Upazila (sub-district) Health Complex: how healthy are these?

Health of a Nation depends, among others, on a well functioning health system. The health system in Bangladesh is a mix of public and private initiatives, including not-for-profit (NGO) health services and informal sector providers. The primary care in the public sector is organized around sub-district health centre (upazila health complex, UHC) with in-patient (31 beds) and basic laboratory facilities, supported by two or three union sub-centres (Union Health and Family Welfare Centre, UHFWC) at the lowest administrative level, and a network of community clinics and community health workers, CHWs. The UHC is staffed by eight to ten qualified allopathic practitioners and supporting staff, while the UHFWCs are staffed by paraprofessionals such as a medical assistant and a mid-wife (with three years training in therapeutics, and eighteen months training in delivery and MCH care respectively, both from public institutions). Unlike other countries, nurses are not trained or employed as public health clinicians for rural settings. While the UHC provides both inpatient and ambulatory care, the UHFWCs (curative and preventive) and the community clinics (preventive) provide only ambulatory care. Thus, the UHCs play a critical role in the organization and coordination of PHC services at the grassroots.

A comprehensive review of the resources of two UHCs (both hardware and software) was done in 2010 to study how these are managed to deliver healthcare services to the community. This descriptive cross sectional study was conducted in two UHCs located in the northern part of Bangladesh. Both quantitative and qualitative techniques were used for triangulation of collected data. Findings reveal that physical infrastructure was adequate in UHC1. An acute shortage of healthcare workers, especially doctors and nurses, was found in both UHCs. Doctor shortage was coupled with the culture of absenteeism and late attendance among half of the appointed doctors in UHC 1. Half of the cleaners and sweepers did not listen to the nurses and did not perform their regular duties. This led to non-qualified staffs such as pharmacist, medical assistant, ward boys and ayas to serve the patients.

Drug supplied to UHC 1 was not managed in a systematic way and discrepancies were observed between the availability of drugs in stock book and shelves in pharmacy. More than 65% of the instruments (both medical and non-medical) were available at the facility and more than 80% of those were functional. However, lack of maintenance was evident. Lack of coordination between the administrative staff and health care worker staff was evident, and overall management was poor by the administrative body.

While allocating resources to the UHCs, demographics, location, needs, disease profile of the area were not considered. Sustainability and feasibility criteria were not considered resulting in unnecessary wastage of existing resources, and delay in services. Lack of doctors and other associate staff also resulted in under or no utilization of facilities such as fully functional operation theatre, labour room and X-Ray machine. Funding for essential and necessary amenities such as fuel for generator was not available. Monitoring and supervision, both from local, district as well as central level, was nearly absent. Lack of coordination and communication between grass root level health workers (including the UHFPO) and the centre was strongly evident.

In short, poor and chaotic management and planning at the central level with regards to human resources, infrastructure sustainability and instruments supply (mismatched) was strongly evident through the lowest level of this system. This resulted in inefficient and under utilization of the facility, and poor health care delivery. From patients’ perspective, most of them came for ordinary health problems and was satisfied with the services (‘something is better than nothing’) while aware of the doctor shortage and other problems.

Need base resource allocation (both hardware and software) considering demographics, local disease profile coupled with strong and regular monitoring and supervision system from all level (local, district and central level) must be considered by the policy makers for improvement of responsive service delivery at UHC level. In addition, active and meaningful coordination and cooperation between the centre and UHC level need to be established for appropriate information exchange and effective (and efficient) policy and program development.

Source: A tale of an Upazila Health Complex in rural Bangladesh: Analysis of its resources, production and delivery of services. MPH Dissertation by Sharmin Sharif (Supervised by Syed Masud Ahmed, BRAC), School of Public Health, BRAC University