Since 1998, community clinics1 have been a vital part of the primary healthcare system, fostering trust and pride within communities by making healthcare accessible. The early groundwork (1978) laid for this initiative continues to shape its ongoing success. At present, there are 14,467 community clinics across the country, managed by the Community Clinic Health Support Trust. While these clinics have made significant strides, challenges in management and staffing highlight the need for improvements to better serve the communities.
Community Health Care Providers2 (CHCPs), who are trained for three months and hold at least a higher secondary education (Grade-12), are the primary service providers at these clinics. As of now, there are 13,923 CHCPs across the nation. Although health assistants and family welfare assistants were initially expected to offer services three days a week, this model has not been very effective, leading to CHCPs taking on the primary responsibility for service delivery.
Many of the essential tools in these clinics are no longer functioning, and the reduction of the available medicines from 31 to 22 types reflects a pressing need for resource enhancement to restore the quality of services.
Originally, community clinics aimed to provide a combination of promotive, preventive, and limited curative services through health education. However, they have now primarily become centers for curative services due to the limited effectiveness of their original focus on promotive activities. The lack of institutional training in diagnosis for CHCPs and the insufficient diagnostic equipment have led to these clinics primarily functioning as medicine distribution points. Consequently, the public visits these clinics mainly to collect medicines, rather than for comprehensive healthcare, despite the availability of services like family planning, MNCH, IMCI, NCDC, NNS, IYCF, Vitamin A Plus campaigns, SRHR, TB control programs, and screenings for cervical and breast cancer.
A SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis reveals several strengths. The rural locations of community clinics make them easily accessible, and their management by local government ensures community participation and accountability. The provision of free medicines is a significant advantage, and there is an effort to integrate health and family welfare services at the grassroots level. Additionally, the establishment of a trust, rather than direct government management, strengthens the system’s foundation.
Despite these strengths, weaknesses are also apparent. Rather than serving as centers for promotive and preventive care, the clinics have become primarily curative service centers. The term ‘clinic’ has created conceptual limitations for primary healthcare services. Instead of hiring medical assistants, nurses, or midwives, CHCPs, who only have general education are tasked with providing promotive, preventive, and curative services, as well as performing the role of a pharmacist. This issue is compounded by poor infrastructure, limited space, and the clinics’ locations in remote areas.
Nevertheless, community clinics present crucial opportunities for healthcare reform. The Health Reform Commission’s report advocates for the establishment of integrated primary health centers to deliver health, nutrition, and family welfare services in each union3, with community clinics serving as sub-centers. This initiative has enabled rural areas to be incorporated into a unified healthcare system, which aims to consolidate two existing types of health centers at the union level into a comprehensive primary healthcare center.
However, several challenges arise in this process. For example, if a medical assistant is hired alongside a CHCP, complications may occur in terms of responsibility allocation. It is likely that the medical assistant will be made the clinic in-charge, which may be difficult for CHCPs to accept, especially when they lose control over the distribution of medicines. Additionally, this could lead to a diminished focus on promotive and preventive care.
Any changes to community clinics must be implemented cautiously to ensure the structural integrity of the system. Furthermore, many clinics lack sufficient space, which could hinder the implementation of large-scale personnel changes.
Based on this analysis, improvements to community clinics are essential. First, there should be a clear focus on the services to be delivered at these clinics. In addition to curative services, there must be a stronger emphasis on promotive and preventive care. To reflect this shift, the name of the community clinic could be changed to “Community Health Center” or “Rural Health Center.”
For the effective expansion of promotive and preventive services, a framework should be developed to include separate personnel, such as family welfare assistants and health assistants, while maintaining CHCPs in leadership positions to ensure a balanced staffing structure.
To incorporate family welfare assistants and health assistants effectively, the Health Reform Commission’s recommended integrated primary healthcare program should be implemented at the union level. This will require restructuring and training personnel from existing health centers and field workers.
If the integrated primary healthcare program at the union level is not feasible, then two health workers should be recruited for each community health center, which would cost the government approximately 500 crore Bangladeshi Taka ($40M USD) annually. Priority may be given to community paramedics, who undergo a two-year course under the Bangladesh Nursing and Midwifery Council4, with a focus on maternal and child health services and health awareness.
This team will conduct health education and awareness activities in local educational institutions and community-based programs. They will also do regular home visits to identify pregnant women, provide antenatal care, and identify children with malnutrition to encourage necessary service uptake.
To improve the delivery of curative services, a medical assistant should be recruited for each community health center. Additionally, the provision of point-of-care diagnostic services should be ensured.
If implementing the integrated primary care program at the union level is not possible, collaboration with telemedicine services, such as “Health Batayan5” and “Sukhi Family6,” through Memorandum of Understanding with the Community Clinic Support Trust, can provide prescription-based telemedicine services.
In this case, medical assistants will assist in conducting vital tests and supporting evidence-based prescriptions through telemedicine. Additionally, CHCPs will provide counseling and distribute medicines based on these prescriptions.
If none of these changes are possible, there is still an opportunity to improve service quality by integrating telemedicine services. In this scenario, the CHCP will assist patients in connecting with the appropriate telemedicine platform, and after receiving the doctor’s prescription, provide the necessary medicines. This would enable patients to access services from accredited healthcare providers while reducing the misuse of drugs.
In Bangladesh, where a significant portion of the population resides in remote rural areas and faces financial barriers to healthcare, ensuring the effective operation of community clinics is essential. Additionally, the government should prioritize expanding telemedicine and digital health services to improve healthcare accessibility.
Note:
1. Community Clinics= Primary healthcare centers in Bangladesh for rural villages.
2. Community Health Care Providers (CHCPs)= Main health workers in community clinics
3. Union= Smallest rural local government unit
4. Bangladesh Nursing and Midwifery Council= Official body for nursing and midwifery education in Bangladesh
5. Health Batayan= National tele health service of Bangladesh
6. Shukhi Family = A digital healthcare platform/telemedicine in Bangladesh