of rural people, their knowledge and attitudes towards public sector health care) and provider factors (different aspects of quality of public health services, access to the service facilities and provide behavior) greatly hamper the utilization of primary health care service in rural areas of Bangladesh (Rahman, 2001). Majority of the ethnic group people (about 60 to 70%) sought health care from the unqualified allopathic provider while resident Bengalis sought care in greater proportion from the semi-qualified para-professional. Another study that only deals with the women aged 15 to 49 years living in rural setting, was not focused on all villagers (Yaya, 2017). Another study contributed as disseminating knowledge about required regulatory reform in the governance level of the district hospital and below. They studied using facility-based survey focusing on supply side constraints where our concentration on demand side through doing household survey. Additionally, they tried to come with the resolution from the corner of supply side only (Roy et al., 2016). This study encompasses all aged- potential care-seekers from CCs within the households were figuring out the insightful information along with the feasible pathways is primarily focused.
A conceptual framework for this study can be deducted from the hypotheses and literature review of this study which has been delineated in the schema presented in the following. The schema demonstrates a chain of relationships between the variables and the demand for health care from the CC. The variables affect the demand via its effects on the intermediate variables and proximate determinants. The relationship we only care about functional relationship where cause and effect relationship prevail. The functional relationship between the dependent and independent variables is depicted below;
Then, YDD = f (XTO, XD, XEd, Xi…)
TO = f (XAbs, XSs, XMp, XDc, XEp,......)
Where,
YDD = Demand for HealthCare from CC
XTO = Traditional Outlook towards the provider of CC
XD = Distance from the Household to CC
Xi = Income of Household
XEd = Level of Education
TO = Traditional Outlook
XAbs = Absenteeism of the Provider of CC
XSs = Short time of Stay at Facility
XMp = Misconduct of the Provider with the Patient and its Attendants
XDc = Common Drug Phenomenon
XEp = Gathered Experience from Prior Visits
In this study, demand for health care is the dependent variable. The prior experience from CC, level of income, level of education, traditional outlook towards the providers, lack of knowledge about health services available at those facilities, awareness of people, etc. It was assumed that these variables are affecting the villagers to choose the provider between the CC and others, i.e. quack, in order to use of health services. The core hypothesis of this study is the traditional outlook towards the health care providers of CC which encompasses a range of factors; specially, the unavailability of the CHCP and the unavailability of drugs which aggregately navigates the potential clients, the villagers, of the CC to seek care from the quacks.
Though the contribution of CC, since its inception in 1998, to the improvement of health sector at rural level is undeniably unparalleled, the benefits from some of those facilities are yet to turn into reality due to some variables of the demand function, we literally assumed that. Traditional outlook generates basically due to the dissatisfactory prior experience of visits at CC what actually navigate the care seeker to seek from other providers than CC and create aggregately, the low level of demand for healthcare. If the level of education is low, then the people may have more traditional attitudes towards formal care of CC and may be more unaware about their health. This will eventually reduce the utilization of formal healthcare from CC. This low utilization represents the low demand for healthcare from CC.
Data Collection:
The study site, Raninagar Upazila of Naogaon district under the division of Rajshahi, was selected purposively due to financial constraint. Then, the target population from two villages; Belghoria village under Kaligram union and Sarkatia village under paroil union; were selected based on the secondary data collected from the MIS department of Raninagar Upazila Health Complex. Data was collected May to July, 2018.
Household survey with structured questionnaire was conducted in order to accomplish the empirical investigation of this study among the households of two villages. About 1700 population in 370 households reside in Belghoria village under Kaligram union and about 500 households are there in Sarkatia Village located in Paryoil Union. In order to have time constraint, only 100 (50 from Belghoria and 50 from Sarkatia) households from two villages were surveyed for this study.
|
Villagers at income groups |
Belghoria Village (50 out of 370 HH) |
Sarkatia Village (50 HH) |
|---|---|---|
|
Poor |
20 |
20 |
|
Middle |
20 |
20 |
|
Rich |
10 |
10 |
First of all, based on three income strata (low, middle, and rich) which can be operationalized by the regular income of the employees and the amount of farm land available for the farmers. Certainly, this is noted that level of income identity was considered from the corner of cost of living exits in the study site. In terms of regular income, more than BDT 10,000/month (solely) and additional farm land was considered as a rich individual, more than BDT 5,000/month but less than BDT 10,000, additional farm land was considered as middle income. Less than BDT 5,000/month was considered as low-income group. In terms of farmland, owners of more than 20 bighas farmland was considered as rich group, more than 5 bighas was middle income group, and below 5 bighas was considered as low-income group. After stratification from All villagers based on income group, interview was supposed to move towards the potential clients among each income groups. Total 50 households from each village were dealt with three different classified groups based on income. According to ESP strategy, five core services of the Bangladesh ESP has been structured including; ANC/PNC, Growth Monitoring, FP short acting, Integrated Management of Child Illnesses (Community IMCI includes the components of Anaemia and malnutrition, Autism), Expanded Program of Immunization (EPI), Social and Behavioral Change Communication (SBCC), NCD Screening, and limited curative care13.Based on the ESP strategy the selection of households was conducted in the third stage from all the villagers. Then, the random sampling method was applied among the potential clients in fourth stage.
Step 01: All Villagers
Step 02: Division based on Income Strata
Step 03: Potential clients based on ESP strategy
Step 04: who had the experience of visiting CC
Step 05: Commence on Systematic sampling among the clients with experience
Households having the children, women with baby lied in this study along with other villagers as per the ESP strategy. About 370 households reside in Belghoria village. From them, 50 HH was randomly selected after completing the prior three steps of stratification. Then a household were selected after every 5 households for facing the questionnaires. Same process was applied for conducting household survey at Sarkatia Village. At first, the collected data was translated from the hardcopy to softcopy through using SPSS application. Then, data analysis was accomplished using the same application.
Ethical Consideration:
To comply with the ethical issues, the study protocol was reviewed and approved by the Research Ethics Committee (REC) of the Faculty of Allied Health Sciences of Daffodil International University. Administrative approval was taken from the proper authority of the health centers. Anonymity and confidentiality were maintained strictly.
It is widely recognized that a significant role of income prevails in seeking health care demand. While health care is generally a normal good, since its demand for health are increases with income (Folland et al., 1993). As far as we are concerned about the health care demand from the CC, we tried to deal with the different income groups in order to figure out in what percentage of them seek care from the CC. It was observed that poor people were warmly welcomed in Sarkatia CC, all of the respondents were visited during the last year. The story was not the same in Belghoria village where poor, 80% of all, were treated at Belghoria CC. If we look at the above table, one of the interesting insights is that people belong to different income groups do not matter. Only matter is that what facility I am talking about those matters, keeping other things constant. Whether potential demand turns into effective demand or not which depends on the CC.
|
Seeking Care from CC |
Belghoria Village |
||||
|---|---|---|---|---|---|
|
Level of Satisfaction Obtained from Seeking Care at Community Clinic |
|||||
|
Highly Satisfied (%) |
Satisfied (%) |
Neutral (%) |
Dissatisfied (%) |
Highly Dissatisfied (%) |
|
|
Poor |
0 |
50 |
25 |
25 |
0 |
|
Middle |
4.8 |
81 |
9.5 |
4.8 |
0 |
|
Rich |
23.1 |
61.5 |
15.4 |
0 |
0 |
|
Relation Matrix of Factors and Seeking care from the CC |
|||||
|---|---|---|---|---|---|
|
Factors |
Breakdown |
Belgharia |
Sarkatia |
||
|
Income |
Yes (%) |
No (%) |
Yes (%) |
No (%) |
|
|
Poor |
80 |
20 |
100 |
0 |
|
|
Middle |
95 |
5 |
90 |
10 |
|
|
Rich |
62 |
38 |
90 |
10 |
|
|
Level of Education |
Illiterate |
95 |
5 |
100 |
0 |
|
Primary |
75 |
25 |
95 |
5 |
|
|
Secondary |
80 |
20 |
95 |
5 |
|
|
Higher-Secondary |
85 |
15 |
90 |
10 |
|
|
Higher Education |
0 |
100 |
100 |
0 |
|
Additionally, it was attempted to figure out how the different level of education works as a navigator in terms of choosing the CC to seek health care services. Notably, the level of education is one of the key determinants of seeking health care from formal providers. In the case of CC, I tried to figure out that how level of education influenced over choosing the health care provider. According to the Grossman model of the demand for health (Folland et al., 1993), an increase in education is expected to increase investment in health. A consistent conclusion in the public health and economics literatures is that education is correlated with the use of preventive health care for adults (Kenkel, 1994). In terms of the Sarkatia village, there is no much difference among the different education holders for taking the decision of going to seek care from CC. The story is almost same for the villagers of Belghoria. Certainly, education has the positive role to play in seeking care from the formal care provider but it does not have much influence over this issue because education basically creates awareness and motivation but the level of awareness and motivation is required for undertaking services from the CC has already been built through the tremendous job done by the Government and other players.
Pouring over the issue of level of satisfaction reflects that how the recipients of the Community Clinic feel about the services and the way they received. In terms of Belghoria village, people from poor group, received health care with 50% satisfaction along with 25% level of dissatisfaction what signals a bad picture of what is going on there. Interestingly, rich groups are highly satisfied with the level of 23.1% which smells out the indecent personality of the CHCP who is busy with making happy the rich individuals. In this story, the main targeted group, the poor, is deprived of getting the care they desire for. Now, if we now intend to look into the situation of Sarkatia village, people from all different groups, are fairly satisfied with the care they have obtained though the share of the poor is still small in comparison with other groups. In the perspective of Sarkatia village, a range of reasons including the availability of CHCP, having a just- mind of serving the people based on equity, cleanliness, low level of nepotism in delivering drugs, etc. bear a positive role for getting greater response from all sections of the people unanimously. The picture is completely opposite in the context of Belghoria village, if it is assumed that the provision of the drugs is same for both CC. It can be figured out the impressive story of the Community Clinic through presenting the mean number of days the recipients visit during the last year.
|
Seeking Care from CC |
Sarkatia Village |
||||
|---|---|---|---|---|---|
|
Level of Satisfaction Obtained from Seeking Care at Community Clinic |
|||||
|
Highly Satisfied (%) |
Satisfied (%) |
Neutral (%) |
Dissatisfied (%) |
Highly Dissatisfied (%) |
|
|
Poor |
0 |
66.7 |
33.3 |
0 |
0 |
|
Middle |
0 |
78.7 |
14.3 |
7.1 |
0 |
|
Rich |
0 |
89.5 |
10.5 |
0 |
0 |
In the perspective of Belghoria village, mean number of visiting days is high both for poor and middle-income groups what may be pointed out as due to the unavailability of CHCP, people were visited several times and significantly, this is lower for the rich group what may be because rich individuals use cell phone to contact with the CHCP before going to the CC. From different angles, it can be said that 50% of the poor and middle-income people have the chronic diseases that is why they visited more times than the rich individuals. The story is not the same for Sarkatia village because the CHCP gave value to the poor recipients and tried to ensure equity irrespective of the social status. Due to his professionalism, people would like to visit the CC. Another aspect of this phenomenon is to share the story of coming back without receiving the desired care clearly represents the availability of the provider, CHCP, of the CC located at the vicinity of the two villages. In terms of Sarkatia, more than 50% of both poor and middle-income group never came back without receiving care. This picture is so dissatisfactory for the people of Belghoria village where only 12.5% and 33.3% people never came back without care from the CC. The functionality and the whole care are primarily dependent upon the availability of the CHCP who should own the quality of sound ethics so that nepotism in terms of providing drugs and selling out the drugs in the market could be prevented. Our strong desire is to visualize the scenario regarding the experience of coming back from the CC which is absolutely horrible what basically happened after finishing the stock of drugs (for each CC, two drug kits are provided for 4 months) at the end phase of the entire duration. About 20% poor people never come back without drugs in Sarkatia village. On the contrary, 12.5% poor of the Belghoria village always obtained the drugs. Interesting story is here about the rich people, about 90% rich respondents come back at least once without drugs.
|
Number of Visits during the last 1 year |
Belghoria Village (Mean number of days) |
Sarkatia Village (Mean number of days) |
|---|---|---|
|
Poor (20) |
7.75 |
6.73 |
|
Middle (20) |
7.05 |
4.85 |
|
Rich (10) |
3.62 |
5.37 |
|
Coming Back without Care from the CC at least once during the last Year |
||||
|---|---|---|---|---|
|
Experience of Coming back without Services at least once |
Belghoria Village |
Sarkatia Village |
||
|
YES (%) |
NO (%) |
YES (%) |
NO (%) |
|
|
Poor (20) |
87.5 |
12.5 |
46.7 |
53.3 |
|
Middle (20) |
66.7 |
33.3 |
46.2 |
53.8 |
|
Rich (10) |
38.5 |
61.5 |
68.4 |
31.6 |
|
Coming Back without Drugs from the CC at least once during the last Year |
||||
|---|---|---|---|---|
|
Experience of Coming back without Drugs (At least once in the last year) |
Belghoria Village |
Sarkatia Village |
||
|
YES (%) |
NO (%) |
YES (%) |
NO (%) |
|
|
Poor (20) |
87.5 |
12.5 |
80 |
20 |
|
Middle (20) |
85.7 |
14.3 |
61.5 |
38.5 |
|
Rich (10) |
50 |
50 |
89.5 |
10.5 |
From the above table, it is obvious that the provision of drugs needs to be scaled up with increasing the monitoring. People are eager to receive care from the CC but the unavailability of drugs navigates people to move to the pharmacist cum quack. Significantly, the people’s perception about the CC as ‘Modified Public Drug Store’ needs to be addressed and undertaken necessary steps to transform that outlook because CC basically did not install as a drug store rather as an emergency health care along with some other routine care. Positive understanding about the CC has a profound significance in moving towards building healthy and productive nation.
Seeking care from the CCs means to avail free medicine and free care where people can reach within 10 to 15 minutes from their home. From the empirical investigation, it is obvious that almost 99% people fall any type diseases either common illness or other particular types of diseases during the last year. In response to those diseases, all of them sought care either from CC or pharmacists cum village doctor or from the other nearby public health facilities. Due to the dramatic transformation since a decade about health as a significant issue of concern as a consequence of massive awareness campaign by a range of stakeholders, some optimistic events are becoming obvious. For instance, the presence of Kobiraj is about to die; about the quacks who are, nowadays, surviving through working both as a doctor and pharmacist at crowded places like bazar; people never chose a quack as a first choice to visit except the quacks are relatives of them or compelled to visit them because of unavailability of CHCP and the drugs; parents are searching rampantly the EPI officers which was completely a different scenario in two or three decades ago, etc. If we be able to scrutinize the demand side factors like income, level of education, etc., it seems clear that these factors do not own robust role to navigate the patients from CC to other providers in significant way. What is assumed that two predominant factors namely; unavailability of the CHCP, and of the drugs, of the supply side strengthens the concept of traditional outlook towards the public facilities i.e., CC. All of the population has the information about the CC i.e., what it is, where it is, what time it opens up and shuts down. Interestingly, there 12 phenomenon exists which can be defined as; it is unofficially announced that if anyone comes after 12 pm, the patient will not get the drugs. On the ground reality, CC has been playing an incredible role to transform the lives of the villagers. Problem like unavailability of drugs impedes the success story of the CC where generally, drugs are supplied by the DGDA for about 4 months based on the list of 27 types of drugs. CHCP is supposed to run his CC with this fixed package of drugs. If once it is finished, the care is stopped. In that case, both parties; patient and provider remain no incentive to operate the CC. In terms of Belghoria village, people said that the CHCP delivers 5 to 6 drugs in each visit. As a result of that, more required drugs finish early what seems meaningless for the CHCP to come and deliver the care because CC can be unfortunately renamed as a ‘Free Drug Store’ which certainly represents the unwillingness of and the tendency to escape from the responsibility of the CHCP. In my investigation, case from the CC located at Belghoria village, where the use rate is comparatively low from other CC located at Sarkatia Village, because of the problems are prevalent presented in the following table.
|
Comparative Analysis between the two Villages where two CCs are Located |
||
|---|---|---|
|
Underlying Factors |
Belghoria Village (Use Rate is low) |
Sarkatia Village (Use Rate is high) |
|
Tendency of the CHCP to Finish the Drugs as early as possible |
Much Prevalent |
Less Prevalent |
|
Statement “Drugs are no More” |
Overly uttered |
Deficiently uttered |
|
Existing a prominent quack with pharmacy |
Prevalent with eminence |
Prevalent with lower or negligible level of eminence |
|
Length of Stay of the CHCP at CC |
Significantly low |
Significantly higher |
|
Cleanliness of the CC |
Seems filthy and messy |
Seems cleaned enough |
|
Proper use of 2-taka Phenomenon [As a local initiative, CSG initiated to the payment of 2 taka at each time of visit except extreme poor and freedom fighters] |
Collected money didn’t use properly |
Collected money used in a proper way |
The core limitation of this study was the number of sample size, 100, is too small to generalize the findings obtained from the survey. It was really difficult to visualize the story of the operation of CC across Bangladesh through only bringing the two villages with too small size of sample.
Succinctly, the hypothesis of this work has partially been accepted. The difference utilization of the CC relies on the traditional outlook towards the CC which is generated through the unavailability of the provider; CHCP, and the unavailability of the drugs. In this context, education and income have little influence. Significantly, people are satisfied with what services are delivering from the CC. If the number of the drug items are provided based on necessity and the CHCP is ethically sound to materialize his commitment, the challenges of CC will no longer remain. In order to mitigate the challenges, concerted framework can play a pivotal role indeed.
From the point of truth revelation, the authors are obliged to disclose and admit the crucial impediments of this study accomplishment. Dealing with the two villages who live in the vicinity of the CCs are located, truly does not represent the whole scenario of Bangladesh at macro level. On that ground, drawing inference with generalization for whole country is quite dubious. Besides, the number of sample size in the survey was not large enough to apply more sophisticated statistical tools. It is certainly noted that this was an attempt to address the phenomenal issues need to be taken care of with an aim to robust services from CCs.
“As the CC grows up with its maturity, people’s expectation is uplifting undoubtedly”-quoted by the UHFPO of Raninagar Upazila Health Complex. In order to deliver health care services with the efficiency through meeting the expectations and mitigating the misunderstanding of the community people, the existing loopholes in the current system of service delivery needs to be addressed with prime concern where short, mid, and long-term plan can be committed. Basically, the unavailability of the provider and the inadequacy of the drugs are the key impediments to transform the CC as a functioning one. These supply side problems create traditional outlook towards the CC what navigates the villagers to seek care from the quack cum pharmacists or others. Amid challenges, CC has been working literally in an impressive way where a bit reform can change the scenario drastically both in the short and long term. On that ground, forming ‘village solidarity group’ with the key stakeholders in a concerted way, where the academic institution, i.e., primary school, can play a phenomenal role in strengthening the CCs.
Recommendations
-
To form the ‘Village Solidarity Group’ for emboldening ‘Community Support Group’ for tackling the impediments towards functioning the CC in an effective way. Particularly, there are two grave concerning issues; absenteeism of CHCP and the availability of drugs.
-
To reconsider the way of the provision of the fixed quantities of the drugs. It should be restructured as need-based aiming at bringing efficiency that will make the CCs more effective.
-
To ensure the mechanism of prompt response to the demand from the CCs.
-
To hold a rigorous trainings and workshops on ‘Drug Resistance’ and ‘Preventive Measures on different NCDs and CDs’ for CHCPs because of making them understand about the efficient use of the drugs and its aftermath in the long run.
-
To update and restore ‘Emergency First Aid Kit’ as per the need with high emphasis.
-
To rethink about the issue of 2-taka phenomenon and its effectiveness.
Competing interests:
The authors declare no competing interests.
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