private sector health - rtm) international private sector health... · private sector health is a...

Private Sector Health

Content Contributors:

• Farhtheeba Rahat Khan

Director, Business Development and Management Unit

Research, Training and Management (RTM) International

• Khaled Ahmed

Capacity Building Specialist


• Kazi Mostafa Tahmin

Capacity Building Specialist


• Zannatul Ferdous

Business Consultant, Industry and Rural Sectors Group

Katalyst- partners in business innovation

Designer & Editor:

• Kazi Mostafa Tahmin

Disclaimer : Every effort has been made to ensure the information in this booklet is accu-rate and all information is believed to be correct at the time of print, however change may have occurred after publication.

Copyright: RTM International 2010, All rights reserved. No parts of this publication may be reproduced in any form without prior consent of the publisher.

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Private Sector Health

Private Sector Health is a project implemented by RTM International in partnership with Katalyst. The project was initiated to promote the growth of health sector in a more qualitative manner by identifying sector constraints and addressing them through developing sustain-able and compatible solutions. The interventions framed under the project are mainly based on the findings of three market assessments conducted initially by RTM International in this sector. In addition to this, various market assessments, rapid surveys and profiling studies were carried out from time-to-time during the lifetime of the project to better understand the sector specific needs and dynamics.

The project team worked in collaboration with the Ministry of Health and Family Welfare and its various departments and directorates in-cluding Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP), National Institute of Population Research and Training (NIPORT), Bangladesh Nursing Council (BNC), Directorate of Nursing Services (DNS), and State Medical Fac-ulty (SMF), towards creating favorable policy environment for effec-tive functioning of private health sector. Similarly, technical assistance was provided to private universities, medical colleges, private medical training institutes, and other related private stakeholders for strength-ening the supply side of Human Resource for Health (HRH) and cre-ating demand for health training courses .

All program activities were implemented under a cost-sharing mecha-nism, where the client (esp. private commercial players) mostly con-tributed the major proportion of the total program cost.

INTERVENTIONS

Introducing B.Sc. Nursing course in the coutry … … … … … … … … … … … … … … … … … … … 4

Strengthening Health Technologist and Medical Assistant Courses … … … … … … … … … … … … … … 8

Introducing Skilled Health Workforce for increasing accessibility to quality healthcare in rural Bangladesh … … … … … … … … … … … … … … 12

Increasing access to qual-ity healthcare for urban poor working in labor intensive industries… … … … … … … … … … … … … 16

Increasing access to qual-ity primary healthcare for rural poor through microcredit programs … … … … … … … … … … … … 18

Case 1, 2, 3 … … … … … … 22

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In 2007, MoHFW approved the policy guidelines for intro-ducing B.Sc. Nursing in Bangladesh

Consequently, RTM-Katalyst initiated policy advocacy towards this end. The project team worked with MoHFW for the development of policy guidelines for a 4-year B.Sc. Nursing course and simultaneously assisted the interested private sector institutions (AIUB, SUB, IMC) in of-fering B.Sc. Nursing and addressing the image issues of nursing profession.

The Government formed a taskforce comprising members from both private and public sectors. RTM facilitated Dhaka University in the development and approval of curriculum, exam module, and university ordinance for introduction of an international standard B.Sc. Nursing course.

In April’07 the GoB approved a Policy Guideline for offering B.Sc. Nursing course. In this policy the Private Universities were not included although they were more interested to start the course. RTM continued working with MoHFW to revise the policy to make it more ‘private sector friendly’ and in December’08 a revised policy was approved, where the Private Universities are allowed to offer B.Sc. Nursing course provided that they have an agreement with a 100 bed hos-pital.

Poor image of nursing profession inhibited the entry of meritorious and better-off students in the nursing courses. RTM organized image building campaigns and advocacy programs with MoHFW, SUB, AIUB, ASSH and The Daily Star to increase the acceptability of nursing profes-sion. International Nurses’ Day was observed. Articles on nursing were published in various leading news papers.

RTM-Katalyst organized a number of dissemination workshops, roundtables and orientation programs with partners and associates for getting inputs of relevant stakeholders, to work in consensus with them and to share the updates from time to time.

Introduction of B.Sc. Nursing course in Bangladesh

Health care delivery is a highly labor intensive process and the pre-requisite of an effective health care system is a sustained supply of required health human resource. Nurses are key components of human resource in health sector and provide medical and administrative services to facilitate function of physicians

and other health professionals . Unfortu-nately, there is an acute shortage of nurses in Bangladesh. There is 1 nurse for every 8047 people compared to 1 doctor for every 4521 people. The general standard of nurse to doc-tor ratio is 3:1, but in Bangladesh the nurse to doctor ratio is 1:3

Market Assessments by RTM-Katalyst re-vealed acute dearth both in quantity and qual-ity of nursing which is impeding the develop-ment of healthcare sector. Detailed analysis of the findings led to framing of intervention.

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WHAT HAVE WE CHANGED

Beginning in the 2007-08 session, 4 public, i.e. DMCH (Dhaka), MMCH (Mymensing), RMCH (Rajshahi), CMCH (Chittagong) and 4 private medical colleges, Kumudini (Mirzapur), SUB (Dhanmondi), IMC (Gazipura), Moulana Bhashani(Uttara) started offering B.Sc. Nursing course.

In 2009-10 another 3 private medical colleges, JRRMC, (Sylhet), North East (Sylhet), Sahabuddin (Gulshan) joined the league. The Armed Forces Medical Institute also started offering B.Sc. Nursing course.

There are now a total student capacity of 400 in public, 205 in pri-vate and 25 in armed forces medical college for B.Sc. Nursing course.

A number of additional private institutions are in the pipeline of approval process, namely TMSS, JIMC, ASSH, Delta and Sikdar. Fur-thermore, a number of other private institutions have applied for permission to start B.Sc. Nursing course e.g. East West (Tongi), Prime (Rangpur), City University (Banani).

More and more private organizations are approaching RTM for es-tablishing an international standard B.Sc. Nursing institute, e.g. Grameen Kalyan of Grameen Bank – a pioneer organization of micro-credit , Ayesha Memorial Hospital and Sajeda Foundation etc.

Social acceptance for Nursing as a profession has risen; B.Sc. Nurses are now eligible for Public Service employment (BCS) ; Initiatives are taken by GoB to upgrade the status of diploma nurses to second class.

A lead private hospital has taken initiatives on nurses’ award; simi-larly, some pharmaceuticals have plans to introduce nurses’ award.

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OUTPUTS

4 year B.Sc. Nursing course is available in the country

Private Universities are permitted to offer B.Sc. Nursing course

4 public and 1 armed forces medical college are offering B.Sc. Nursing course

7 private medical colleges are offering B.Sc. Nurs-ing course

Curriculum, ordinance and examination module for B.Sc. Nursing course are available

A clear policy guideline is in place for offering B.Sc. Nursing in private sector

By 2011, approximately 310 Nursing students will graduate.

Professional recognition of nursing has signifi-cantly increased

Nursing day is celebrated by private organizations in addition to GoB

Locally graduated nurses will reduce the depend-ence on foreign recruits.

FUTURE DIRECTIONS

Although different initiatives have been taken to expedite the process of getting the permis-sion for offering B. Sc. Nursing course, there is a significant concern over the lengthy time requirement for this approval. RTM-Katalyst assisted a num-ber of institutes in this process. But capacity building is neces-sary among the stakeholders so that a self sustaining mecha-nism is available in the market for institutionalizing this certi-fication procedure.

With systems for B.Sc. Nursing education in place, specific

plans and programs for strengthening the course are required. There is an acute shortage of qualified teachers for B.Sc. Nursing course. Cur-rently doctors are taking classes in the relevant disci-plines. RTM-Katalyst realizes that there is a strong need for teachers training, also, short trainings can also be designed for the existing teachers who are doctors.

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PARTNERS & ASSOCIATES

Ministry of Health and Fam-ily Welfare (MoHFW)

Director General Health Services (DGHS)

Bangladesh Nursing Council (BNC)

Directorate of Nursing Ser-vices (DNS)

American International Uni-versity of Bangladesh (AIUB)

State University of Bangla-desh (SUB)

University of Dhaka (DU)

International Medical Col-lege (IMC)

American Super Specialty Hospital (ASSH)

The Daily Star

MAJOR EVENTS CALENDAR

February 2010 Dissemination Seminar on the Revised Policy Guidelines for offering B.Sc. Nursing in Private Sector

January 2008 Stakeholders’ Workshop for dissemination of the Policy Guidelines to conduct B.Sc. Nursing course in Private Sector

April 2007 MoHFW approves the Policy Guidelines to conduct B.Sc. Nursing course in Private Sector

September 2006 Stakeholders’ Workshop to finalize the Policy Guidelines for introducing B.Sc. Nursing course in Private Sector

May 2006 Celebrating International Nurses’ Day

November 2005 Roundtable Discussion on giving Nurses due recognition: Promoting Nursing Education

A recent Rapid Assessment Study on Profiling of Health work-force by RTM-Katalyst identified that most of the students en-rolled in B.Sc. Nursing belong to lower middle and lower income families. But the tuition fees for B.Sc. Nursing in private institu-tions range between TK.1.3 and 2.5 lacs over 4 years. Since it is hard for students to afford this fee, private medical colleges have made contractual arrangements with students based on which the students, after graduation, will work in these hospitals for 3 to 5 years to repay the education expenses. Different scholar-ships and cost sharing options need to be streamlined further to encourage more students enrolling into the course. Banks and financial institutions can extend loans to students. Similarly, pharmaceutical companies, private hospitals, mobile operators and other large private sector players can come forward to assist these students.

Last but not the least, to uplift the status of nurses more innova-tive and motivational initiatives are required. In this context, private sector institutions offering B.Sc. Nursing and the em-ployers of nurses can play a major role.

Huge demand for nurses exists in the national and international market.

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English language and Computer Science are included in HT and MAT curricula to make students internationally competent

RTM-Katalyst initiated discussions with the MoHFW and its relevant departments regarding the need for upgrading HT and MA course curricula. Subsequently, MoHFW formed different sub-committees for revising the curricula for 7 HT Courses. Study tours for relevant GoB personnel were organized to neighboring countries of India and Thailand to acquaint them with the training systems in place for HT courses in these countries. All relevant literature available in the country were collected via overseas tour were assessed and required changes were brought to all 7 HT cur-ricula. A series of workshops were organized with key experts and specialists in the field to finalize all the curricula. The governing body approved these curricula in Dec 2008. Following this, orien-tation sessions on revised course curricula were organized for key faculties/coordinators of HT courses. RTM-Katalyst provided all technical and financial assistance for all these actions.

Similarly, RTM-Katalyst facilitated the improvement in teaching at MAT institutes. A curricula committee was formed to conduct a need assessment to revise the MAT curriculum which was last updated in 1985. Stakeholder workshops were organized for finalizing the curricula. The Govern-ing body approved the curricula in January 2010. Recently a consultative workshop was organized for private sector institutions to ensure better clinical placement of MA students. In addition ToT materials were developed for MAT trainers. WHO and SMF played the lead role in finalizing the policy guidelines for HT and MA courses, while RTM provided support in the process. RTM-Katalyst advocated with MoHFW in all formal and informal interactions for approving these guide-lines. Finally, GoB approved both the HT and MATs guidelines in January 2010.

In the process it was also felt that the dissemination methods of relevant GoB accreditation bodies were not strong enough to ensure accessibility of training institutions and students to information related to health training courses. A website was developed for SMF which will serve the informa-tion exchange platform for training institutions and students.

Strengthening Health Tech-nologist and Medical Assistant Courses

The demand for Health Technologists (HTs) and Medical Assistants (MAs) in Bangladesh is increasing more than ever before with the rapid growth of Private Healthcare sector. The stan-dard ratio for doctors to health technologists is 1:5 whereas in Bangladesh the ratio is 3:1. Similarly, 40% vacancy exists for MAs in public sector alone. On the contrary, the supply of skilled HTs and MAs fall

much short of their demand. The public institutes alone cannot meet this demand and the training materials for these courses require improvements in terms of inclusion of latest technol-ogy and recent develop-ments in healthcare . Such findings from the Market Assessment Studies con-ducted by RTM-Katalyst led to framing of this interven-tion.

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As of today, 45 private training are operating since the training was

opened for private sector in 1996. With the revision of HT policy in 2010, reducing the fixed deposit from Tk.50 lacs to Tk.10 lacs, there will be significant participation of training institutions in the HT edu-cation field.

Nine more HT institutes are in the approval process

Since 2008, 25 private institutes are offering MA courses. Approval

of 11 more MAT institutes is under process.

By the end of 2012, there will be about 1600 competent MAs from

private sector institutions alone to serve the health sector

By the end of 2011, there will be about 3500 better skilled HTs from

private sector institutions alone to serve the health sector

The capacity of Govt. regulatory bodies related to MAT and HT has

been enhanced

OUTPUTS

MAT curriculum has been upgraded with informa-tion on new disease pro-file, modern treatment and health issues, basic English and Computer Science

ToT materials for MAT teachers are available

Since private sector is a new entrant in MATs, awareness programs were organized for them to ensure clinical place-ment of MAT students studying in these insti-tutes

GoB has revised the HT policy guideline to make it private sector friendly

Seven HT courses have been upgraded as per international standards

A well-functioning web-site of SMF is available which carries informa-tion related to examina-tion, student enrollment, curricula, policies and other public notifications.

Website of SMF developed with technical and financial assistance from RTM– Katalyst

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FUTURE DIRECTIONS

Training systems for HRH espe-cially those related to allied workforce have grown in the country albeit with lesser atten-tion given to affiliation and qual-ity. The system of offering train-ing courses under proper regula-tory framework needs further strengthening. MoHFW and rele-vant bodies have a major role to play in addressing these issues. There is a huge scope of improve-ment in teaching practices of MAT and HT courses. Based on ToT materials developed under

the project, appropriate training programs for trainers of MAT and HT need be organized on a continuous basis for improving the teaching standards. Consid-ering the resource limitation of public sector donors and devel-opment partners can play an important role in such initiatives. In addition, GoB may continue to integrate quality enhancing pro-grams/orientations in their yearly plan.

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HTs – Health Technologists are employed in Pathology, X-ray, Pharmacy sections of public and private hospitals and diagnostic centers.

MAs – Medical Assistants fall next to doctors in providing healthcare services. They are employed in Govt. health structures, private hospitals, clinics, NGOs and also in some garment factories.


April 2010 Consultative workshop organized for private MATS for better clinical placement of MA students

February 2010 Orientation programs for trainers of HT courses on the revised curricula

November 2009 Consultative Workshop for finalizing revised MATS curricula

September 2009 Needs Assessment for revising MATS curricula

October 2008 Stakeholders’ Workshop for finalizing 7 HT curricula

July 2008 Overseas tour to understand systems in place in neighboring countries for offering HT courses


Ministry of Health and Family Welfare (MoHFW)


State Medical Faculty (SMF)

Center for Medical Educa-tion (CME)

Health Technology Insti-tutes (HTI)

Medical Assistant Training School (MATS)

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A recent Rapid Assessment Study on Profiling of Health work-force by RTM-Katalyst identified that 90% students joining such courses come from poor socio-economic backgrounds. But the tuition fees for these courses in private institutions range be-tween TK.0.9 and TK. 1 lacs over 3 years. Different scholarship and cost sharing options should be streamlined to encourage more students enrollment into the course. Banks and financial institutions can offer specialized student loans. Similarly, phar-maceutical companies, private hospitals, diagnostic centers, mo-bile operators and other large private sector players can come forward to assist these students.

Students (S.S.C) and their parents are not aware of the huge de-mand for MAs and HTs. Recent studies reveal that students join these courses since they have come to know about the demand for such health work force through their relatives, friends, village locals who belong to the medical community. Private training institutes can organize community awareness programs, as a part of their marketing strategy to promote the courses to get meritorious students.

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System for offering training courses under proper regulatory needs further strengthening

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Community Paramedics is an improved version of FWV with upgradation of 18 month FWV course to 2-year program

Consequently RTM-Katalyst started discussions with MoHFW, DGHS, NIPORT,SMF and other relevant bodies to address these two major problems. MoHFW took the decision to introduce the CHW course under SMF. Draft guidelines and curriculum for community health workers were developed which were finalized in a stakeholders’ workshop. In Nov 2008, MoHFW approved the guidelines and in Dec 2008 the governing body approved the curriculum . As per the guidelines these courses could be offered only by private institutes in remote areas, to promote enrollment of students from grassroots level. In such settings access to various books and references is not easy feasible. Considering this fact, a guidebook and ToT materials were developed for students and trainers of CHW Course.

To address the existing shortage and predicted future crisis of health workers for RH-FP and MCH services, RTM worked with MoHFW for opening training courses similar to FWV in private sector. Accordingly, MoHFW took a decision to introduce CP course, as an improved version of FWV with upgradation of 18 month course to 2-year period. The curriculum of FWV has been upgraded with incorporation of additional and specialized components on MCH, FP, communica-tive English and IT. RTM-Katalyst provided all required technical and financial assistance related to both these courses.

The project team also provided assistance to develop websites for NIPORT as information ex-change and dissemination platform for training institutions and general public.

Introducing Skilled Health Workforce for in-creasing accessibility to quality healthcare in ru-ral Bangladesh

A large number of people in rural settings of the country go to un-qualified healthcare providers in the absence of easy accessibility to skilled health workforce. Bangla-desh Health Watch 2007 reports the existence of 7 categories of such unqualified providers in rural Bang-ladesh. On the other hand, there is a nationwide shortage of FWVs and their new recruitment remained inoperative for the last 12 years. This unavailability of FWVs is ham-pering the MDG progress related to maternal mortality, infant mortality

and family Planning which is cited in the Annual Program Review 2009 of HNPSP. But these were identified much earlier in the rapid assessments conducted by RTM-Katalyst in 2007-08 . Accordingly, the project team framed interventions to address both these problems, one related to primary healthcare and the other on RH-FP and MCH services.

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18 private training institutions are currently offering CHW course, in addition 14 other institutions are under approval process

About 80% healthcare in rural parts of the country are provided by non qualified persons. Enough production of CHWs can change this scenario where CHWs will provide quality Primary Healthcare ser-vices to the rural people.

9 private institutions have applied for offering CP course

By 2012, there will be about 600 CHWs to provide health services for rural people

Availability of enough CPs in the country will enhance the progress towards MDG goals related to Maternal Mortality and Infant Mortal-ity

Employment opportunities for women have increased both in public and private sector as 70% of CP students are female.

Introduction of CHW and CP course have created new employment avenues for students from poor economic background.

Capacity of Govt. regulatory bodies related to CHW and CP is en-hanced

OUTPUTS

GoB affiliated 1-year CHW course is available for producing basic PHC worker

CHW course is being offered in 18 private insti-tutes

GoB approved standard curriculum and guide-book are available for CHW course

GoB affiliated 2-year CP course is available for producing skilled RH-FP and MCH service provid-ers

Curriculum and module for CP course have been developed

A well-functioning web-site of SMF is available which carries informa-tion related to examina-tion, student enrollment, curricula, policies and other public notification.

A well-functioning web-site of NIPORT is avail-able which carries infor-mation related to CP in-stitute list, curricula, poli-cies and other public noti-fication.

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FUTURE DIRECTIONS Courses similar to CHWs and CPs are not new in the country. Differ-ent NGOs and development partners, in the absence of systematic gov-ernment accredited health training programs, have designed short term courses and trained personnel as CHWs and CPs to serve their project/program purpose. But the quality of such courses is not uni-form. In fact, there should be a proper system for offering training courses controlled under a single and recognized body. This is what the project has ventured out. The current intervention was framed not just to address the surface-level problems but also to promote locally adaptable and accredited training programs.

The project has established the basic grounds required for CHW and CP courses but further improvement will be necessary to utilize the full potential of these developments. For enhancing the quality of teaching of these courses, specific ToT programs for trainers of these courses is

required. MoHFW and relevant bodies have a major role to play in addressing these issues. Again since public sector has limited financial resources for such programs, donors and develop-ment partners can come forward to support such initiatives.

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Ministry of Health and Fam-ily Welfare (MoHFW)


State Medical Faculty (SMF)

National Institute of Popula-tion Research and Training (NIPORT)

Private CHW Training Insti-tutes

CP – Community Paramedics are intended to provide healthcare services to rural people with main focus on Reproductive Health (RH), Maternal and Child Health (MCH), and Family Planning (FP)

CHW – Community Health Workers are groomed and educated to assist healthcare providers and trained to provide basic primary healthcare (PHC) services to rural people.


April 2010 Dissemination program on CP guidelines

November 2009 MoHFW approves of CP guidelines

July 2009 Stakeholders’ Workshop for finalizing CP guidelines and curricula

November 2009 Stakeholders’ Workshop for finalizing CHW guidebook

October 2008 MoHFW approves of CHW guidelines

September 2008 Stakeholders’ Workshop for finalizing CHW guidelines and curricula

May 2008 Consensus building for introduction of CP course

Sustainability and demand for training courses are guided by principles/systems of quality assurance and accreditation

In addition, advocacy with GoB may be continued to integrate quality enhancing programs/orientations in their yearly plan. A recent Rapid Assessment Study on Profiling of Health workforce conducted by RTM-Katalyst identified that students joining 2-3 year training programs belong to lower middle and lower income families. Different scholarships and cost sharing options can be introduced to encourage more students enrolling into the course. Banks and financial institutions can extend loans to students. Similarly, pharmaceutical companies, private hospitals, diagnos-tic centers, mobile operators and other large private sector play-ers can come forward to assist these students.

Students (S.S.C) and their parents are not aware of the prospec-tive job opportunity of CPs and CHWs. Moreover, since these are totally new courses, even the medical community is not aware of their availability in the training market. Private training insti-tutes can play a major role through organizing community awareness programs, as a part of their marketing strategy to promote/market the courses to get enough students. Further GoB and Prominent players in the private health sector such as pharmaceutical companies, private hospitals, diagnostic centers, and the media at large can come forward to promote these courses and contribute in improving the health standard of the rural population of Bangladesh .

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Linkage establishment between healthcare service providers and industries—a case of Brothers Furniture and Shimantik

The rationale was that if services are brought by the factory instead of being provided via a doctor who is employed by the factory itself, quality to services are ensured. A pilot was thus initiated through an MoU signed between Brothers Furniture and Shimantik, where Shimantik was responsible for providing healthcare services to about 200 workers of Brothers Furniture Ltd. Shimantik sends a three member team (one MBBS doctor, one Paramedic and one Family Planning Service Promoter) every week to provide primary healthcare services especially on dust borne diseases, minor surgeries and services relating to family planning. Brothers Furniture pays a fixed amount (BDT 4000) per month to avail this service. The workers also get pro-fessional services in Shimantik Health Centers along with cer-tain discounts on medicine, tests and other special services. This MOU was initially signed for a 12 month period to make a package of integrated healthcare service available to the urban poor, at the same time it would open up a solid clientele for Shimantik.

RTM-Katalyst carried out rapid assessments, on-site evaluation and stakeholders meetings (managements, workers) to evaluate the effectiveness of the program. The learning from this experi-ence can contribute in developing a stronger model which can be replicated in the future through likeminded organizations.

Increasing access to quality healthcare for urban poor working in labor intensive industries

Industrial workers and day laborers mostly have limited access to public healthcare ser-vices due to the nature and timing of their

work whereas, they are actually more vulner-able to health hazards and communicable diseases. Different health campaigns on the factory premises have been initiated by some garments factories, but in most cases they have a paramedic/medical assistant/doctor placed in their premises for providing health-care services with no linkage to any healthcare organization which limits the scope of treat-ment.

RTM-Katalyst took an initiative to establish linkages between industries and clinic/organizations that provide healthcare services.


Shimantik – A National NGO, working predomi-nantly in national level health projects, has a num-ber of clinics in different unban poor areas of Dhaka and Sylhet Brother Furniture – A leading furniture manufac-turer with a retail chain in Dhaka , having more than 200 laborers in their central factory at Shajadpur area

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WHAT HAVE WE CHANGED This pilot turned out as an effective model which has created a win-win relationship between service provider and service receiver and it significantly decreased the worker absenteeism and increased overall productivity. The workers are also happy to have healthcare services within easy reach, every week about 15-20 workers consult the doctor in Brothers own vicinity and 2-3 of them go to the Shimantik Clinic for additional healthcare services; Some also visit the clinic regularly for their family health and reproductive care needs. However, it has been found that the model would be more successful if the health service provider’s clinic is within walking distance from the factory and if both the parties initiate better communication to optimize the benefits of such scheme.

Brothers Furniture and Shimantik have completed the first year of this scheme and are continuing the model with some customized mo-dalities. Shimantik has also received a number of requests from other furniture companies to develop similar integrated health scheme.

RTM-Katalyst believes that this model could be replicated in different forms which will create a new avenue to improve the health status of the urban poor and also open up a business proposition for small-medium clinics/healthcare service providers.

OUTPUTS

In-house healthcare fa-cilities are available for the laborers of Brothers Furniture.

Special discounts on lab services and medicines are available to the labor-ers.

The average labor days lost due to ill health has decreased.

Productivity of the labor-ers has improved

New sustainable business opportunities are open for Shimantik

Improved awareness on various epidemic and communicable diseases among the laborers is noticed.

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FUTURE DIRECTIONS Integrating the Health Care Services model in factories where workers are vulnerable to illness and injuries will help to deliver primary healthcare services to the urban poor. This can be replicated by NGOs that have healthcare centers in the vicinity of factories which will in-crease the utilization of healthcare facilities. Replication of this model can be initiated by arranging dissemination workshop among other labor intensive factories. Since the industries (Apparel, Furniture, Leather, etc) are growing and becoming more competitive at home and abroad the issue of complying with international standards of safety procedures and provision of access to healthcare are becoming all the more important. Manage-ments of factories are mainly concerned with pro-ductivity and bringing down absenteeism due to sickness to the minimum. However other issues such as buyer requirements or strict government policies can also become driving forces in the future for factories to adopt this model to deliver health-care services to their workers.

Introducing healthcare as a bundle product for micro-credit beneficiaries—a case of TMSS’ health sub-center

The Millennium Development Goals to improve the well being of the poor masses demand an integrated and combined ap-proach to poverty and health. TMSS strongly believes in this concept and thus has integrated Health with microcredit in some of its branches on a pilot basis. TMSS’ health sub-center comprises of one Paramedic, one Health Worker and one Clini-cal Assistant. TMSS operates different other programs and has its own paramedic training program.

RTM -Katalyst during its market assessment for paramedics found the existence of different models of healthcare delivery in NGOs. The TMSS’ model of healthcare delivery looked promis-ing both from the angle of sustainability as well as accessibility to health services. A series of discussions with TMSS led to strengthening the pilot and assessing its real benefits. The process prompted a quality-based paramedic program which could turn out better qualified and skilled paramedics.

Increasing access to quality primary healthcare for rural poor through microcredit programs

In Bangladesh as in many other developing coun-tries, microcredit has become a huge success and it effectively reaches a ‘significant proportion of other-wise disadvantaged people’ (low/unstable incomes, little/no land/assets, low social status, few/no alter-native sources of financial services). NGOs, multilat-eral organizations, and governments are using it as a tool to meet the poor’s credit need leading to pov-erty alleviation and empowerment. But economic empowerment alone does not provide a complete solution to effective poverty eradication, other fac-tors like health, education are also instrumental in determining the quality of livelihood.


TMSS : One of the largest NGOs and a leading Micro-Finance Institute (MFI) in Bangladesh, has programs in health and education.

Palli Karma-Sahayak Foundation (PKSF) public-private apex body that channels funds to MFIs for microcredit pro-vision

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OUTPUTS

Improved teaching prac-tices are followed in TMSS paramedic insti-tute

Microcredit beneficiaries and rural population avail quality healthcare services at affordable cost

More skilled paramedics are available for rural population

The number of loan de-faulters has decreased

Significant increase in new loan subscriptions is noticed

The number of new mi-crocredit members in-creased

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RTM-Katalyst entered into an agreement with TMSS to im-prove the quality of the paramedic training program and estab-lish the institute as a model for paramedics course. Conse-quently, RTM-Katalyst designed a 21-day long Training of Trainer (ToT) programs for 20 trainers of TMSS’ paramedical institute. This ToT had a dual target of generating better skilled paramedic for TMSS as well as creating a pool of skilled train-ers who can train teachers from other institutes .

Later in 2009, RTM-Katalyst carried out a number of analyses and stakeholder workshops to evaluate the economic and tech-nical feasibility and sustainability of this model, find out the income generating potentials and make an operational plan for other MFIs/NGOs to scale up the model for countrywide healthcare coverage. Following these evaluations RTM-Katalyst organized dissemination seminar for other partner NGOs of PKSF so that more MFIs could start ensuring healthcare for their beneficiaries.

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The microcredit enterprises in Bangladesh have experienced a huge growth. However in recent times it has become intensively competitive. So, MFIs’ are looking for new competitive strengths and value added ser-vices. Health with microcredit can renew and add new market bonds between the MFI and its customer base.

The paramedics working in the health sub-center of microcredit branches in the rural areas are rapidly re-placing the quacks and unqualified village medical practitioners, thereby ensuring quality healthcare. These paramedics are usually from the same community.

Health with microcredit has significant impact on MFI sustainability and performance. Loan default and customer attrition are major problems confronting MFIs, directly impacting their operations and even sur-vival. By addressing the beneficiaries’ health needs, MFIs can reduce loan defaults and increase income, as improved health condition leads to increased productivity and regularity at work.

MFIs’ beneficiaries are predomi-nantly women (90% to the total) who are generally more vulner-able to health problems and in the case of a member of the fam-ily falling sick the burden to nurse and care those suffering from illness usually falls on the women. Poor women face in-creased health risks due to over-work and susceptibility to repro-ductive health problems. Such client problems directly impact MFIs loan recovery and threaten financially self-sustainable or-ganizations; therefore, it is in the best interest of the MFI to prioritize health education and health pro-grams to promote sustainability of the microcredit operations.

In the TMSS pilot, this initiative worked as a promotional activity to attract new members and retain the existing members, increased the net surplus of the MFI branch even after incurring significant expenditure for the Health sub-centers, leading to a two-fold growth in Micro Enterprise (ME) graduate flow .

TMSS was confident that with inclusion of health services to its beneficiaries, the number of loan defaulters will decrease. Surprisingly, TMSS not only witnessed a tremendous reduction in loan defaulter rate but also saw a remarkable increase in the number of members over these years.

The staff salaries and operating cost of the sub-center are spent from the microfinance surplus where an increasing fraction (about 30%) of the cost is covered by the sub-centers’ own income. By having own in-come the Health sub-centers reduces its dependency on MFIs profitability.

FUTURE DIRECTIONS

MFIs contribution towards poverty alleviation is commendable. Time has come for these MFIs to recognize beneficiaries’ non-financial needs to better achieve comprehensive poverty alleviation. Better health is not only a necessary component of poverty alleviation, but may be a complementary strategy. World Health Organization’s Com-mission on Macroeconomics and Health (CMH) indicates health is also “a means to achieving other development goals relating to poverty re-duction.” Better health increases people’s productivity, thereby adds significant value to income-generation. Therefore, health programs are valuable complementary strategies to microcredit programs.

Since retaining doctors in remote and rural health facilities re-mains a challenge, a paramedic will better serve the option. When it comes to basic healthcare services the skilled paramedics are well placed. TMSS recently received funding for expanding the ‘Health with Microcredit’ model in 20 health sub-center from Islamic Re-lief. The effectiveness of ‘Heath with Microcredit’ in making afford-able and accessible quality healthcare services to pro-poor can greatly attract the donor communities’ interest in replicating such models for eventual sustainability.

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With microcredit programs reaching saturation stage, integration of health programs can add real value to their business

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Ms. Mosammat Anowara Begum, 40, is a micro-credit beneficiary of

TMSS for the last 15 years whose life changed for better through TMSS

health facility. Ms. Anowara lives in Chandihara village, 1 km away

from Mokamtola micro-credit branch area office of TMSS. The first

loan she took was Tk.3000 with which she bought a cow. She started her

earning through selling milk. At that time she was staying in a small

mud-hut. In course of time, she sold the cow and did some minor

renovations of her home. Ms. Anowara rotated the cycle of taking new

credits from TMSS, buying cow, selling milk, selling the cow again,

undertaking some refurbishment at home and buying more cows. She had been quite successful as

she got her daughter married with the money she saved in this process. At a point of time, she had

four cows and was able to contribute Tk.3600 per month to her family. Along with Ms.Anowara ,

there are three more earners in the family : her husband and her two sons (all day labourers).

Ms. Anowara had been suffering from menstruation problems since her last delivery in 1997. She

visited different unqualified providers such as Palli-chihishok, Kabiraj and had no remedy over the

years. She even traveled more than 6 km a day to visit the Upazhilla Health Complex where the

doctors were almost absent. With all these she ended up with expending Tk.20000 – 30000 over

consultations and medicines and further complicating the problem leading to prolonged abdominal

and back pain which became severe in the past 3 years. As she was sick most of the time, it hampered

her small business. On one hand, a lot of money earned by the family went for her treatment. On the

other hand, she couldn’t continue her house renovation works.

It was during this time that TMSS was doing its campaigning on quality health issues in Chandihara

and nearby villages, to promote their health services at micro-credit branches. Being convinced by the

counseling of the paramedic at this campaign, Ms. Anowara visited TMSS’ health sub-center at

Mokamtola branch. The paramedic at the clinic did some preliminary investigation and referred her

to TMSS’ Rafatullah hospital. Through a simple ultrasonograph, the root cause of her problem was

identified. Ms. Anowara was given one-month medications and she found her alright on completion

of the course. For all this, she had to spend just Tk.1000.

Ms. Anowara is happy to share her story and how without any further delay her problem was well-

identified and properly solved. Now she has her own Pucca house with strong roofing. Having learnt

from her personal experience, Ms. Anowara now refers all her relatives and village people to TMSS’

sub-center.

Case 1

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Tania Sultana, an 18 year old lady from Sat-mile Barinagar of Jessore

Sadar, is studying B.Sc Nursing in International Medical College (IMC)

at Gazipura, one of the first private medical colleges to start B.Sc

Nursing course. Tania’s family includes, her younger sister and her

parents. Her younger sister is 11 year old and studies in class XI, her

older sister got married recently and moved out.

Her father who works in a Jute mill in Panchagarh is the only earning member of the family and gets

TK 6,000 per month. They have some farming land in the village which is mostly given away for

sharecropping. They get their rice and vegetables etc from there. She does not know how much is

earned but the total monthly expense for her family is about TK 10,000.

Tania gets about TK 4,000 from her home every month to meet all her expenses (tuition fees, hostel,

books, pocket money etc). In IMC, she already paid TK 10,000 for admission and regularly pays TK

2500 per months as tuition fees. There is an additional fee of TK 50,000 as development fees which

she could not manage to pay yet.

Her father falls sick frequently due to overwork and wants to come back home to live together, but

cannot do so because his income from the job is essential for the family. Before Tania’s sister got

married she worked as a nurse and contributed to the family earnings, now times are hard because

that added income is no longer there. Tania plans to work in this hospital after graduating to pay her

fees since her father cannot pay the entire amount. She believes that she can earn about TK 15,000

per month after graduation.

In Tania’s family the current per capita income is TK 2,500 which will fall to TK 1,000 if her father

quits the job. However, Tania believes the situation will change as soon as she finishes the course, if

she earns as expected their family is per capita income will be TK 4750 per month (after reducing the

fee payment) even if her father quits the job.

Case 2

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Monirul Islam (28), (Foreman, Machineries Dept, Brothers Furniture) supervisors 18 workers. He

used to spend 200-500 Taka per month on healthcare, generally buying medicines as per drug-seller

suggestions. His subordinate workers did pretty much same and it was normal for any of his team

member to be absent for 1-2 days/month due to various illness.

After introduction of the health arrangement with Shimantik he and his team member now consult

with the doctor if they fall sick. This availability of qualified health professional has significantly

reduced their absenteeism due to sickness.

He also had his wife treated in Shimantik health center. She had a UTI infection when he brought

her here from his home village. The ambulance service was there to take her to the hospital. The

service in the hospital was good; he had some tests done in Shimantik and a few others in other

places. It cost him 410 taka for the tests in Shimantik which might have cost him 500 taka.

Ultrasound test was probably done free of cost (as far as he recalls). He bought most of his medicines

from other pharmacies but saline and other items were given free by Shimantik. Later after the

infection healed, he went back to consult the doctor about other problems his wife was having. The

doctor suggested diabetes test, which came positive. The re-checking was also done free of cost. Overll

he spent around 4000 taka on treatment and transport to Dhaka and thinks he probably saved around

1000 – 2000 taka for getting the service from Shimantik.

Monirul’s team members know about the services he got from Shimantik and hence know what they

can get. According to him this sort of association with health service providers adds value to a factory

as an employer and offers a more comprehensive healthcare solution for the poor workers and their

families.

Case 3

24

Major Studies and Publications

• Policy advocacy for certification of nurses’ and paramedics’ skill

development programs

• Market assessment on nurses’ and paramedics’ skill training

• Market assessment of Medical Information

• Market assessment on health technologists

• Market assessment on paramedics

• Integrating a market development approach into healthcare programs in

Bangladesh (AFE)

• Study on health service provider groups in the health sector (Bangladesh

Health Watch)

• Study on the training and supply of health workers in the health sector

(Bangladesh Health Watch)

• Rapid assessment on health workforce profiling

• Need Assessment on Current and Future Demand for nurses in the country

(MoHFW & KAT)

• Rapid assessment on integrated healthcare service intervention

• Study on the feasibility and sustainability of bundling primary healthcare

with microcredit beneficiaries

25

26

“It is high time for us to boost the production of skilled health workforce

to meet the country’s demand

and

to capture the International Market for skilled workforce”

27

Katalyst is considered to be one of the most successful market development projects in

the world. Since 2003 Katalyst has achieved significant jobs and income impact by

increasing the competitiveness of micro, small and medium sized enterprises in selected

urban and rural sectors. Katalyst follows a pro-poor, market development approach in

promoting economic growth. We focus on sectors with high growth potential in terms of

jobs, productivity, and profitability, and where there are other strategic economic

considerations (such as export potential). Katalyst partners with a wide range of private

and public sector organizations in order to leverage our resources and maximize impact.

Research, Training and Management (RTM) International was established in 1994 with

the name and title 'JSI Research and Training Institute, Bangladesh' (JSI Bangladesh) as

an independent national NGO in Bangladesh. The organization has been renamed in

2006 as RTM International. It provides high quality technical and information support

for the development of local capacity to identify sustainable approaches that improve

and maintain health, education, gender equity, environment and human rights. It

operates closely with national and international development organizations,

government departments, NGOs, independent experts and specialized public institutions

both in Bangladesh and other countries. RTM has positioned itself as a regional resource

center for South Asia to carry out technical assistance and other consulting assignments.

It houses an excellent team of professionals with medical, public health, economics,

education, research, business administration and other diverse backgrounds.

27

581 Shewrapara

Begum Rokeya Sharani, Mirpur,

Dhaka - 1216, Bangladesh

Phone: 880-2-8034814, 8034469

Fax: 880-2-8034638

E-mail: [email protected]

Web: www.rtm-international.org

RTM International

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