Localising Primary Healthcare in Bangladesh

Meet alumna Shoma Nurun Naher, Director of Health and Environment at the DASCOH Foundation in Bangladesh. A physician by profession, Shoma felt frustrated by the service gap that keeps many in Bangladesh from receiving adequate healthcare. With the goal of helping ensure primary healthcare at the community level, Shoma joined The Hague Academy for the Inclusive Service Delivery & the SDGs course in 2022. She was drawn by the promise to learn about ways to localise healthcare.

In Bangladesh, Shoma paints the picture to us, the health care system lacks public facilities, needs more skilled workers, is underfunded, and is affected by political instability in its governance.

“We’re really struggling with this in our country”.

According to the World Health Organization (WHO), Bangladesh’s healthcare system is underfunded and undermanaged. The national government spends only about 3% of the country’s gross domestic product on health services, which then only covers a third of all health expenditures. The rest is covered by patients in out-of-pocket expenses. For too many, these expenses are too high to bear.

Hierarchical and Ineffective Healthcare

Bangladesh is divided into different levels of responsibility and types of services offered. The lowest one consists of community clinics. These are healthcare facilities for people seeking initial medical advice or treatment. Above them is the subnational system, with a more complex level of health care, needing larger facilities, more capacity for emergency health care, maternal health services, child specialists, and so on. Maternal health services include sexual and reproductive health services.

This has created a system of differing competencies, where citizens, especially women, find themselves not having the health care they need. Those that need specialised – or even just more urgent primary care – do not have immediate access to health services. Instead, they need to deal with overburdened community clinics that refer them to the care they need, and much less have the resources to offer treatment on the spot.

According to the WHO, primary healthcare is key because it addresses the health needs of people at the community level, focusing not only on comprehensive care, but also on prevention, promotion, and education. Its potential lies in being as close as feasible to people’s everyday environment. As Shoma explained to us, this is simply not the case in her region, as healthcare facilities are lacking coordination with local governments.

Training: Ensuring equitable and quality services for all

Shoma came to The Hague Academy intently on finding ways to bridge the gap between local communities and health services. During the training, Shoma learnt that municipal authorities could play a pivotal role in reducing health disparities in communities. Given their knowledge of local circumstances, they are better placed to identify and respond to gaps in services, and to harness opportunities to enable health coverage for their citizens. If given the tools to do so, local municipalities can implement actions to improve health coverage by leveraging and redistributing existing resources. However, national-level action is still needed to address local health governance challenges around regulation, accreditation, and the accountability of a system.

Shoma wants to link local governments to the community health facility in an effective, sustainable, and feasible way to guarantee at least a certain quality of care. To ensure equitable and quality services to all citizens, especially to the poor, it is vital that both national and local decision-makers anticipate and plan for healthcare needs.

“Our health centres are under the national government” she explains, “and they have a policy responsibility to support local initiatives”.

During the course, a study visit to Molenlanden in the Netherlands was inspiring for Shoma. Particularly, learning that policy advisors in Molenlanden are visiting community members and maintaining a dialogue to better come up with solutions for better service delivery.

“I asked a lot of questions because I think this can be replicated in Bangladesh. If you talk to people directly, you will learn that they don’t necessarily need a big hospital in their community. They just need clear and easy access to services, and this can be ensured in different ways, for instance with comprehensive primary health care”.

Shoma finally shared one further impression of the course, namely that it was an enriching experience to exchange with participants from around the world. One example stood out to her:

“Two participants from Liberia and Cairo referred to the key role that they, as researchers who also do outreach work in their communities, are contributing to the localisation of all SDGs [Sustainable Development Goals]. I think it is important to bring this back home and involve actors from the academia”.

Back Home Action Plan

Shoma returned to Bangladesh with an action plan with three components. First, to focus on health, designing a proposal to ensure a link between local governments and primary health facilities at the community level. This will engage municipal-level decision-makers in mapping activities and conducting analysis to plan more responsive and efficient healthcare. Second, to provide capacity strengthening within her organisation, so that they can later on work on capacity strengthening of local authorities to plan and manage healthcare provisions.

Finally, as Shoma shares:

“The third component relates to linking the work of my organisation to the SDGs. We are working on too many projects, all strongly related to different global goals. We can make this link and this will allow us to better measure progress without major additional funding”.

Now and into the future

After the training in The Hague, Shoma delivered training to her team in different segments, covering the different topics of the course. “I also just completed an exercise in which we linked the SDGs to our strategic objectives!”

In the years to come, Shoma dreams of communities where they have the means to help everyone in it, and no one is left behind.

“Regarding my long-term plan, we are still far from a success, but I believe that it’s a good start to think and plan for a big shift where the local government structure of my country will be stronger, skilled and accountable to ensure inclusive service delivery”.

Join the Inclusive Service Delivery & the SDGs course!

Are you interested to learn how different levels of government can cooperate to effectively realise inclusive public service delivery? Make sure to join the Inclusive Service Delivery & the SDGs course.



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