[ Women's health]
Realistic aspirations for Bangladesh
Gonoshasthaya Kendra is a pioneer NGO in rural health-care delivery in Bangladesh. A close scrutiny of its experience shows that maternal mortality can be reduced even in remote rural areas. Costs can be kept low by adequately training traditional birth attendants. To achieve such goals, however, a fundamental shift is needed in public-service provision. Official providers must be made directly accountable at the local level.
[ By Rafiqul Huda Chaudhury and Zafrullah Chowdhury ]
In 2000, the UN declared the Millennium Development Goals (MDGs), one of which is to reduce maternal mortality by three quarters until 2015 (with 1990 as the baseline). It is formidable task to make the MMR drop to 144 in Bangladesh. The experience of Gonoshasthaya Kendra (GK) in rural Bangladesh, however, shows that it can be done. In the villages where this non-governmental organisation is active, MMR amounted to 186 in the years 2002 to 2005.
People’s health centre
“Gonoshasthaya Kendra” literally means “people’s health centre”. GK is one of the largest NGOs dealing with health matters in Bangladesh. It was established shortly after the nation’s independence in 1972. Today, the organisation serves over one million people in close to 600 villages all over the country. It provides a wide range of primary health care (PHC) as was envisioned in the WHO’s Alma Ata declaration in 1978.
GK has designed a pro-poor social health insurance scheme, is running a pharma-production site to manufacture generic drugs, and is active in many other ways as well. This essay, however, only discusses activities directly related to maternal health, a context in which GK services include
- birth and death registration,
- registration of pregnant women,
- identification of their blood group,
- immunisation of expecting mothers against tetanus,
- identification and regular follow-up of high risk mothers to ensure their timely treatment,
- referral to hospitals if necessary,
- promotion of additional nutrients and a balanced diet for pregnant and/or lactating women and newborns with family members and
- promotion and delivery of family planning services.
GK provides primary health services through a cadre of village-based health workers. Most of them are female and have completed the Secondary School Certificate examination in science. Initially, they receive six months training in basic physiology, anatomy and other fundamentals of primary health care. After successful completion of the formal training, they are posted at GK centres for 12 months of practical training. During this period they work under close supervision of their senior colleagues.
GK health workers in the villages are linked to referral hospitals for the secondary and tertiary levels of care. Some of these hospitals are run by GK, others by the government.
Presence at the local level
According to Bangladesh Demographic and Health Survey data (NIPORT 2007), doctors and/or nurses attend only 13 % of rural births in Bangladesh. In view of this reality, GK felt something had to be done to meet the acute shortage of trained birth attendants, and decided to involve the existing traditional birth attendants (TBAs) in safe delivery in rural areas.
For that purpose, TBAs must understand the scientific facts of pregnancy and know how to handle standard deliveries. Trainings in these matters are periodically repeated, reinforced and updated.
Without further supervision from GK paramedics, TBAs who have undergone these courses are capable of delivering babies competently at the mothers’ homes. Exceptions are cases of complications, which, however, can normally be diagnosed beforehand. In the years 2002 to 2005, almost 90 % of births were thus attended by adequately skilled persons. The national average is of only 18 %. These statistics include medical staff who were present in cases of expected complications. Only ten to 12 % of deliveries in GK areas were assisted by untrained birth attendants (relatives, quacks, untrained traditional birth attendants) as against 68.7 % for the country as a whole (NIPORT 2007).
The home continues to be the place of delivery in Bangladesh. For cost reasons, that will stay so, and the GK experience shows that it is possible to reduce the MMR nonetheless. In GK areas, more than 70 % of deliveries take place at home. The national share is of 85 %.
GK promotes nutrition education among family members, particularly on the need for additional nutrients and balanced diet of pregnant and lactating mothers and newborns. In this effort, GK organises “Bou-Shasuri” (daughter-in-laws and mother-in-laws) meetings. These meetings discuss, among other things, workloads and nutritional needs of pregnant women and their need to get adequate rest during daytime. Mother-in-laws are urged to allow their daughter-in-laws to eat early on with the children, instead of insisting on the tradition of women being the family members who only get to eat what the others have left over.
Ensuring accountability
GK actively cultivates local participation in health-care delivery. One way of doing so is the constitution of Village Health Committees. These committees are composed of members from various segments of society. Usually, they are headed by a female elected member of the lowest tier of the local government (Union Parishad).
To ensure accountability, GK health workers are answerable for each maternal and child death in the village they work in. For this purpose, so called “death meetings” are arranged. Family members, teachers, priests and local elected representatives take part, including, of course, members of the Village Health Committee. Such meetings discuss the possible causes of the death at hand and explore whether or not it could have been avoided.
Beyond this village-level social auditing, all GK field-level health workers have to independently prepare detailed case histories and submit reports to their respective supervisors within 72 hours of the reported death explaining why a maternal and neonatal/infant death could not have been prevented. Supervisors scrutinise these reports diligently.
On this basis, GK managed to reduce maternal mortality and its underlying factors considerably. From April 2002 to April 2005, GK field-level health workers systematically collected data from a panel with cohorts in different parts of Bangladesh, monitoring the outcome of pregnancies. The data cover the affected women’s health record from conception until 42 days after delivery.
Due to this effort, 46,320 live births are on record. On average, in 1.86 of 1000 cases the mother died. There were also 48,362 pregnancy terminations, and in such cases 1.78 of 1000 women died. In GK programme areas, MMR has been declining over the long term – from about 300 per 100,000 live births in the period 1993 to 1997 to 186 per 100,000 live births in 2002 to 2005. Most recently, MMR in GK areas was 42 % below the national figure.
All 86 women who died due to pregnancy, childbirth, and puerperium related causes had received antenatal care-visits at home. On average, they had been visited five times for antenatal care (ANC). Moreover, GK health workers identified high-risk mothers and closely monitored their health status and provided necessary services. That included timely referral of complicated cases to specialists/health facilities.
At the national level, ANC services are considerably lower. Whereas 100 % of pregnant mothers got ANC services during their latest pregnancies in GK villages, that was only the case for 60.3 % of pregnant mothers in Bangladesh as a whole. Only 21 % of the concerned women in Bangladesh received three or more ANC visits, compared with 91 % of women in GK area during their latest pregnancy. Close monitoring of high-risk pregnancies is not routinely available at national level. Better ANC services contribute to the fact that maternal mortality is significantly lower in GK programme areas than elsewhere in rural Bangladesh.
Policy lessons
There are two major differences between the GK strategy and the one of the government. Both distincitions have direct implications on the lives of poor rural mothers:
– Traditional birth attendants: while one should probably not expect the government of a very poor country to provide a health infrastructure with doctors, nurses and paramedics at the village level, it would make sense for the government to tap into the potential of TBAs. So far, it is not doing so. The GK experience shows that it is crucially important to train and involve TBAs. The government should replicate this approach. In Bangladesh, the idea of universal coverage with professional health staff is plainly utopian for the foreseeable future. Any attempt to marginalise TBAs is therefore irresponsible.
– Accountability: GK paramedics and health workers are held accountable not only by their supervisors (who in turn are accountable to their supervisors) but also to the communities they serve. For that purpose, GK has set up Village Health Committees that involve the local government. Government health workers, however, are neither accountable to local governments nor to the communities they are supposed to serve. Instead, they report to the bloated bureaucracy of the central government. It would make a fundamental difference in public-service provision if service providers were made accountable at the local level.
References:
Bangladesh Health Watch Report: The state of health in Bangladesh 2006: Challenges of achieving equity in health. Dhaka, December 2006.
National Institute of Population Research and Training (NIPORT), Mitra and Associates, Measure DHS, Macro International (USA), 2007: Bangladesh Demographic and Health Survey 2007, Dhaka
Rafiqul Huda Chaudhury
is a former UN regional adviser on population and development. Presently, he is the honorary adviser of Gonoshasthaya Kendra’s research department.
»» rafiqulchaudhury@yahoo.com
Zafrullah Chowdhury
is Gonoshasthaya Kendra’s projects’ coordinator.
»» gk@citechco.net
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