More than Free Help

This paper describes not an easy success story. It describes the challenges met on the way to shift from charity-dependent services to discover sustainable health care provision in the context of Bangladesh. The challenges are partly the challenges of the health service and the country itself. Partly the challenges are posed by the approach. The questions are manifold. When and how can the services be handed over from a donor organisation to a community? What, if any, will be the role of the donor or initiator after the handing-over? When community groups initiate services, how can they be linked with government services? How to make sure people have equal access and fair chances to obtain the services? Who can control and manage the quality of services? What percentage of the cost is reasonable to recover from the users, and how much should come from other sources?

In order to increase sustainability and to reach otherwise un-reached populations German Red Cross (GRC) and Swiss Red Cross (SRC) and their implementing partners are interested in handing over management of the health services to local communities. This requires a high level of confidence and trust in the potential of the local communities as well as intensive investment in capacity building on two fronts: the implementing and donor organisation as well as the local community. It also requires a shift in attitude and management approach of all sides. For example, the typical project approach, where targets and activities are determined at the start and funding is allocated to agreed activities is not so suitable to allow community groups to move at their pace, with their own ideas. It needs flexibility from the funding organisation with regard to time and type of activities employed to reach the goal of community managed services.

GRC and SRC opted for self-help promotion, promotion of the capacity of community-based organisations to identify and sort out their own problems. It implies scope as well as capacity in decision-making and implementation at community level. Capacity can be built effectively through participatory techniques. Scope for participation requires that the funding or support organisation is willing to let go of its own plan and join the community group on their road to self-managed development. This shift in management approach and attitude towards community participation requires many efforts as well as time. This process of community mobilisation and management itself often takes at least 7-8 years as our own experience in Bangladesh shows. The projects described below vary in maturity from 3 to 8 years.

Maternal and Child Health Care centres:
From charity to sustainability

The Bangladesh Red Crescent Society (BDRCS) currently operates a nationwide network of 61 Maternal and Child Health Care (MCH) centres, 5 maternity hospitals, 3 general hospitals, 3 outdoor clinics, 2 eye clinics and 5 blood banks. Since 1972 the health institutions of BDRCS filled gaps where the government services did not reach. The German Red Cross is supporting mainly the MCH centres in their approach of change from charity to sustainability since January 2001.

In the past, because of sufficient donor support and donor mandate to provide free health care for the rural poor the BDRCS and its donor partners never emphasised the issue of sustainability. But over time, also BDRCS had to take the crucial decisions on how to change their health policy for the future in order for its health institutions and MCH centres to become self-reliant. Looking at the many other private and NGO health providers in the country which sprung up over the years, the BDRCS made first attempts in 1994 to introduce a cost-recovery system for medicine in their MCH centres. The cost-recovery system changed over the years into the current system of service fees and reduced medicine prices on an individual user basis. Through bulk purchase under the BDRCS umbrella and tax exemption of the organisation BDRCS can afford to provide services still more charitable than some other providers. Free services are given to those patients identified locally by health providers and the local community as the poorest.

Shifting from complete charity to sustainability needed a lot of conviction and establishment of trust and transparency with the users. The move away from charity first brought huge criticism, since nobody was willing to pay for services of an organisation that had always provided free health care and was known for its charity. In the clients’ eyes, there was no change of policy, but local staff were taking advantage for their own benefit. On the health provider side, at first providers felt awkward to ask money for services and till today some staff have difficulties in practicing health care for fees.

Besides their health activities, each MCH centre was encouraged to utilise their assets to do some income-generating activities at the same time. These activities are promoting optimum use of the centre and at the same time increase operating funds for the health services. Excess funds allow establishment of an exemption system for the poor and disadvantaged of the catchment area. Monthly income and performance is openly displayed in each centre. Money is regularly deposited in the centre bank accounts. The local community members who are also signatories for the account keep the books.

Community ownership with community involvement in elected Centre Management Committees, comprising of local men and women of the area and building up their management capacity from early on increased the local interest in using and maintaining their own services. Training of health service providers in all areas of Essential Service Package including safe delivery and basic pathology tests, as well as excellent cooperation with the government EPI and family planning services are now inclusive aspects of primary health care at the MCH level.

A standard treatment guideline was introduced emphasising quality health care, supporting the promotion of health services. Time spent for each client was increased with quality examination and slowly clients got convinced that for a limited price they got better and more profound examination than in a doctor's chamber. Mouth to mouth propaganda increased the number of clients which again had a positive effect on the sustainability of the centres. Regular doctor supervision provided by the adjacent Thana Health Complex, besides BDRCS own supervision and local community supervision is ensured and secures quality of services. Where quality could not meet the standards despite much effort, BDRCS has had the courage to close down the respective centre.

Health provider quality on low cost was introduced through the process of replacing elderly BDRCS staff by young, dynamic and well-trained women from the local community. These community midwives were trained in a government accredited nursing school under the nursing council. They provide same quality services at one third of the previous cost, and it is performance related. On the spot daily supervision and accountability to the local community assures good performance by the health provider, which in turn again secures clients and centre income.

Centralised management and supervision through an organisation is not sustainable in the long run. Developing the capacity of the villagers to manage a centre effectively was found to be the solution to sustain the services. This required trust and reliance by BDRCS on the local villagers and their capacity. All MCH centres have an elected committee in place, comprising of 10 to 15 male and female community members. The members are planning, monitoring and supervising all centre activities. Mature centres get fully released into self-reliance, where BDRCS has only a coordinating function. Financial, human resources and logistic management is all given in the hands of the local committee members. Since July 2002, 12 MCH centres have been self-managed and have proven their ability to do so. In fact, many centres show the same or even better performance than under centralised management. Since thrown into independence, the local community has proven to show a higher interest to maintain good quality services than previously when solemnly under BDRCS supervision.

For BDRCS the shift of policy required high level of trust in local communities. After all, the centres continue to use the emblem. It also took courage to risk their reputation as a charitable organisation. Villagers still now demand free medicine at times, comparing BDRCS with free government services or their services delivered in the past. As found in a recent evaluation of one of the Primary Health Care programmes the new generation however appreciates the shift and is happy to pay for quality services. They acknowledge that their capacity and their local assets have been increased in order for the centres to remain there in the future. And the users keep returning to seek services in their 'own' centre.

Chakaria Community Health Project:
Empowerment instead of material support

Chakaria Community Health Project (CCHP) started in 1994, supported at the time by German, Dutch and Swiss Red Cross. The Centre for Health and Population Research (ICDDR,B) implements the project in six unions in Chakaria Upazilla in Cox’s Bazar district, covering a population of around 1,400,000. Two additional unions are monitored for comparison of health indicators in this action research project.

CCHP aims to discover appropriate strategies to ensure people’s participation in health matters, as a strategy to increase health services available to rural populations. The project put health on the agenda of existing indigenous Self-Help Organisations active in various fields such as religion, education, economics etc. Like in the BDRCS-MCH experience, there was an initial ‘charity’ type expectation. Substantial relief activities in the recent past after disasters had strengthened relief attitudes and expectations of handouts. The ICDDR,B project staff was expected to bring free goods and services. The project took special care and time to convey the message that the project would not provide material support. After a period of awareness raising the participants of these groups recognised that part of the health problems and lack of health services could be solved by themselves. They also realised that women had to be allowed to participate in order to solve hygiene and maternal and child health related problems. In the initial two years CCHP’s interventions with the community concentrated on community mobilisation and health awareness raising. The indigenous organisations and the newly established women’s groups soon formed Health Committees.

Health awareness raising led to demand for more Primary Health Care services and access to curative care. The project extended technical support to the Self-Help Organisations to establish Village Health Posts. By mid 2002 the Self-Help Organisations were running 7 Village Health Posts, and soon also 27 sub-centres. Most have made a permanent building for the Village Health Post. Volunteers are raising awareness on common health problems in schools and villages. Community midwives and paramedics are available now and attended births and ante and post-natal care attendance is increasing. Since one year the Self-Help Organisations are forming Health Cooperatives. The Cooperatives will generate income through savings and other activities. Part of the income will go towards funding the community managed health services. So far, quality management and the salaries of two doctors remain part of the project input. A major difference with the BDRCS-MCH centres is there is no issue of ‘transforming’ existing services into community-managed services. The services in CCHP are established and managed from the start by the community committees. Like in the MCH centres, the committees actively seek cooperation with government services in the field of EPI, family planning etc

A study completed in 2003 confirmed that users value the services of the Health Posts, the project-trained Community Health Workers and paramedics. Around 55% of the villagers make use of the services. Some 30% of households buy a yearly Family Health Card that gives subsidised access to the services. The Village Health Posts derive income from the cards, session fees and a small profit on medicines, even though the medicines are sold below the regular market price.

Working through the existing organisations has advantages; the organisational structure already exists, motivation to meet comes from within the group etc. Disadvantages include total absence of women members, and lack of involvement of poor. Traditionally, affluent and influential people lead these organisations. It means poor have less access to the decision-making. It does not mean poor have no access to the services. In the period April-June 2003 out of 1946 patients treated at the Health Posts, 327 patients were considered poor. From them 209 paid a reduced fee, the remaining 118 paid no fee. The Health Posts operate a poor fund for this purpose.

The average operating cost for a Village Health Post is Taka 12,000 to 15,000 (USD 200 to 260) per month. Cost of the other services (e.g. Community Health Workers) should be added to that. Part of this amount can be covered from the service fees. The ultimate aim is high: fully self-financing. At the moment the project supports the formation of Health Cooperatives to generate the missing part of the funding (by June 2003 78 Health Cooperatives were running). In addition laboratory services will be run from the project office. Project input for doctor salaries, and support to the Community Health Workers will continue till end 2004. After that, the costs should be shared among the Health Cooperatives, fees from services in the villages, and the laboratory income.

Dushtha Shasthya Kendra Hospital
Cost recovery in a Slum...

The 20-bed hospital managed by Dushtha Shasthya Kendra (DSK) is an example of secondary health services managed through an NGO, with professional contributions from private practitioners and cost contributions from users. The permanent medical staff includes 5 medical officers, 7 nurses and 3 operating theatre staff. The hospital is able to meet wide ranging secondary care needs through a system of private consultants that are called in when the need arises. They provide their services for reduced fees.

Primary focus is on quality service provision for people living in the slum areas where DSK runs a Primary Health Care project. The location of the hospital is somewhat far from the Primary Health Care area. Therefore the original target group does not visit easily. Nevertheless, the hospital manages to attract 9% of its clients from slum, 70% from low-income groups, 20% from middle, and 1% from higher income groups.

Monthly operating cost of the hospital in 2002 was around Taka 300,000-350,000 (USD 5100-6000), serving 3181 outdoor clients and 563 indoor clients that year. In the same year DSK managed to recover 48% of running costs through user fees, even though occupancy rate was – and still is – below optimal (40% in the second quarter this year). The mid-term evaluation team already concluded that the current size of the hospital is inadequate. With the same staffing and infrastructure more beds can be managed, and more beds could increase income. Minimum viable size is thought to be 50 beds.

The pilot project hopes to find a model that has an alternative to donor support for the part of costs that will not be recovered from user fees. Providing health service contracts for staff of NGOs can add some regular income. So will the interest-generating savings account/system, but neither will ever bring in enough to fully finance all recurring costs. Capital investments most likely will continue to need outsider financing. The project continues to improve the current implementation level and to study other financing possibilities.

Like in the BDRCS-MCH and CCHP examples, also in this project staff and management approach and attitude had to some extent get used to the fee-for services and community-oriented approach. Commitment to quality services for those members of the public that usually get no or low quality service had to be built carefully and continuously. It may come as a surprise that the hospital faces problems of competition, where the project was initiated to provide services to those without access. Health seeking behaviour, also among poor clients is determined by many factors, of which cost is just one. A Health Financing Scheme for a provincial referral hospital (176 beds) in Takeo, Cambodja showed similar findings: attracting patients through consistent high quality services, transparent, affordable and fixed prices, but also through volume of services turned out to be key issues.

Requirements for success of the approach

Although the above projects have substantial differences in inputs and outputs, critical reflection shows some common findings. Community managed services can be an effective way to shift from charity to more sustainable forms of health services provision in the context of Bangladesh. It takes investment in changing attitudes and practices at the level both funding and implementing organisations. The following points were found crucial in the examples described in this paper.

High level of participation (not token participation) and decentralisation of decision making to local communities where community members are not only allowed to listen to the plans, but to shape them, leads to high ownership feeling and high commitment. Combined with increased management and implementation capacity it enables community-based organisations to take charge effectively.

Shift in attitude: staff and management of the host/funding agency need to accept and actively committed to the community management approach as well as the idea of fees for services. Community members need to come forward and to be willing to take charge and also to be committed to the objectives and ensure transparency and accountability. Patients and clients need to shift their expectations.

Creating demand: interest in preventive services needs to be cultured constantly by raising awareness of their benefits. It also needs clients and patients to hold management committees accountable for transparency and quality of services. It takes time to make high quality services the new norm for selecting or seeking health services.

Quality of services: strongly related to the previous point is the need for consistent high quality of services to convince patients and clients to come and seek services here and not elsewhere or not at all.

Recruitment of local staff with relevant qualifications and certified training helps to build trust and accountability in the community. Direct employment by the local communities makes supervision by local communities easier, helps prevent staff transfer and allows performance based remuneration controlled by the local committees.

Management support: the host or donor organisation needs to be able to entrust community members and staff members with the management of the services, and to invest in building that capacity when necessary. It also requires active involvement of community members in real decisions related to the financing and management of services. Transparent decision making processes and fund/account management is an absolute must.

Shift in donor practice: community managed projects cannot be fully predicted in detailed log frame planning and monitoring schemes in the traditional way. Plans evolve to some extent, and may change more than in donor-led projects. Planning, reporting and financing requirements need to be flexible enough to cope with this and provide enough scope for gradual increase and take-over by bottom up planning. This can be done through process oriented project financing, planning and management. Usually, staff time and training of community members make up a large chunk of the project expenses.

Lack of alternatives: if enough services are available, or donations are coming in easily these schemes obviously will not work

Recognising needs of everyone: although services may target more vulnerable groups, all projects mentioned above decided not to use a classic target approach of working only with those groups. By recognising everyone’s needs, and building in safety checks for equity for all, the projects draw on total communities, and thereby create a broader base/hold in the community. The value of this approach is also recognised in literature addressing sustainable development.

Conclusion

This presentation just highlighted a few aspects of each of the projects. In each project the aim departed from the traditional orientation of service provision without community input. The examples show that community managed health services can help meet health service needs in Bangladesh, and that cost sharing by users can to some extent help meet the cost of services for the huge population in Bangladesh, and thus complement government efforts.

Establishment and management of health services by community groups is a challenge that can be met, as the above shows. So it seems, is the ‘selling’ of quality services to poor and low incomes groups. Long-term quality management and financing of that part of costs that cannot be recovered from users are still partly unsolved challenges. The experiences of the BDRCS-MCH centres, DSK and CCHP will help us understand that better within the next couple of years.

The maturity of the projects in the examples varies from 3-8 years. The older examples give confidence that interest in community-managed services can be sustained. Management committees survived several tests of time already. It gives us at GRC and SRC in Bangladesh enough confidence to continue along this path.

Against the backdrop of charity expectations within and outside the Red Cross/Red Crescent Movement, the examples from Bangladesh show that several societies managed to move from charity to sustainability …not an impossible task for any organisation willing to invest in the shift.

*For time constraints, this presentation could not be included into the MMS Symposium’s programme, but only into the reader. The authors would like to thank BDRCS, CCHP/ICDDR,B and DSK for their cooperation with the publication of this paper. Contact: srcross@bdonline.com