Gender and Development

Bangladesh

Urban Primary Health Care Project II

Molly’s story is unfortunately too common in poor households in Bangladesh. Couples’ and in-laws’ awareness about gender and reproductive health care issues is important for better family health. Ideally, a couple's decisions about family size and contraceptive use should be made jointly, with equal consideration given to the concerns of the wife and the husband. However, when there is an imbalance of power relations between women and men, the opinions of the man are often dominant in the decision-making process. Various studies have shown that providing men with information about reproductive health issues and involving them in counseling sessions help make them more aware of the importance of shared decision-making, and more supportive of contraceptive use, taking care of pregnant wives, handling pregnancy related crises, sharing responsibilities for taking care of newborn babies and family health care in general.¹

In Bangladesh, the urban population has been growing rapidly as a result of migration by the poor and vulnerable from rural to urban areas. Studies have shown that because of inferior living conditions, difficult income earning means and limited public health care facilities, health conditions of the urban poor particularly for those who live in slum areas are no better than in rural areas. Rapidly growing urban slums without adequate primary health care facilities or services sometimes become the cause of epidemics of emerging or reemerging communicable diseases.

In 1997, at the request of the Government of the People’s Republic of Bangladesh (GOB), the Asian Development Bank (ADB) approved the Bangladesh: Urban Primary Health Care Project (UPHCP) to provide primary health care services to as many poor people as possible in six city corporations and municipalities. While the Local Government Division (LGD) of the Ministry of Local Government Rural Development and Co-operatives (MOLGRD&C) was the lead-executing agency, Dhaka City Corporation led the implementation with Chittagong, Rajshahi and Khulna City Corporations complementing as associate implementation agencies in the first phase. In the second phase, the Ministry itself with seconded officers has been implementing the Project. UPHCP II has now been extended to the remaining two city corporations, i.e., Barisal and Sylhet and five new municipalities-Comilla, Bogra, Sirajgonj, Savar and Madhobdi. The first phase of the project lasted over 6 years during 1998-2005. The second phase covers another 6 years to be completed in 2011. This case study reports on results in the first two years of the Phase II Project.

To provide a package of primary health care services for Bangladesh’s urban poor, the UPHCP II has developed a unique implementation strategy which uses NGOs and the private sector for service delivery. The Project has been providing preventive and curative services for women and children by increasing access to primary health care (PHC) services which includes child health with immunizations, reproductive health care, limited curative care, nutrition related services, health education and assistance for women who are victims of violence. The goal of the Project is to improve delivery of PHC services by strengthening the capacity of local governments in planning, managing, financing, coordinating, monitoring and evaluating PHC services. The main beneficiaries of the Project are poor women, adolescent girls and the disadvantaged in urban areas. The Behavior Change Communication (BCC) workers of the Project do routine visits to urban slums where most of the poor people live. They provide information about Project facilities, good hygiene practices, children’s immunizations and reproductive health care. They organize courtyard meetings with mothers and their in-laws including male members of the families to talk about health care issues and family welfare. In slum-based schools, Project community workers conduct health information and counseling sessions.

Gender Action Plan

Of the 20 million people living in the Project area, 50% are women. About 40% of these women are poor and mainly depend on health care services provided either directly by public agencies like public hospitals, maternity centers or other clinics run by the Ministry of Health and Family Welfare (MOHFW) or City Corporations (CCs) or through some NGOs. The Project is addressing gender and development objectives set out in the Gender Action Plan developed during the design of UPHCP II. The Gender Action Plan aims to

• Contribute to a reduction in child and maternal mortality and morbidity rates.
• Ensure delivery of a package of preventive and curative health services to women and especially to poor women with a household income of less than Tk 700 per month by providing at least 30% of the services free.
• Ensure female victims of violence receive first aid, counseling, crisis management services and referrals to appropriate legal and counseling bodies.
• Improve the nutritional level and eventually reducing the poverty level of poor urban women and children by providing nutritional supplements to the moderately to severely malnourished.
• Construct women-friendly PHC centers to facilitate women’s increased demand for health care services; assure institutional and financial sustainability of the PHC system to provide accessible, cost-effective, efficient and quality services to meet the needs of poor urban women.
• Develop awareness programs and disseminate information through appropriate media to encourage more women to access health care services provided by the Project.
• Prevent communicable diseases through environmental safeguard measures and proper management of sanitation programs such as community based latrines, solid-waste disposal and clinical waste management.
• Build capacity of concerned officials, technical persons and public representatives through training, fellowships, study tours focusing on pro-poor and gender sensitive aspects of the Project.

Project Activities and Achievements

A series of interventions are provided under each component of the Project, which are significantly improving the health of the urban poor.

Provision of PHC through Partnership Agreements and Behaviour Change Communication and Marketing. The PHC service packages include

1. Reproductive health care (safe motherhood and contraception, RTI)
2. Mother and child health care
3. Vaccinations
4. Management of common and minor diseases and injuries
5. Control of endemic diseases, e.g., TB, pneumonia, diarrhea
6. Diagnostic services
7. Management of emerging problems, e.g., HIV/AIDS, Dengue etc
8. Health education and Behavior Change Communication
9. Violence against women related services
10. Normal Delivery & C-section Delivery through CRHCC/CMC
11. Primary eye care services

The delivery of these services was contracted out to the NGOs through Partnership Agreements based on competitive tendering. The Project has been divided into 16 Partnership Areas and each has been served by the selected NGO which provide services to 300,000-400,000 people of whom 70% are female. This population is served through Primary Health Care Centers/Child Health Care Centers (PHCC/CHC) or Community Reproductive Health Care Centers/City Maternity Centers (CRHCC/CMCs).

Beneficiaries receive required services free of charge from the UPHCP contracted NGOs. Even for other fee-based services, the Project authority ensures affordable services in comparison to market prices in other health care centers and hospitals. Behavior Change Communication workers identify individuals experiencing domestic violence during their routine work at the community and household levels or during counseling and consultation sessions at the clinic. Clients are referred to clinics to get need-based PHC services. Community supervisors and counselors provide counseling to the victims and their families. The community leaders like the elected Ward Commissioners resolve some of the cases at the community level. The rest of the cases are referred to legal aid-related NGOs like the Bangladesh National Women Lawyers Association which provides legal support to such victims. The lawyers provide advice and send legal notices to the person/s committing the violence as necessary. Some of these cases are settled mutually in the presence of the lawyer. The majority of the cases are referred to the organization dealing with legal aid to provide legal support to women victims of violence. If necessary, cases are transferred for legal action to the court.

Strengthening the Urban PHC Infrastructure. To improve access and coverage of PHC services, the Project has constructed a total of 143 PHCC/CHC or CRHCC/CMC buildings in the four city corporations and some PHCC/CHC provided services through rented facilities where the land was not available for the construction of the building. All the PHCC/CHCs are located near the slums and other densely populated areas. The Project also financed the provision of equipment and furniture of the PHCC & CRHCC. All the centers have separate toilet facilities for men and women, waiting areas with comfortable sitting arrangements, gender-friendly examination areas and room for expansion if necessary.

Building the Capacity of City Corporations and Their Partners. The Project component on building capacity of city corporations and their partners was designed to strengthen the capacity of local governments to plan, finance, budget, monitor and supervise urban PHC services. It includes:

1. establishing dedicated units within each city corporation to handle these functions
2. conducting training in specific topics in urban PHC
3. providing fellowships in PHC management, health financing and health management information systems
4. providing study tours
5. introducing systematic supervisory activities by providing funds and equipment to develop testing and integrated supervisory instruments
6. training city corporation supervisors on how to use them
7. conducting informational seminars and providing training to partners

All the behavior change communication and health care awareness training materials include strategies to address health-related complications with all family members and not with wives only.

Support for Project Implementation and Operation Relevant Research. In the first phase, the Project Implementation, Operation and Research component was designed to ensure smooth and efficient project implementation and included the establishment of a central Project Implementation Unit and Project Implementation Office in initially 4 City Corporations. In the second phase, a Project Management Unit has been established for overall project management and 11 Project Implementation Units have been established (one each in 5 Municipalities and 6 City Corporations). To date, the UPHCP has conducted 6 research activities on Improved Hygiene Education, Community Based Safe Motherhood, Violence Against Women, Improved Weaning Practices, and for Sexually Transmitted Diseases/Sexually Transmitted Infection Management. The Project also supplied insecticides and equipment for the control of dengue and other mosquito-generated diseases to these four-city corporations.

Summary of Project Achievements and Impact

The major indicators of the Executing Agency Monitoring Survey 2005 and Project Completion Review Survey 2006 to assess the effects of the Project were child mortality, immunization, vitamin A, antenatal and postnatal check-ups of pregnant women, acute respiratory infection, oral saline preparation, contraceptive prevalence, tetanus toxicity, delivery care, consumption of iodine salt, family income, functionality of the centers, and quality of services in the centers. A total of 1,600 households (50 in each center catchments area) were randomly selected for data collection. The findings of the survey are described in Table 1 below. The people of the catchments areas benefited significantly due to increases in immunization coverage and vitamin capsule administration coverage with related child and infant morbidity and mortality decreasing considerably.

The knowledge and awareness of mothers in the Project area regarding acute respiratory infection, oral saline, and modern contraceptives is considerably higher than it was before the Project as evidenced in Table 2.

The surveys collected information from 1,600 households affected by selected common diseases during 2001 and 2006 to assess changes in the incidence of these diseases in the catchments areas. The total population of the surveyed households was 6,127 in 2001, and 6,699 in 2006. The survey results in Table 3 demonstrate that the incidence of common diseases declined, indicating a reduction in morbidity as a result of improved primary health conditions due to Project interventions.

The surveys also indicated that 97.8% of pregnant women had received at least one antenatal checkup, and 90.5% at least one postnatal checkup; and 99.4% of mothers with 12-23 month-old children had received two doses of tetanus toxic vaccines. As a result, the maternal mortality rate dropped to only 18 per 1,000.

Areas for Improvement

The Project has made substantial contributions towards improving the health status of its target population, 70% of whom are female. Areas that need improvement include:

• A gender-based survey could further highlight the issues of women’s participation in health related decision-making, financial management of women’s health care needs, awareness of adolescent girls on reproductive health issues, and in-laws’ attitudes towards daughter-in-laws’ pregnancy complications.
• The Project’s female beneficiaries’ request for income generation training and financial support reveal the lack of support by their husbands towards family health expenditures and this remains to be addressed more effectively.
• The Gender Action Plan of the UPHCP II which contains specific programs to address social issues related to health care is yet to be approved and adopted by the Project Authority.
• A Project-based study conducted in 2004 on violence against women suggested that in order to prevent domestic violence, socio-cultural norms, attitudes, values and beliefs had to be challenged. The community workers need to use various strategies to address gender and violence issues using mass media, popular theatre and awareness raising especially for students.