Health
In the health sector, the long-term projects (leprosy, mother-and child health, etc) continues apace. But, responding to two growing problems, RDRS also works on raising awareness of HIV/AIDS and arsenic contamination of drinking water. It also conducts training and mobilisation among the local elite, the wider community and the staff on a number of issues.
Community Health Programme Review
By CORDAID, The Netherlands, June 2001
BACKGROUND:

RDRS operates a substantial Community Health Programme (CHP). In the early 1970s, RDRS provided curative health care services with support from its Core Partners (LWF Related Agencies). Since then RDRS has developed activities in mother and child health care and tuberculosis and care component of the programme was added towards the end of 1999, also supported by CORDAID.

In June 2001, CORDAID conducted a review of CHP with the following objectives:
To assess the results and effects of the health programme.
To assess the level of sustainability.
To examine the present situation of the role of Non Government organization NGOs, and specifically RDRS, within the health services in Bangladesh, particularly in the North.
A team of three consultants from The Netherlands, India and Bangladesh conducted the review during 4-23 June 2001. The major observations, findings and recommendations are summarised as follows:

GENERAL IMPRESSION:

CHP has a wide coverage and its activities are well known and recognised by the community and local government. RDRS has established a strong community base which is being used for implementing a wide variety of health activities

PROGRAMME ASSESSMENT:

Maternal Health Care Programme

CHP has 266 clinics providing maternal care services in 6 Districts. About 60% of the clinics take place at the government’s Union Family Welfare Centres (UFWC), the others mostly at the Federation centres (CBOs developed by RDRS). Attendance at these clinics is good and the coverage of pregnant mothers is about 40%. In general, customers are satisfied. Most pregnant mothers pay the user fees.

Skills of the Community Clinic Workers (CCW) need to be strengthened. Medical monitoring and supervision are not adequately functioning. The referral system for emergency obstetric care at the government centres is not well established.

Leprosy and Tuberculosis Control Programme

RDRS Bangladesh is a collaborating partner of the "National Tuberculosis and Leprosy Control Programme". Under this programme CHP operates 37 clinics in Lalmonirhat and Kurigram Districts of Northwest Bangladesh. The government supplies the drugs and the national guidelines are followed.

Tuberculosis (TB): 1,565 new TB patients were detected in 2000. Fewer women than men detected is particularly striking. Case-detection can be enhanced through contact examination, health education and utilisation of the community groups. Smears of TB-suspects are sent to government health facilities (Thana Health Complex) for microscopic examination. This is also confirmed by a cross-checking system which has been introduced by the programme.

Leprosy: About 700 leprosy patients are detected annually. Majority of them complete their treatment, though no cohort analysis is performed to monitor case holding properly. Most reactions occurring during treatment are detected and treated. A medical audit during the review indicated no substantial over-diagnosis or misclassification of leprosy patients. A rehabilitation programme has been established to train disabled leprosy patients in some vocational skills.

Eye Care Programme

The eye care programme is an excellent clinical programme. The quality of service is adequate and there is a good attendance at the clinics. However, performance of the ophthalmic health assistants could be strengthened through more onsite training and medical monitoring. Essential records, e.g. treatment given to patients, could be further organised while more attention should be given to preventive and community eye care activities.

Sustainability

The financial sustainability was of more concern, since CHP depends strongly on the support of one partner, i.e. CORDAID. Hence, a variety of options were explored, which may broaden the resource of the project. It was found that user fees are currently well implemented and accepted, but the contribution to the total budget is limited.

SPECIFIC RECOMMENDATIONS:
Maternal Case services:
Pregnant women of any gestational age should be registered.
Supervision of clinical performance of Traditional Birth Attendents (TBA) and need-based training for them should be enhanced.
Quality of services offered by the Community Clinic Workers (CCW) should be improved through skills training.
A survey should be conducted to validate the claim of reduction of mortality in the RDRS working area.
Referral linkages with the Emergency Obstetric Centre (EOC) of government or higher medical facilities should be enhanced.
Syndromic case management of RTI/STI at the Aditmari Maternity Centre should be strengthened through refresher courses.
A medical audit should be iconducted at least once in two years.
Comprehensive Leprosy and Tuberculosis Control and Community based Rehabilitation:
If patients with leprosy reactions do not respond to the standard prednisolon schedules, they should be referred to the specialized Danish Bangladesh Leprosy Mission (DBLM) hospital.
Patients released from treatment should be educated on the possible reactions after treatment.
Rehabilitation programme should target patients with disabilities in general, not leprosy patients only.
Contact examination for smear positive TB cases should be enhanced, particularly to improve case detection among women.
If doubt exists about the accuracy of diagnosis of TB among referred patients, they should be re-assessed.
Community-observed therapy could be implemented.
Health promotion activities should include HIV/AIDS education, also to minimse long-term iympact on the TB epidemic.
CHP management should be strengthened.
A more consistent framework of objectives and strategies should be developed to facilitate the formulation and monitoring of programmes.
Community Based Eye Care Project:
Medical monitoring for the Ophthalmic Health Assistants (OHA) and standardised record keeping system should be introduced to strengthen the eye care programme.
Team members of the eye care programme should be made familiar with the national nutritional blindness program so that they prevent and treat eye problems due to Vitamin A deficiency.
Organization of the Community Health Project:
The three projects should be combined into one programme to enhance the efficiency of CHP.
Training modules have to be reviewed and updated periodically.
Technical, managerial and leadership skills of CHP staff should be strengthened.
CHP should have a Human Resource Development (HRD) plan.
FUTURE DIRECTIONS:

Based on the review, some future directions for CHP could be formulated. Concerning service delivery, RDRS should operate within the context of the Essential Service Package (ESP) and should reach consensus with government health authorities on the services to be delivered first. Ideally, national guidelines should facilitate collaboration at the local level. The review team recommends:

Expand the programme but not substantially.
Develop a health policy.
Strengthen linkages with government.
Enhance involvement of community groups in health care.
Make relevant changes in the approach and contents of CHP only when the consequences of the Health and Population Sector Policy (HPSP) become clear.
CONCLUSION:

In general, the performance of CHP/RDRS has been satisfactory. Over the past years, CHP/RDRS has been able to diagnose and treat thousands of leprosy and TB patients. Furthermore, increasing number of pregnant mothers are receiving ante-natal care through the services of CHP/RDRS, while some important eye care services of high quality are provided to those in need.

Copyright © 2001 RDRS Bangladesh. All rights reserved.