This paper presents the findings from a study that has been carried out on the basis of in-depth analysis of the information collected from survey, different literatures, secondary sources and participatory discussions with concerned stakeholders in partial fulfillment of the requirements for the Master of Population Sciences from the University of Dhaka. The study considers family planning services provided by Union Health Family Welfare Centers in order to acquire comprehensive insight of family planning program in rural Bangladesh. It is expected that this research will contribute to some extent in taking requisite measures in improving family welfare program with the intention of recuperate clinic-based service delivery mechanisms and assist in prioritizing population control programs for rural Bangladesh by the policymakers and other stakeholders.
Family Planning Program in Rural Bangladesh
Bangladesh has experienced a dramatic decline in fertility unprecedented for its poor social and economic conditions. The total fertility rate (TFR) declined from about 7 per cent in the 1970s to around 2.7 per cent in 2007. The Bangladesh Family Planning Program is recognized as a success story in the contemporary Third World. However, the country still has a high population growth rate and needs to reach replacement-level fertility as soon as possible. The national contraceptive prevalence rate (CPR) of about 54 per cent in 2007 should be raised to over 70 per cent to achieve replacement-level fertility.
The family planning programs could enhance the efficacy of their services by broadening the contraceptive options offered to people in the rural areas. Since individual contraceptive preferences, beliefs, and needs vary within populations, service programs should accommodate the widest possible range of method preferences among the potential contraceptive users. This does not necessarily mean that every family planning program should have to provide all methods, but the overall program efforts should be sufficient, so that the prospective users have reasonable, if not absolutely equal, access to a variety of methods.
Door-to-door service delivery has long been the centerpiece of Bangladesh’s family planning program. The rural Bangladeshi woman’s primary connection with health services has been through the family welfare assistant, a female community-based family planning worker, who visits married women of reproductive age in their homes to promote family planning and supply women with pills and condoms. As of 2005, the Bangladesh government employed some 24,000 of these personnel, while roughly 6,000-8,000 were employed by nongovernmental organizations (NGOs).
The lowest-level government clinic in rural Bangladesh is the family welfare center, which serves some 24,000 people, the average population of a union. The center is staffed by a male paramedic (known as a medical assistant), who provides basic health services, and a female paramedic (known as a family welfare visitor). These women, who provide family planning and maternal and child health services, typically have a high school education and 18 months of technical training. (Some family welfare centers also have a physician to provide general health services.)
The family welfare visitors are supposed to conduct ‘satellite clinics’ eight times monthly at various sites in each union, to give contraceptive injections, insert IUDs, and provide prenatal care. For the most part, however, the system does not encourage women to establish a relationship with a local clinic for reproductive and general health problems as well as for family planning. Instead, the program has relied heavily on the domiciliary services provided by the family welfare assistant.
Objectives of the Study
The general objective of the study is to suggest measures to improve family planning services by union health and family welfare center (UHFWC). However, the specific objectives of the study are as follows:
- to assess the quality of family planning and contraceptive services of UHFWC ;
- to assess their infrastructural ability in the functioning; and
- to suggest measures as how to improve their functioning and strengthen family planning program in rural Bangladesh
Rationale of the Study
Not only rural people of Bangladesh are skeptical by and large in effectiveness of family planning program at UP level in fulfilling the demands of the public, numerous research findings show that there is a lack of institutional support in the functions of the program. Experiences indicate that although there are around 4300 family welfare centre throughout the country, many of them do not functioning well or are not able to provide requisite services in practice. According to the Union Parishad Ordinance 2009, UPs, like parliament are authorised to form standing committee to oversee family planning services. Experience shows role of union parishads needed to strengthen for better healthcare service. Functioning of UHFWC would help to control population growth and overall health status of rural people by properly monitoring service delivery.
This study has been conducted to obtain an in-depth assessment of role of UHFWC, their effectiveness and make policy recommendations for effective functioning.
Information for this study were collected from both primary and as well as from secondary sources. Thus the sources of information were:
- Sample survey with the service recipients
- UP/upazila health and family welfare service providers
- Various studies on rural family planning program
Survey, discussions, observations and literature review had been exercised as the methods of collecting information regarding family planning services at UP level. The following strategies were taken:
Methods Used with Numbers
|Survey with family planning service recipients/clients|
|Discussions with FPI/FWV/FWA|
|Observation in-depth interview with clients|
Three unions, under Sudharam upazila of Noakhali district had been selected purposively; on the basis of accessibility and affordability, respective health and family welfare centers were assessed and clients/service recipients were surveyed. Data collection from the field was conducted during 2-9 June 2011. Four field assistants were recruited for collecting data and interview purpose. They were given day-long orientation on the overall objective of the study, field perspectives and data collection techniques. The selected unions are:
During the period, a total of 120 face-to-face interviews were conducted, 40 from each family welfare center, with the service recipients who came to receive family planning services during the reporting time. Interviewees were chosen from the waiting queue of the service centre on a first-come-first-serve basis.
The field assistants spent a full day observing interactions between clients and staff at UHFWC. They were asked to record the three centers’ opening and closing times, the presence of staff, the volume of clients and waiting times to see staff. They were also expected to describe the facility and services being provided with particular attention to privacy, general orderliness and cleanliness, and existence and condition of latrines for clients. Further, the observers recorded the interactions between clinic staff and clients, commenting on whether the staff treated clients in a respectful manner, whether they seemed to make clients feel at ease, whether they used language clients could understand, whether they responded to clients’ needs and concerns, whether they encouraged clients to return, and whether they behaved in ways that reinforced or minimized social distance.
Besides interviews with women clients and clinic observations, the study also draws on other sources of data- interviews with staff of the observed centers. However, as this intensive study was designed to provide insight into social processes and women’s subjective experiences in clinics, the data are not meant to be representative.
Limitations of the Study
The study has some limitations and these are as follows:
- The unions chosen for this study purposively, on the basis of accessibility, acceptability, affordability and availability.
- Personnel of union health and family welfare centers were busy with various activities. As such it took more time than estimated to get them for interview.
- Due to time constraints and budgetary limitations it was difficult to approach some of the selected UPs for survey.
- Problems were experienced to talk to the respondents, particularly with the women on family planning issues. Another problem that the study encountered was during working hours respondents were not always willing to provide time for interview.
- Frequent disruption of electricity and power cuts created problems for data compilation, analysis and report writing.
Evolution of Family Planning Program in Bangladesh
Family Planning at Pakistan Era
Bangladesh Family Planning Program evolved through a series of development phases that took place during the last 62 years. Family planning efforts in this country began in the early 1950s with voluntary efforts of a group of social and medical workers. Categorical FP program emerged during 1965-95 with the objective to control population growth as a strategy of economic development. The family planning program in Bangladesh has undergone a number of transitional phases. The phases may be illustrated as follows:
Phase I: 1953-59: voluntary and semi-government efforts
- Family Planning Association initiated family planning program in 1953 as a voluntary effort.
- The effort was limited to the small scale contraceptive distribution services in urban areas particularly through hospitals and clinics.
Phase ll: 1960-64: Government sponsored clinic-based family planning program
- In 1960 the government sponsored clinic-based family planning activities under health services started.
- The Government set up a target of providing family planning services to 6.7 per cent eligible couples and opened a family planning center in every hospital and Rural Dispensary.
Phase lll : 1965-70: Field-based government family planning program
- The family planning program was launched throughout the country as a priority program.
- A massive field oriented family planning program administered by a BOARD.
- Full time field staff and part-time village organizers known as dai (a female village mid-wife) were recruited and trained to provide motivation and service close to the door-steps of the rural people.
- Selected clinical and non-clinical methods offered.
Family Planning Program after Independence
Phase IV : 1972-74: Integrated health & family planning program
- Administrative process for decision-making was shifted from the autonomous Family Planning Board and the Council to the Ministry of Health and Family Planning.
- Family planning services functionally integrated with health services at the field level.
- Oral pill was introduced in the family planning program as a method of contraception.
- The provision of part-time village level dais was abolished.
Phase V : 1975-80: Maternal and Child Health (MCH)-based multi-sectoral program
- In August 1975, a separate Directorate of Family Planning and an independent Division of Population Control and Family Planning in the Ministry of Health were created.
- A National Population Council – the highest policy making body – was constituted with the President of the People’s Republic of Bangladesh as the chairman and development-concerned ministries as members.
- A Central Co-ordination Committee was also formed with the Minister for Health and Family Planning as chairman and secretaries of concerned ministries as members to coordinate implementation and review progress of multi-sectoral population activities under different ministries.
- In January 1976, the Government declared the rapid growth of population as the number-1 problem of the country.
- In June 1976, the Government approved a National Population Policy outline.
- Full-time male and female field functionaries were recruited on regular basis to cause a thrust of the MCH-FP program in rural Bangladesh.
Phase VI : 1980-85: Functionally integrated program
- Delivery of MCH-FP services were functionally integrated with Health at Upazila level and below.
- MCH-FP became also a function of health officials.
- The National Population Council (NPC) was reconstituted into a high powered National Council for Population Control (NCPC) headed by the President of the Council of Ministers.
- An Executive Committee headed by the Minister for Health and Population was formed.
- An unified command had been established at the top by the merger of the two divisions of Health and Population Control under one Secretary of the Ministry of Health and Population Control.
- Upazila Family Planning Committee had been formed to be chaired by the Chairman of Upazila Parishad for facilitating implementation of the program at the local level.
Phase VII: 1985-90: Intensive family planning program
- A broad-based multi-dimensional intensive MCH-based family planning program was launched.
- Improved family planning and MCH services were provided.
- Rapid FP- MCH infrastructural development by commissioning more service centers (Union Health and Family Welfare Centers- UHFWC) in rural areas was initiated.
- Unit-wise FWA registers were introduced for record keeping family planning and demographic events of households.
- Satellite clinic – an outreach activity – was introduced to deliver MCH-FP services in remote & rural areas.
- Involvement of community leaders and NGOs was increased.
- Branch of National Council for Population Control was setup in each district under the chairmanship of District coordinator.
- FP-MCH program as “Social Movement” was launched.
Phase VIII: 1990-95: Reduction of rapid growth of population through intensive service delivery and community participation
- Expansion of MCH-FP service delivery with enhanced quality of care.
- Increased resource allocation for program implementation.
- Promoting family planning as an integral part of development activities through inter-sectoral collaboration.
- Mobilizing community support and participation.
- Increased involvement of NGOs and private sectors for supplementing and complementing government efforts.
- Enhancing women’s status through education and participation in social, economic and political life.
Phase IX: 1998-2003: Health and Population Sector Program (HPSP)
- Health and Population Sector Program was introduced in 1998.
- However, the government upon review, decided in January 2003 to reestablish separate organizational structures and authority for health and family planning as they existed before July 1998.
Phase X: 2003-2011: Health, Nutrition and Population Sector Program (HNPSP)
To overcome the multidimensional problems and to meet the challenge according to the spirit of the International Conference on Population and Development (ICPD), the Government of Bangladesh launched the Health, Nutrition and Population Sector Program (HNPSP) in 2003. This aimed to reform the health and population sector. The program entails provision of a package of essential and quality health care services responsive to the needs of the people, especially those of children, women, elderly and the poor.
Within the HNPSP, the health and family planning structure is now functioning under separate management system. In the meantime, the FWA register and house visitation by the FWAs have been reintroduced in the program after 5 years. The MIS unit of the Family Planning Directorate has been functioning independently as before after 5 years and started publishing monthly reports on performance of RH, FP-MCH. The ultimate goal of the HNPSP is to achieve NRR-1 by the year 2011.
Family Planning Service Outlets
- Azimpur Maternity and ChildHealthTrainingCenter
- Mohammadpur Fertility Service and TrainingCenter
- Two model clinics attached to two medical college hospitals
- Family Welfare Visitors Training Institute (FWVTI)- 12
- NGO clinics- 05
- Population, Health and Nutritional Cell-Bangladesh Betar
- Population Cell-Bangladesh Television
- Model clinics attached to medical college hospitals- 06
- MCH-FP clinics at district hospitals- 64
- Mother and ChildWelfareCenters (MCWC)- 62
- RegionalTrainingCenter (RTC)- 20
- NGO clinics- 104
- MCH-FP units at Upazila Health Complex (UHC)- 407
- Mother and ChildWelfareCenters (MCWC)- 12
- NGO clinics- 68
- Union Health and FamilyWelfareCenters (UHFWC)- 3,500
- Rural Dispensaries (RD)- 1,275
- Mother and ChildWelfareCenters (MCWC)- 23
- Satellite Clinic (organized 30,000 per month)
- Domiciliary Services (CBD) 23,500 unit
An Overview of Healthcare Service in Rural Bangladesh
Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth. It has achieved a credible record of sustaining 90 per cent plus vaccine coverage in routine EPI along with NIDs (national immunizations days) since 1995. But some of this progress is uneven and there still exists inequalities between different groups and geographical regions. A major constraint identified towards reaching the MDGs and other national health goals is the issue of shortages in the health workforce and the uneven skill mix.
Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care. Primary Health Care (PHC) has been chosen by the government of Bangladesh as the strategy to achieve the goals of “health for all” which is now being implemented as revitalized primary healthcare.
The Public Sector
The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a healthcare hub. These units have both in-and-out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC units have a package service called ‘comprehensive emergency obstetric care services’ (EOC) available, with an expert gynecologist, an anesthetist and skilled support nurses on duty round-the-clock and basic laboratory facilities. At a lower tier, the Union Family Welfare Centre (UHFWC) are operational, constituted with two or three sub-centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants- SBAs), to provide skilled services within a household setting.
The number of health assistants is determined according to the size of the population. The health assistants and family welfare assistants are supervised by a Health Inspector (HI) and a Family Planning Inspector (FPI) respectively, posted at the union level. The UHC is staffed by ten qualified practitioners and supporting staff, while the UHFWCs are staffed by professionals such as a Medical Assistant (MA/SACMO) and mid-wife (Family Welfare Visitor), both trained in formal institutions. The UHFWCs provide out-patient care only. A union-level health and family welfare center provided the first contact between the people and the healthcare system and was the nucleus of primary healthcare delivery. As of Ministry of Health and Family Welfare (MoH&FW) website there are 407 upazila health complexes, 1,275 rural dispensaries (to be converted to union-level health and family welfare centers), and 3500 union-level health and family welfare centers.
Above the sub-district are the district hospitals (100-250 beds) and medical colleges (serving a group of districts with around 650 beds) providing secondary care, and national tertiary level care facilities. A common tendency is observed in terms of utilization- a stark imbalance in service utilization at public health facilities. There is low utilization of most facilities at the primary level (upazila and below) and over utilization of facilities at the secondary and tertiary levels.
The Private Sector
In the private sector, there are traditional healers (kabiraj, totka, and faith healers like pir/ fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training. All of these informal providers are deeply embedded in the local community and culture and are easily accessible, providing inexpensive services to the villagers with occasional deferred payment, and payment in kind being accepted instead of cash. To this is added an emerging cadre of semi-qualified community health workers/volunteers, who are formally trained by the NGOs (such as BRAC, Gonoshasthya Kendra etc); their numbers have been increasing since the 1990’s with the expansion of PHC infrastructure in the country.
Government Agencies Working at UP Level
The national government has always relied on different government departments which were created depending on the needs at different point of time for the discharge of service delivery functions. These agencies are part of the functional ministries of the central government present at different tiers of administration stretching down to local levels. Various services are delivered at the local level through these field level administrative structures. At UP level a total of 12 agencies of government are working. Some of the officials are directly form central government and some are deputed from Upazila level. Table 2 illustrated a list of government officials working at UP level.
Government Officials and Human Resources Working at UP Level
Salaries/Benefits and Accountability
|50% salary from the govt. and 50% from UP. Accountable to both UP chairman and UNO.|
|Accountable to officer-in-charge of concerned thana.|
|Agriculture Extension Directorate||Sub-Assistance Agriculture Extension Officer|
|Salary from directorate and accountable to Upazila Agriculture Officer.|
|Health Directorate||Health Assistant|
|Salary from directorate and accountable to Upazila Health Officer/Civil Surgeon.|
|Family Welfare Directorate||Family Welfare Assistant|
|Salary from directorate and accountable to Upazila Family Welfare Officer/Deputy Director- Family Welfare at district level.|
|Family Welfare Visitor|
|Salary from directorate and accountable to Upazila Family Welfare Officer/Deputy Director- Family Welfare at district level|
|Primary Education Directorate||Teachers of govt. primary schools|
|Salary from directorate and accountable to Upazila Assistant Education Officer.|
|Teachers of non-govt. primary schools|
|Not regular govt. staff. Accountable to Upazila Assistant Education Officer|
|Anser/VDP Directorate||Team leader and members of Anser/VDP|
|Irregular payment. Salary and uniform are given according to work. Provide training on and loan for IGA.|
|Fisheries Directorate||Field Assistant (one for a no. of UP)|
|Salary form directorate and accountable to Upazila Fisheries Officer.|
|Cooperate Directorate||Field Assistant (one for a no. of UP)|
|Salary form directorate and accountable to Upazila Cooperative Officer.|
|Livestock Directorate||Field Assistant (one for a no. of UP)|
|Salary form directorate and accountable to Upazila Livestock Officer.|
|BRDB||Field Assistant (one for a no. of UP)|
|Salary form BRDB office and accountable to concerned Upazila Office.|
|Public Health Engineering Directorate||Field Assistant (one for a no. of UP)|
|Salary form directorate and accountable to concerned Upazila Office.|
1 (at Upazila level)
|Salary form LGED and accountable to concerned Upazila Office.|
An Analysis of the Role of UHFWC in Family Planning Service Delivery
Capacity of the Surveyed UHFWCs
The study investigated the capacity of the three union health and family welfare centers during the fieldwork and through the interviews with concerned personnel. The capacity includes existing manpower, infrastructure facilities, and eligible couples under the jurisdiction of these UHFWCs etc. A brief account of stocktaking of these family welfare centers are illustrated below:
Like other union health and family welfare centers throughout the country, the surveyed UHFWCs provide basically two kinds of services: general medication and family welfare services. The family welfare services are of two kinds- family planning (method-based counseling and contraceptives distribution to the eligible couples) and mother and child health (pre, during and post natal care and child care). Office time-table of these clinics is supposed to be from 8:30am to 2:30pm. Nevertheless, all these clinics were not found to be open before 10am during the field inspections.
Some Facts Regarding UHFWCs Surveyed
|# of eligible couples|
|Average daily clients at the center for FP purpose|
|Satellite clinic per month|
|# of community clinic|
|Contraceptives for temporary methods received per day from the clinic (average)|
|Permanent contraceptive received per month (average)|
Source: Interview with FPIs and FWVs
Manpower of the Surveyed UHFWCs
Designation of the staff
|Sub Assistant Community Medical Officer (SACMO)|
|Family Welfare Visitor (FWV)|
|Family Planning Inspector (FPI)|
|Family Welfare Assistant (FWA)|
Source: Interview with FPIs and FWVs
A medical officer has been appointed at Chaprashirhat family welfare center recently but has hardly been found at his workplace once in a week.
Findings from Client Survey
Profile of the Clients Surveyed
The demographic characteristics of the respondents in the sample survey of the inhabitants of four UP were kept at a minimal level. It was confined only to the age-sex structure of the respondents and their family size and composition. These are briefly described below:
Age-sex Structure of the Respondents
As the study was on the family planning services, the respondents, naturally, were all female with an average age of about 25.8 years. The modal age group for the male respondents was 20-22, the age generally considered to be the average age of the prospective reproductive age of women in the context of Bangladesh.
Age of the Respondent
Name of surveyed union
Family Composition of Surveyed Respondents
The average family size of the surveyed respondents was 4.05. This was remarkably low compared to the average family size in Bangladesh (4.9 persons per family; Population Census 2001). This is remarkable considering that Noakhali is generally regarded as a conservative area, resistant to family planning. It is also to note that the average family size and structure is not varied that much in all the four socio-economic categories.
Household size by Union Surveyed
Name of surveyed union
Household size by Respondent’s Economic Status
|Household economic status|
|Lower middle class|
Literacy and education seems to be fairly low (see Figure 1) among the respondents surveyed. The informally educated (e.g. can write name only) constituted the majority group (30.8 per cent), followed by SSC holders (20.8 per cent). The illiterates were around 21 per cent.
Subjective Social Status
The respondents were divided into four broad socio-economic categories based primarily on their own perception of their socio-economic status, moderated by the interviewers own observations on their appearances and living standard. The distribution of the 120 respondent surveyed, by their socio-economic status are shown in Table 8.
Respondent’s Economic Status
|Household economic status|
|Lower middle class|
Provision of Services: Perception and Satisfaction
The women surveyed were asked a few questions on physical conditions of the union health family welfare centers, attitude of the staff and on the overall quality of services. They expressed their opinion on these issues.
Majority of the respondents (84.2 per cent) answered that they came to the clinic exclusively with the complexity and needs for family planning. The rest came for both family planning and general medication purpose. Approximately three-fourth (70.8 per cent) of the women surveyed visit the clinic as and when required (Table 9). Differences among the socio-economic as well as educational categories do not exist in respect of the extent of visit.
How Frequently You Visit This Centre by Union
Name of the Union
Once in a month
Twice a month
More than twice a month
As and when needed
Note: Figures in the parenthesis indicate numbers
On an average, the women had to wait 26 minutes to consult with FWV/FWA. In Neazpur union the time for waiting went to more than half an hour. Well, more that nine-tenth (92.5 per cent) opined that the place (the waiting room or surroundings of the clinic) is dirty. In Narottampur union, all respondent were unsatisfied with the environment of the UHFWC.
Usually How Long You Have to Wait to Talk with FWV/FWA
Name of the union
The extent of satisfaction of the clients surveyed with the behavior of the staff has been in Table 11 measured in terms of percentage. It is seen that two-fifth of the respondent were dissatisfied with the treatment of the clinics’ staff and around one-third were neither satisfied nor dissatisfied. There did not seem to be a great deal of variation among the socio-economic as well as the educational categories in respect of their approval rating for services, although there were occasional deviations.
Level of Satisfaction with Behavior of the Staff
Name of the Union
Neither satisfied nor dissatisfied
Note: Figures in the parenthesis indicate numbers
Opinion of Clients Regarding Attitude of the Staff Towards Them
Name of the Union
Note: Figures in the parenthesis indicate numbers
46.7 per cent of the respondents found staff attitude was negative while consulting with them (Table 12). However, 72.5 per cent of the women complained that the FWV/FWA did not listen to their problem with requisite attention. Two-third (66.7 per cent) expressed that the staff never, usually, maintain their privacy while another around one-fourth (23.3 per cent) said they occasionally maintain it.
Interestingly, 64.2 per cent of the respondents asserted that the FWA do not visit door-to-door. However, the observations along with records kept in the respective family welfare centers hardly support with the opinion of the surveyed women. The FPIs and FWVs, during in-depth interview, said they visit every eligible couple under their jurisdiction at least once in every month.
Findings from Observation
Apart from face-to-face interview with the clients of the surveyed union family welfare centers, the researcher and field investigators observed closely to the women came for getting family planning medication. The researcher talked informally to them and recoded the interactions. Following are the synopsis of the observation made by the researcher and field investigators:
Client-Service Provider Relationship
The experiences of women observed ranged from very positive to very negative. In some instances, the family welfare visitors appeared to make an effort to establish a friendly relationship with their clients. They spoke gently, showed concern, encouraged clients to return to the clinic and assured them that the centre would help if they had any problems with their family planning method. A woman from Neazpur union described her visit to the family welfare center as follows:
‘I sat down in a chair inside Apa’s office, and she asked me my name, many things about myself- how many children I had, how old my youngest child was, etc. She asked me whether I talked to my husband about method. I assured her that it won’t be any problems. Then she said, ‘No, there shouldn’t be any major problems. She told me that if I had any serious problems in the meantime, I should come and see her again. Apa behaved nicely with me. There were no difficulties. She examined my eyes. She used an instrument to measure my blood pressure. I didn’t suffer any discomfort.’
Two others who had visited the clinic gave similar descriptions- i.e., they received the method they wanted after being screened for contraindications and were treated respectfully and kindly. The fact that women repeated what the family welfare visitor had told them about possible side effects suggests that she is a skilled communicator.
The interviews and observations show that, however, at least some clients were treated harshly by staff. Interactions took on the hierarchical character that is very common in rural areas of Bangladesh, where communication often reflects relationships of social and political patronage. In poor households, access to land, employment and a variety of other benefits (including many government services) is mediated by more powerful households, and the poor, in turn, must provide a variety of services and display social deference.
In such observed hierarchical interactions, providers seemed to assume that clients had nothing useful to say, and they elicited very little information about the women’s problems or histories. When a diagnosis was made, providers simply gave clients pills or a prescription, without telling them their problem. The clients behaved subserviently and did not ask questions. They clearly knew very little about the clinics they attended, such as their hours of operation, qualifications of the staff, what services they were equipped to provide and whether there was a system for determining the sequence in which clients would be seen.
In all centers observed, women were seen pleading for services. In Chaprashirhat UHFWC, the researcher arrived just before the clinic’s opening time- 8:30am. The guard opened the door and let her sit down on a bench, where he was joined by a growing number of clients; according to the women who were waiting, the paramedic was habitually late.
When the FWV finally arrived, at around 11am, many clients pushed their way into the consulting room, begging to be seen. She scolded them for crowding around, and some left the room, but she made little effort to establish any system. Over the next two hours, clients continued to enter the consulting room haphazardly, often several at a time. In some cases, the family welfare visitor told the ayah, her helper, to dispense a small amount of medicine or some iron tablets, and then quickly dismissed these women without speaking to them directly.
Other clients were separated out and told to wait. A few women who had come for contraceptive injections or prenatal check-ups seemed anxious. The FWV spoke gently with them, asking questions to make them feel more at ease. In other cases, however, she was rude, and scolded her clients. She told a woman who had come because of contraceptive side effects, ‘When I gave you the pills I told you that you might feel dizzy. Now why are you coming here and complaining, disturbing my work?’
Many women were still waiting when she suddenly shouted: ‘I’m closing now! My time is 1pm. We have other things to do!’ For the next hour, these women pleaded with the family welfare staff, who continued scolding them and saying she was closing. Eventually, however, she saw them all.
In Narottampur UHFWC, the paramedic arrived at 11:35am, sat down and was surrounded by clients, who all started to tell her their problems at the same time. She interrupted, saying rather loudly, ‘You must stop this! Can’t you see that there are outsiders present here?’ A few women with small crying children were seen first because they were creating such a disturbance.
A woman who had been standing nearby said, ‘Apa, please examine me.’ She replied, ‘What is wrong with you?’ The woman said, ‘Apa, I am taking the pill. My body is weak. I have no strength and my head spins.’ She said, ‘You should stop the pill and use an IUD!’ The client said fearfully, ‘No, no, I will not use an IUD!’ The FWV then ordered the ayah, ‘Give her some vitamin pills.’ The ayah gave the woman seven or eight tablets in a small plastic bag, and the paramedic said, ‘Take the medicine and hurry up and go! Don’t crowd me!’
Later, she refused to examine a woman who wanted to know whether she was pregnant, saying, ‘No, I will not see any more people now. I have washed my hands. I will not see anyone else!’ It appears that hand washing was done after, not before, patients were examined. She later relented, however, and told the woman she would examine her.
Confidence on Service Providers
The researcher interviewed all of the family welfare visitors in all centers, and they all seemed to know the basic principles of client counseling. However, the contrasts between the family welfare visitors’ descriptions of how they treated clients, and our direct observations and interviews with clients, indicate that interpersonal skills, including common courtesy, are applied selectively.
The clients themselves were less critical about their treatment: Nearly half of the observed women who commented on their visit indicated that their overall experience was good, saying in most cases that the family welfare visitors at the centers were skilled in their work, that they had helped them and that they were glad they had gone to the centers. The ratings of the other half of the observed women were divided more or less equally between mixed and negative, and among them, only a few said they would not go back to the centers. Most expressed a willingness to overlook rude behavior and various discomforts, as long as the outcome of the visit was positive. For example, a woman who had reported being too intimidated to ask questions because the FWV seemed so irritable said: ‘I was not very satisfied with the treatment that they provided. But if I don’t use some kind of contraceptive, I will have a baby. We are poor people. How would we feed another child, arrange for its marriage? I am very fortunate to be able to get the family planning injections.’
In general, the clients interviewed in this study were not very critical of the condition of the centers, nor of the quality of the services they received, and they assumed the family welfare visitors and assistants were technically competent. They appreciated even the smallest gestures of concern and courtesy, and criticized staff only when their behavior was unusually rude. It is learned of few cases in which female clients challenged a paramedic or openly protested rude treatment: One woman noted that another client had argued with a paramedic over medicine, and one woman refused an examination out of embarrassment.
Cleanliness of the Centers
In the direct observations, it is found all of the centers to be unacceptably dirty. The clients, however, simply did not notice the lack of hygiene and commented negatively.
In most of the centers that were observed, there was visual privacy in the examining room, but the consultations could usually be overheard, and often other patients would crowd into the family welfare visitor’s room. No one complained about this, although one woman said that she used to feel embarrassed but now was used to it. None of the women reported being alarmed when family welfare visitor failed to wash their hands before performing examinations, or when they used the same pair of gloves for pelvic exams or IUD insertions on several clients. These clients probably believed that sterile gloves are intended only to protect the paramedic.
Unless specifically asked, no one mentioned that the latrine was filthy or that it was kept clean but locked and designated for staff and IUD clients only. Although some women reported rudeness, and a few were intimidated by the providers’ harshness and hesitated to ask them questions, clients usually felt that the providers were skilled and said they would return to the clinic.
Another woman waited almost two hours in a hot, uncomfortable room with no fan. The clinic was dirty and littered with trash. She was thirsty, but the tap was broken. The ayah was unfriendly, and the paramedic belittled her and told her to stop coming around begging for medicine. Yet she explained: ‘Even though they behaved badly, I have to be content. We are lucky if we can get the free medicine that they give out at the clinic. If I have another problem, I will go to the centers again, because they don’t charge a fee and you can get free medicine. We are poor people; how are we going to get better treatment than this?’
The issues that emerge from the research have more to do with relations between clients and providers, accountability and broad institutional policies than with technical skills, standards and protocols. Three themes surfaced repeatedly:
- Poor communications were evident in many of the encounters between service providers and clients. Certainly, one cannot assume that less- hierarchical communication would occur automatically: Patterns of interaction are not easily altered when underlying social inequalities remain unchanged. Nonetheless, behavior is not immutable.
- The issue of entitlement to medication often sparked bad feeling and suspicion among clients, who believed that staff were withholding and illegally selling drugs. On their part, the clinic staff seemed to see clients as constantly pestering them for medicine to which the women were not entitled.
- Rural women often do not receive the medicine they believe they need, for a combination of reasons. In some cases, the medicine they request may be inappropriate for the problem. In others, family welfare centers may have run out of specific medications and nutritional supplements because of genuine shortages in the government health system or inadequate logistics. In any case, service providers appear to respond to drug shortages with informal rationing, which creates tension between providers and clients. Even when drugs are not being sold illegally outside the clinic system, shortages may create the suspicion that they are.
- The contrast between how family welfare assistants responded in their interviews and how they acted when they were observed suggests that rudeness to clients is more than a reflection of ignorance, and that interpersonal skills and common courtesy are sometimes used quite selectively. Most of the family welfare visitors observed seemed to know how to treat clients well, implying that domineering behavior, while normal, need not be inevitable. Although they had been taught that establishing communication and even being courteous was part of the job, institutional policies and incentive systems seem to convey the message that only certain types of clients deserve decent treatment.
Conclusions and Recommendations
In Bangladesh the major service delivery functions have been historically remained out of the purview of close monitoring and evaluation system. The line agencies of the national government are entrusted with the responsibilities of providing services throughout the country. The local level public officials are responsible and accountable for their actions and inactions only to their immediate higher line management. Over the years, the quality of service delivery is declining, resulting widespread dissatisfaction of the beneficiaries. Lack of close and effective supervision and monitoring has been identified as the most important reason for such state of affairs. Though the union parishads have an obligation to oversee and monitor the functions of union health and family welfare centers, in most cases the parishads are either not aware of their duties, or they are doing their jobs on paper only.
Information from both primary and secondary sources has been used in this study. For primary sources, service recipients, all are women, of the centers were interviewed. The findings of the present study will provide a sense to the relevant stakeholders about the increase the quality of services of UHFWC.
It has also been revealed form the study that efforts to improve the quality of care in family planning programs have tended to concentrate on method-specific quality improvement efforts. The voices and views of clients are considered indispensable in efforts to improve the quality of care in family planning and reproductive health programs. To hear women’s voices, one must ask questions in ways that encourage them to speak; furthermore, to understand what women are saying, non-articulated aspects of their lives often have to be taken into account as well. The overall assessments of care in this study raise several points about what hearing women’s voices means in the context of research on quality of care.
According to the most frequent comments and complaints of the women with whom the researcher spoke, improvements in quality of care would almost certainly include better, and free, access to effective medicines. This suggests that women’s needs would be more effectively met if family planning services were better integrated into health services.
Providing information and education is needed so that rural people understand basic reproductive health, know their rights and what to expect, and make informed decisions in utilizing health services. People who are better informed about public-sector health and family planning services would also be in a better position to demand that service providers become more accountable to their clients.
According to a World Bank report published in 2009, 40 per cent of doctors at rural healthcare centers are regularly absent. Reasons for their absenteeism include the poor pay and standard of living in villages, as opposed to that earned from their private practices. The insufficient supply of medicine, obsolete equipment and inadequate facilities in rural hospitals are also barriers to proper medical treatment within an infrastructure which was originally one of the best in the region.
The below-standard or simply unavailable healthcare in villages has forced many patients- 80 per cent of the population, according to a report by a civil society network which monitors the healthcare situation in the country- to turn to non-state health care providers. The greatest necessity, however, is that for a self-propelled, constantly supervised system of rural healthcare with a strong monitoring mechanism which will hold accountable doctors and staff for the number of patients examined and treated, cured and referred and the nature of treatment administered at these health centers. The study, however, on the basis of findings the following recommendations are put forward for consideration of the government, relevant authorities and all stakeholders.
- To improve the quality of care offered in clinics, a way needs to be found to shift the emphasis away from simply distributing medicine and vitamins, and toward examining, diagnosing and counseling clients. Accountability mechanisms are needed to inhibit the punctuality of staff, regularizing office time-table, and illegal sale of drugs in public-sector health facilities and to dispel the popular perception that this is taking place.
- Communication between service and clients is a great problem. Giving the family welfare assistants greater roles and status in union family welfare centers could be one of several strategies for making client-provider interactions more constructive and beneficial for clients.
- As a matter of fact FWAs are the lifeline of the family planning program in Bangladesh- they are the main actors. Apart form FWA, the acute shortage of doctors, nurses and technicians in rural health centers has forced many patients to resort to traditional healers or, for those able to afford it, to seek medical care in the cities, overburdening the city’s already crowded hospitals. Immediate recruitment in the vacant positions, especially at field level (family welfare assistant) would increase door-to-door visit which ultimately would boost-up family planning program in a great extent.
- Many NGOs in Bangladesh are involved in organizing and mobilizing the poor, and especially women, in poverty-alleviation and health-promotion programs. At present relatively few are serving healthcare. In the future, donors might provide funding to encourage and assist NGOs to successfully pressure the health system, by developing health education and advocacy skills among the rural poor.
- Being a service delivery institution under its jurisdiction, UP should play a supervisory and monitoring role in order to improve quality of service of family welfare centers. In this connection, union standing committee on family planning should be activated (which are found to be non-functional in four unions surveyed during the field survey of this study) and be given supervisory role. This will also prepare the ground for active involvement of all concerned in the process.
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Annexe I: Questionnaire for Recipients
Assessing Services of Union Health and Family Welfare Center