Name- Yeamin Saik Bishor

Id- 2311565630
Semester- Third
Course- Pbh101
Section- 03
Faculty- MSHn
Group- 02
Topic- “Primary Healthcare”
What is Primary Healthcare?

Primary healthcare is a core idea in the medical sector that emphasizes giving people and
communities easily accessible, all-encompassing, and community-based treatment. It plays a
vital role in improving general health and well-being and acts as the initial point of contact for
those seeking healthcare services.
Primary healthcare is defined by the World Health Organization (WHO) as essential healthcare
that is provided to all members of the community at a cost that the community and nation can
afford, based on methods and technology that are practical, scientifically sound, and socially
acceptable. Individuals and families must fully participate in the process. The essential concepts
of affordability, community participation, and accessibility are emphasized in this definition.
The Alma-Ata Declaration of 1978, a landmark international conference that highlighted the
importance of primary care as a means of achieving the goal of "Health for All", has given rise to
the concept of primary care. Primary health care is not just about treating disease, but also a
holistic approach addressing broader determinants of health such as social, economic and
environmental factors.
Key factors are:
Accessibility: irrespective of socioeconomic status or geographical location, primary health care
should be easily accessible to all individuals. It involves providing services that are
geographically close to the community and can be made available at convenient times.
Comprehensive care: Primary healthcare is intended to provide a wide range of services,
addressing both preventive and curative aspects of health. This includes vaccination, family
planning, maternal and child health services, chronic disease management and health education.
Community Involvement: Engaging communities in their healthcare is a cornerstone of primary
healthcare. The Commission recognizes the importance of including individuals in decisions on
their health, promoting community participation and providing tailored care to meet local needs.
Coordination and continuity: primary care supports coordination between different levels of
healthcare services to ensure a seamless transition from primary, secondary or tertiary care
settings. This coordination facilitates continuity of care and increases the efficiency of healthcare
delivery.
Affordability: Primary health care seeks to provide cost effective services at affordable prices
for individuals and the community. It means the implementation of strategies to reduce financing
obstacles and improve healthcare's ability to be economically accessible.
Bangladesh’s Healthcare System
One of the biggest problems facing Bangladesh's healthcare systems is the delivery of healthcare.
The primary obstacles to health care delivery in Bangladesh are described in this study using real
facts, including absenteeism, corruption, a lack of physicians and nurses, inefficiency, and
mismanagement. This paper comes to the conclusion that effective health care delivery depends
on good governance, which includes monitoring and training, allowing more non-governmental
involvement, and attending to the needs of informal healthcare service providers. It also
concludes that low returns on health investments occur when governance issues are ignored.
Improving the population's health, protecting against financial risks associated with health, and
increasing the health sector's responsiveness to patient demands all depend on an efficient health
system. According to the Global Fund (2011), a health system is made up of all the institutions,
individuals, and behaviors whose main goal is to promote, restore, or sustain health. Thus, for
disease control strategies to be successfully scaled up, health systems strengthening (HSS) is
essential (Coker et al. 2004; Barker et al. 2007; George Shakarishvil etal, 2012). Further research
(Travis et al. 2004; George Shakarishvil et al., 2012) indicates that one of the primary obstacles
to achieving the Health Millennium Development Goals (MDGs) is the existence of poor health
systems. As a result, health system reform, or HSR, is crucial to improving the effectiveness of
all health systems. HSR is a continuous process of fundamental change in institutional
arrangements, management, financing, policy, regulation, and the delivery of health services. It is
spearheaded by the government and aims to enhance the population's overall health by
improving the health system's performance (Federal Ministry of Health, 2004). Health care
systems contribute significantly to global empowerment and account for 9% of global output,
making health systems not simply a development problem but also a health-related one. States
within a nation as well as other nations and regions have varied approaches to implementing
HSR. Differences in priorities, aims, and values are the source of this.

Successes of Bangladesh’s Health Sector

Despite having few resources, Bangladesh has made notable progress in the health sector, setting
an example for other developing nations. While newborn, mother, and fertility rates have
decreased dramatically over the past few decades, important health indices like life expectancy
and immunization coverage have risen noticeably (Ferdous Arfin Osman,2008). Bangladesh is
notable for having made significant advancements in the field of healthcare. The government
strongly emphasized the significance of childhood immunization as a crucial tool for lowering
children mortality even before modern global health programs emerged. Due to its impressive
advancements over the past 20 years, Bangladesh's Expanded Programme on Immunization
(EPI) is regarded as a success story in the country's health system. It offers nearly universal
access to vaccination programmes based on the proportion of infants aged less than 1 year who
are vaccinated with BCG preventive TB vaccine. That's 2% from 1985 to 2009; it was 99 % by
2009. As well-brac, 2009, further improvements have been made in the coverage of other
vaccines. However, the Health System continues to encounter problems such as inadequate
quality of care, high maternal mortality rates, limited access to services and poor child health
(Ferdous A. Osman, 2008).

Challenges of Bangladesh’s Health Sector

Healthcare is provided in Bangladesh through privately owned clinics or government-run
institutions. Bangladesh continues to fall behind in providing health care services to both the
wealthy and the impoverished. Our neighbors, India and Thailand, have made significant strides
in the last several years with regard to medical knowledge and experience, technological
advancements in healthcare, and the establishment of first-rate hospitals and health management
organizations. In order to do this in our nation, technological cooperation with hospitals that have
sophisticated medical technology is required, as is emulation of health management
organizations in established Asian and Western nations.

Significance of Primary Healthcare

In the field of health systems around the world, primary care has a major role to play in terms of
individual and collective health as well as overall human health. The importance of general
medical care is underlined by a number of key elements:
Preventing Focus: Primary healthcare places a strong emphasis on health promotion and
preventative interventions. Primary healthcare helps minimize the strain on the healthcare system
by addressing risk factors, promoting healthy lifestyles, and administering immunizations.
Accessibility and Affordability: Regardless of socioeconomic background, primary healthcare
is intended to be available to all community members. It guarantees that basic medical services
are accessible in the vicinity of a person's residence, encouraging early intervention and lowering
the need for more costly, specialist treatment.
Holistic Approach: Primary healthcare takes a holistic approach, taking into account the wider
determinants of health in addition to treating illnesses. This encompasses elements that affect a
person's well-being on a social, economic, and environmental level.
Early identification and treatment: Early health problem identification and treatment are made
easier by primary healthcare. Frequent examinations, screenings, and prompt action assist in
detecting health problems early on, when they are frequently easier to treat and less expensive.
Cost-Effectiveness: Primary healthcare helps to ensure cost-effective healthcare delivery by
treating health concerns at the primary level, where interventions are usually less resource-
intensive. This is especially important in environments with limited resources.
Reducing Health Disparities: Improving access to and the quality of healthcare is largely
dependent on primary healthcare. It helps close the disparity between various socioeconomic
groups by emphasizing equity and acting as the gateway to healthcare services.
Global Health Equity: Reaching the objective of global health equity requires primary
healthcare. It is consistent with the Alma-Ata Declaration's tenets, which promote "Health for
All" and healthcare systems that are able to accommodate a wide range of demographics.
Resilience and Pandemic Preparedness: A strong primary healthcare system makes a nation
more resilient to pandemics and medical catastrophes. As shown in instances of global health
emergencies, it offers a basis for community-based initiatives, fast response, and surveillance.

Current Status of Primary Healthcare in Bangladesh

Reforms in the Health Sector: The Health and Population Sector Strategy (HPSS), which was
launched in 1998, sought to combine family planning and health under the Ministry of Health
and Family Welfare (MOHFW). The ensuing Health, Nutrition, and Population Sector Program
(HNPSP), which ran from 2003 to 2010, aimed to improve healthcare results, lessen disparities,
and update the industry.
Health Facilities and Staff: Primary, secondary, tertiary, and super-specialized care facilities
make up Bangladesh's healthcare system. Union Health and Family Welfare Centers (UHFWC),
Upazila Health Complexes (UHCs), and Community Clinics (CCs) are examples of primary
health institutions. There are still issues, such the dearth of qualified medical professionals—
especially nurses—and the urban bias in their allocation.
Maternity and Child Health: Community clinics are being established, UHFWCs are being
updated, and health assistants and family welfare assistants are receiving training as part of the
initiatives to enhance maternity and child health. Immunizations, illness prevention, family
planning, and curative treatment are all included in maternal and child health services.
Healthcare Disparities and Challenges: There are notable geographical differences in the
distribution of healthcare providers, which indicates an urban bias. Although there has been
progress in lowering the under-five death rate and raising vaccination rates, there are still issues
with getting trained help during birthing, particularly in remote regions.
Birth Attendance and Maternal Mortality: Although it has decreased, maternal mortality is
still an issue. Only 18% of births are attended by trained medical professionals, suggesting a
need for more institutional deliveries and professional help during labor.
Disease Control: There have been encouraging developments in the fights against TB and
malaria. The nation is on pace to meet MDG objectives linked to TB and has seen a decline in
the incidence and fatality rates of malaria.
Issues and Prospects for the Future: Issues include inadequate dietary habits, the requirement
for more qualified medical staff, and low community understanding of the Millennium
Development Goals (MDGs). Achieving universal healthcare and meeting MDG objectives
depends on making improvements in these areas.
Primary Healthcare Landscape in Bangladesh
With 139 million inhabitants, 40% of whom live in poverty, Bangladesh is the most densely
inhabited country in the world (HIES 2005). The MOHFW is committed to reaching the
impoverished and vulnerable, especially women and children, as per the Bangladesh National
Strategy for Accelerated Poverty Reduction (NSAPR 2005), which takes into account the human
components of poverty (deprivation of health, education, nutrition, and gender disparities). The
1998 launch of the Health and Population Sector Strategy (HPSS) paved the way for the creation
of the swap and the Health and Population Sector Programme (HPSP), which included reforms
like better and more effective service delivery through the unification of the MOHFW's two
wings—health and family planning (FP). The goals of the present Health, Nutrition and
Population Sector Program (HNPSP), which runs from 2003 to 2010, are to modernize the GOB
health sector, achieve the health-related MDGs, and improve health outcomes and health
disparities while also improving treatment quality. The MDG (4, 5, and 6) objectives have been
attempted to be included in this publication, while somewhat different targets for HNPSP are
provided. The Health, Nutrition, and Population Sector Programme (HNPSP) 2003–2010
Revised Programme Implementation Plan (RPIP) divided the sector into four sub-sectors:
Ministry Level Sector Development, Population Programme (PP), Health Programme (HP), and
Nutrition Programme. This allowed for a proposed budget for the entire program. Under HP and
PP are the main components of reproductive health (RH). Primary healthcare (UHC, UHFWC,
USC & CCs), secondary healthcare (District Hospitals), tertiary healthcare (Medical College
Hospitals), and highly specialized care (specialized institutions) are the four main categories of
health facilities in Bangladesh. It was intended for HPSP to build 13,500 new community clinics,
with a capacity of 6000 people per facility. At the moment, 6708 CCs work as DGFP Family
Welfare Assistants (FWA) and DGHS Health Assistants (HA), while 7156 CCs are given to non-
governmental organizations (NGOs) (HEU 2007). In addition to providing family planning
services, maternity and child health care, including immunizations, communicable disease
management, symptomatic curative therapy for common ailments, and upward referrals, the HA
and FWA also conduct home visits and operate out of CCs (if operational) (HNPSP 2005). 3622
Union Health and Family Welfare Centers (UHFWC) are under DGFP at the union level, while
upgraded UHFWC (previously known as Union Sub-centres, USC) are under DGHS. UHFWC
employs one MLSS, one Pharmacist, one Aya, one Family Welfare Visitor (FWV), and one Sub-
Assistant Community Medical Officer (SACMO). There is a post of FWV exclusively in the
Unions, where no UHFWC has been built (HNPSP 2005). Regretfully, FWV training at
NIPORT-managed FWV Training Institutes has ceased since 1997. The program began in the
1970s. Since FWVs primarily assist rural women, it is anticipated that ending their training will
have a negative impact on maternity and child health in Bangladesh (BHW 2007). The positions
of a Medical Officer, Medical Assistant, and Pharmacist are held by each of the 1275 upgraded
UHFWCs (HNPSP 2005). At the Upazila level, there are 60 Rural Health Centers (RHCs) that
offer both inpatient and outpatient treatment, and 431 Upazila Health Complexes (UHCs) that
have 31–50 beds apiece. Nine medical professionals work in each of the UHCs, including a
dental surgeon, a nursing supervisor, senior staff nurses, two medical assistants, medical
technologists in radiology, dentistry, and pharmacy, an EPI technician, and other support
personnel. In addition, the UHCs have the positions of Senior FWV, Assistant Family Planning
Officer, Medical Officer (MCH), Upazila Family Planning Officer (UFPO), and two FWVs
(HNPSP 2005). 61 District Hospitals (DHs) make up the nation's third tier of healthcare
facilities. Comparing DHs to UHC, the latter have smaller facilities with an average bed size of
133 (ranging from 48 to 375). Additionally, the districts have Maternal and Child Welfare
Centers (MCWCs), which are housed in the district town and provide clinical contraception and
Comprehensive Emergency Obstetric Care (C-EmOC) under the direction of the DGFP. Medical
College Hospitals (MCHs) and Post Graduate Institutes and Hospitals comprise the fourth tier of
the public health system. In addition to one dental college, one homeopathic medical college and
hospital, and one ayurvedic degree college and hospital, there are fifteen government medical
college hospitals (MCHs) (HEU 2007). Approximately 1200 physicians are now produced
annually by these MCHs (BHW 2007). There are 21 specialized hospitals in Bangladesh that
treat conditions including leprosy, infectious disorders, chest infections, etc. One of the biggest
issues facing Bangladesh's health system is the lack of qualified medical staff, particularly
nurses, with just two and five doctors for every 10,000 people (BHW 2007). There are 7.7
qualified healthcare professionals for every 10,000 people in the nation, including physicians,
dentists, and nurses. There is a strong metropolitan bias in the distribution of skilled providers. In
metropolitan areas, there are 18.2 doctors, 5.8 nurses, and 0.8 dentists per 10,000 people; in rural
areas, the comparable numbers are 1.1, 0.8, and 0.08, respectively. Additionally, the figures
demonstrate that there are five times as many male physicians per 10,000 people as there are
female physicians per 10,000 people.

Health Centers and Community Clinics

Challenges
In rural Bangladesh, where 70% of population live, there was no provision of government-owned
static one stop comprehensive Primary Healthcare (PHC) Center at door steps of people.
Available government health services included only preventive healthcare by CHWs &
government-owned Union Health Center (a PHC center), one for roughly about 25,000
population. So, comprehensive PHC was not easily available & accessible. People generally
required to depend on nearby unqualified medicine shops or on quacks for treatment Children &
women did not have required & adequate care for their illnesses or pregnancies.
Towards a Solution
Community Clinic (CC) is the innovation of Bangladesh Government to extend Primary Health
Care to the doorsteps of rural people all over rural Bangladesh. Thousands of people are getting
services from the CCs and it has become an integral part of national health system. It is a unique
example of Public-Private Partnership (PPP) as all the CCs have been constructed on community
donated land while construction, medicine, service providers, logistics and all other inputs are
from Government (GoB) but management is both by community and GoB through Community
Group (CG). Community owns CC and plays active role for its improvement. People are
satisfied with the services of CC as it is a ‘one stop service outlet’ in respect of health, family
planning & nutrition. One Community clinic for every 6,000 population have been established in
the rural areas. At present 14,000 Community Clinics are on operation (Source: WHO) and the
number is increasing gradually. From 2009-2015, about 460.88 million visits were made to CCs
for services of which 9.071 million emergency and complicated cases were referred to higher
facilities for proper management. Among the service seekers of Community Clinics about 80%
are women and children. On average 9.5-10 million visits are in Community Clinics per month
and 38 visits per day per Clinics. For primary level, service time is 9am-3am. It is a one stop
service outlet for Health, Family Planning and Nutrition. It is a preventive-biased center as it
provides mainly health education and health promotional services. All the Community Clinics
are outreach sites for routine immunization and NID. In addition, it provides limited curative
care (treatment of minor ailments), screening of NCD-Hypertension, Diabetes, identifying
emergency and complicated cases with referral to higher facilities in urban health care. In a
substantial number of CCs, normal delivery is being conducted subjected to the availability of
skilled manpower, proactive CG, committed local health management and where from patients
can be referred within a short time or necessary support.
Community clinics are built on the land provided by the community people and all other
supports are provided by the Government. In collaboration with community people and
government this initiative is sustainable because as long as community people need service they
will provide the logistic support and so long as government face the demand from people they
will provide support from their side. This programme is easily replicable because the resources
and services are provided by government so according to the change in demand from community
people over time government can change the supply and programme module.

Government Policies and Initiatives

Bangladesh aims to provide the right to access quality healthcare without facing financial
hardship to all citizens to achieve Sustainable Development Goals (SDG) and Universal
Healthcare Coverage (UHC). As a part of its existing primary health care system, the government
of Bangladesh in 1998 started to establish Community Clinics (CC), one CC for roughly each
10,000 people in rural Bangladesh. By 2001, the physical infrastructure of 10,723 clinics was
constructed and approximately 8,000 community clinics were operational. The original project
was later thwarted following a regime change in 2001, which was later revived under the
Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB) project in 2009.
The Ministry of Health and Family Welfare (MoHFW)’s Community Based Health Care
Operational Plan (June 2011-2016) aimed to establish 13500 Community Clinics (CC) within
June 2016. Up to 30 September 2017, a total of 13 442 CCs were reported to be in operation.
According to the Finance Minister’s budget speech in June 2023, there are a total of 14,384
community clinics as of FY 2022-23, in current estimates of population, this amounts to one CC
for each 12000 people. However, according to the Facility Registry of MoHFW, a total of 14114
CCs were reported. Community Clinic turns the concept of public-private-partnership into reality
as all Community Clinics are constructed on lands donated by people of the community being
served; costs relating to construction, medicines, and all necessary logistics, salaries of service
providers are met from the government revenues and development funds but the management is
borne by the community people. Each Community Clinic is headed by a Community Healthcare
Provider (CHCP) who works 6 days a week; a Health Assistant (HA) and a Family Welfare
Assistant (FWA) who work alternatively 3 days a week. A Community Group (CG) that is
pivotal in the management of CC consisting of 13–17 members, headed by the elected Union
Parishad (UP) Member manages the CC. In the catchment area of each CC, there are three
Community Support Groups (CSGs) each comprising 13–17 members. Since inception,
community clinics have been playing an epoch-making role in improving the overall antenatal
and postnatal care, family planning and nutritional services, providing treatment for diarrhea,
pneumonia and other childhood infections and counseling on the consequences of early marriage
in Bangladesh. With the integration of ‘Community Clinic Health Assistance Trust Act, 2018’,
millions of people are getting services from the community clinics whereas just a decade ago
healthcare facilities in the rural areas were very poor. Community health centers offer low-cost
healthcare services such as dental, medical, and behavioral healthcare. Studies estimate that the
provision of care in community health centers ultimately saves the central health care system an
impressive amount of money annually by eliminating unnecessary emergency room visits and
other hospital-based care. There is no denying that community clinics are essential in Bangladesh
as they promote accessibility and affordability of healthcare services, particularly in rural areas.
They contribute to disease prevention, early intervention, and health education, ultimately
leading to improved health outcomes and a stronger healthcare system. According to a survey
conducted in 2016 by ICDDR,B the formation of Community Support Groups (CSGs) for
expectant mothers, receiving antenatal care increased to 84% after forming CSGs compared to
69.6% before forming them. The CSG based community support system can play a significant
role in improving healthcare if implemented at a large scale.

The National Health Policy-2011 stipulates the following issues for women’s health
1. To reduce maternal mortality and fertility rates by providing access to reproductive health for
the marginalized sections of the population.
2. To revitalize family planning and reproductive health care in order to attain replacement level
of fertility.
3. To ensure gender parity in health services and ensure women’s right to health care including
mental health service in their lifecycle.
4. To ensure necessary basic medical facilities to all strata of people as per Article 15(A) and
18(A) of the Constitution.
5. To undertake programmes for reducing the rates of child and maternal mortality within 2021
and reduce these rates to acceptable levels.
6. To adopt satisfactory measures for ensuring improved maternal and child health at the union
level and install facilities for safe and clean child delivery in each village
7.To strengthen and expedite the family planning programme with the objective of attaining the
target of Replacement Level of Fertility.
The National Population Policy-2012 stipulates the following goals for advancement of
women
1. To reduce child and maternal mortality rates and ensure safe motherhood for better child and
maternal health.
2. To ensure gender equity and women’s empowerment and reinforce measures against gender
discrimination in the family planning and programmes related to women and children.
3. To formulate gender sensitive work strategy in all government and nongovernment programs
and activities.
4.To prevent all sorts of violence against women and children as well as women and child
trafficking and sexual harassment against them.
5. To create equal opportunity for boys and girls in health care, nutrition, education and
employment.
Promises made in the National Women Development Policy, 2011:
1.To ensure rights to nutrition and to have physical and mental health of highest standard all
through the life cycle of women i.e. in the childhood, adolescence, during pregnancy and in old
age.
2. To strengthen primary health care for the women.
3. To reduce maternal and child death.
4. To conduct research to combat the fatal diseases of AIDs and health of women during their
pregnancy in particular and publicize health information and raise awareness.
4. To educate and train in nutrition;
5. To improve reproductive health of the women and ensure rights in women participation in
selecting family planning method;
6. To give particular importance to the need of women concerning safe drinking water and
sewerage system.
7. To ensure participation of women in all the aforesaid services planning, distribution and
preservation.
8. To ensure equal gender rights in making decisions as to family planning.
9. To increase facilities in work place particularly in case of breast feeding which will influence
infant’s development.
Promises spelt out in 7th Five Year Plan
1. Life cycle based disease prevention and curative healthcare services.
2. Equal access to nutrition;
3. Modern reproductive health and family planning services;
4. Women’s decision-making over reproductive health;
5. Safe water and sanitation services;
6. Freedom from violence; and
7. Ending child marriage.
Targets in 7th Five Year Plan to ensure Health and Nutrition services for women :
1. To reduce Total Fertility rate to 2.0;
2. To reduce Child mortality rate (under 5 years/1000 live birth) to 37;
3. To reduce Child mortality rate (in 1000 live birth) to 20;
4. To reduce maternal mortality rate (per 100,000 live birth) to 105;
5. To increase full vaccination coverage of 12 months children to 95%.
The following women aspects have been enshrined in the Gender Equity Strategy 2014
1. To ensure MOHFW policies, strategies, operational plans and other programmes adhere to the
principles of gender equity and effective practice in line with the GOB commitment to equality.
2. To ensure equitable access to and utilization of services by women, girls, boys and other
socially excluded people within a rights-based approach.
3. To ensure gender-sensitive human resources (service providers) in the health sector with
appropriate skills development for health service providers to deliver gender sensitive, non-
discriminatory services.
4. To ensure gender mainstreaming in all programmes with MOHFW and other ministries and
organization’s through equitable planning, policy making and budgeting.
5. To encourage fruitful dialogue between the deprived people and the civil society for planning,
implementation and review of services and gender equity strategy of the Ministry of Health and
Family Welfare.
6.To ensure well-coordinated work process to provide governance and leadership in health
system.
Conclusion
Bangladesh's healthcare industry has both triumphs and difficulties. Despite having few
resources, the nation has achieved great strides in areas like maternal and child health and
vaccination coverage. The execution of programs like as Community Clinics, a public-private
collaboration offering primary healthcare at community level, demonstrates creativity and
dedication to enhancing accessibility and cost, especially in remote regions.
Nonetheless, there are enduring problems, such as a lack of trained medical personnel,
particularly nurses, and an urban bias in the delivery of healthcare. Even though the government
has put laws and plans in place to deal with these problems—such as the Community Based
Health Care Operational Plan and the Health and Population Sector Strategy—achieving
universal healthcare and reaching the Millennium Development Goals will need consistent work.
It is imperative that primary healthcare be prioritized in accordance with the Alma-Ata
Declaration and global health equity goals. The Community Clinics serve as excellent examples
of the importance of primary healthcare in addressing larger determinants of health due to their
emphasis on preventative treatment, early intervention, and community participation. Going
forward, improving the general efficacy and resilience of Bangladesh's healthcare system would
require sustained investment, smart changes, and community involvement.

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