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Monday, 19 December 2011

Community Clinics: taking healthcare where the people are?


For every 6,000 population, a Community Clinic is envisaged to bring family planning, preventive, and limited curative services closer to the population (within 30 minutes walking distance), with improvement in quality of services delivered from a fixed point round the year. In all, 18,000 CCs will be established. The programme started in 1998, but was later abandoned. It was revitalized in 2009 with the coming of the new Awami League government. Out of total 18,000 clinics proposed, as of 2011, 10,000+CCs are functioning.

Each CC consists of two rooms with drinking water and lavatory facilities, and a covered waiting area. Funds for building the clinics were provided centrally, but communities had to donate land so that there was a feeling of ownership. To boost the latter, each community was required to set up a group to support and assist with the management of the CC, although the staff and supplies are provided by the government. Each clinic has two staff, one health assistant and one family
welfare assistant. A new cadre of Community Health Care Provider (CHCP) is being appointed for each CC in the revitalized CC project since 2009. S/he will be in-charge of the CC and the other staffs will help her/him to run the CC as per government guidelines. Staff from the CCs would continue to provide a limited range of outreach services, especially in the early period after opening, and is supervised by staff from higher levels in the system (e.g., Health inspectors and Family Planning inspectors from the Union level facilities). The clinics are visited monthly by the union level service providers (e.g., Family welfare visitors and Medical Assistants) to provide additional services. There is a training programme for CC staff and a specified allocation of equipment and a range of drugs necessary to deliver the ESP services.

The specific functions of CCs in brief are:
·       BCC: hygiene, diet, immunisation, intestinal, breast-feeding etc.
·       registration of pregnant women
·       informing pregnant women in advance to attend the clinic for FWV services and ensuring that pregnant women come for antenatal services.
·       maintaining the expected date of delivery information to provide assistance if danger signals appear.
·       referral to higher levels
·       providing FP methods: pills and condoms
·       EPI: informing families in advance about outreach clinics and ensuring that children are immunised at the correct times.
·       minor treatment: ORS, Vit. A, anti-helmintics, ARI, DOTS for TB, MDT for Leprosy, anti-malarials etc.

Recently, a quick exploration of the activities of the CCs were done to assess the progress of the revitalized project. In total, 69 CCs (distributed in 17 sub-districts) were included in this study. Key findings from the quick exploration are summarized below:
ü  Most of the lacked adequate physical infrastructure such as properly furnished, well ventilated and gender segregated visiting rooms for the patients; the provision of drinking water and toilets in the CCs were also not satisfactory; sometimes these were used for purposes other than healthcare delivery centre;
ü  Locations of some CCs were not convenient; either it was quite out-of-the way from the village or there was no accessible road;
ü  Shortage of scheduled staff was a problem in many of the CCs visited; there was also the problem of irregular attendance and absenteeism;
ü   There was also insufficient instruments for patient examination and care; the condition of the instruments were not good and maintenance was lacking;
ü  Most of the CCs did not follow the scheduled working hours i.e., six hours a day, six days a week;
ü  Participation of the community in the affairs of the CCs was poor; sometimes they were found to be ignorant about its location, opening and closing hours, services available and the purpose of such a poorly functioning establishment in the village;
ü  Formation of the Community and support groups was very slow; community and stakeholders were not sufficiently aware about its purpose and modalities. Involvement of Local Government Institution was minimal and non-committal. Meetings used to be held irregularly and documentation of the meetings was not properly done;
ü  Recent recruitment of the Community Health Care Provider (CHCP) was politicised; participation of women into the affairs of the CCs were grossly absent though the services are targeted mostly towards women.
Two years have passed since the revitalized project started working, but the community clinics are still at a very preliminary and disorganized state. The operational guidelines are not properly followed and the CCs lack infrastructure, staff and leadership to deliver the committed services to the community. Efforts to involve the community are poor as the community groups are yet to take the initiative to run the CCs based on felt need of the people.

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