Service Delivery System

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Service Delivery System family planning related works and the working methods, through which the willing eligible couples are served in kind or with consultation/advice. The system of organisation eventually means providing the contraceptives and the contraception methods such as condoms, oral pills, intra-uterine devices (IUDs), hormonal injection, sterilisation, and norplants to intending acceptors and the treatment of their complications with the help of paramedics and medical persons. Later, maternal health and the children's primary healthcare (in a limited scale) were included in the system of service delivery.

The service delivery system in the population and family planning and health programmes emerged in Bangladesh in the 1960s. The system is divided into two groups: home service delivery and clinical service delivery programmes. Initially, the clinics were used as the main service points for supplying condoms and foam tablets. Rural health sub-centres, rural health dispensaries and charitable dispensaries were the outlets of contraceptives to people coming to these places for treatment of their diseases. Doctors used to advise their patients to avoid unexpected pregnancies. But the practice could not promote use of contraceptives at a large scale among the common folk. Only the highly educated and enlightened class of the society started demonstrating a significant contraceptive prevalence rate.

In 1953, Dr Homaira Sayeed, a professor of Dhaka Medical College, took an initiative to convince eligible women to adopt the method of hysterectomy or sterilisation. This set the beginning of intervention in the fertility behaviour of the people of this region. The real service providers were the highly qualified and skilled medical practitioners. Steps were taken to supply contraceptives on individual initiative and action. No network was set up and no system was introduced to deliver the available contraceptives to the willing couples and therefore, service delivery remained a major problem in implementation of the family planning programme.

An eligible couple willing to adopt any method of contraception needs a smooth, regular and uninterrupted supply and delivery of skilled services at its doorstep. But such a service delivery system did not develop until the mid-1960s, when the government appointed district and thana family planning officers in all the districts and thanas for propagating family planning activities in urban and rural areas. The thana family planning offices and rural dispensaries became the centre of service delivery. Their programme included both clinical and non-clinical methods, as well as the conventional and non-conventional ones. Temporary centres and camps were arranged in the villages for providing temporary clinical methods like IUDs.

Thousands of traditional birth attendants, popularly known as dais, were recruited in the villages to give the intending clients/couples the most primary information about contraceptives and to deliver contraceptives to the hard-to-win-over but ultimately motivated clients. A great number of low-income-group people got the service free of cost. More and more of the common people started using contraceptives with spread of information and knowledge about them. Every month the dais received a certain quantity of contraceptives from the thana family planning offices to distribute in the rural areas. They are traditionally engaged as birth attendants in almost all rural families of different income groups and have the opportunity of being acquainted with the mothers including the would be ones, who initially accepted contraceptives only out of curiosity. Very soon they understood their utility. Even an urge for better types of contraceptives and birth control methods had developed in them.

IUDs and sterilisation were introduced in 1966. IUDs like plastic loops or plastic coil were delivered in the beginning by lady doctors in the hospitals and clinics. Lady health visitors serving in charitable dispensaries of the district council or in the sub-divisional hospitals of the health department also did the same job. Later, they were given the training on how to insert IUDs and were appointed as paramedics. They performed the IUD insertion usually in a prearranged space in the thana family planning office, in a common-room of a primary school, in a union council office or in an unused union agricultural seed store building. The lady family planning visitor was accompanied by the thana family planning assistants, who carried with them the necessary logistics and clinical instruments like uterine sound, volselum forceps, speculum duct, scissors, dialator, antiseptics, spirit lamp, stove, torch and Mackintosh sheet. Technical requisites like insertion tables were not available in the villages and so, very simple choukis (bedstead) were used. Every month the thana family planning officer initiated a programme of distributing monthly allowances to the dais and supplying them with conventional contraceptives for distribution to the clients. This was also accompanied by programmes of IUD insertion and male sterilisation. General physicians were given training to perform sterilisation of male (vasectomy) and female (tubectomy or tubeligation). Records of performances and of incentive money paid to the service receivers were maintained in registers.

After 1971, the government of Bangladesh took an initiative of making the clinical service delivery system more effective through inclusion of the medical personnel of the health department in the family planning programme. In 1976, literate and trained female family welfare assistants were deployed in urban and rural areas, at least one for five thousand people. They had the responsibility to contact every eligible couple in one or two months and supply them with oral pills. They were to regularly maintain motivational and service delivery contacts with 800 couples on an average and to refer willing couples to receive clinical methods of family planning from the temporary service delivery centres. The government established one permanent health and family welfare centre in each union and twelve family welfare visitor training centres in headquarters of twelve large districts. The mother and child services programme was integrated with family planning services. Maternal and child welfare centres (MCWC) were established in some district and sub-divisional towns.

During 1978-80, each of the district MCWCs received an assistant director and a thana medical officer was appointed in each thana to supervise and monitor the service delivery system. A coordinated service delivery system at the thana and ward level within the integrated health and family planning programme was introduced in the beginning of 1980s. In the later half of the decade, attempts were made to enlist all the eligible couples. Family welfare assistants started making record of their demographic characteristics and reproductive health and fertility behaviour. A strong basis for a scientific population control planning programme was set. Satellite clinic programme was organised in all wards, where there was no health and family welfare centre. These clinics offered health education, primary healthcare and family planning services (supply of hormonal oral pills and condoms, pushing of hormonal injectables).

As the family planning programmes became more and more MCH based, emergency obstetric care service and the programme of safe motherhood were introduced in early 1990s. Four model clinics in four medical colleges and Mohammadpur Model Clinic (Dhaka) were set up during this period. In 1993, an expert group for field action plan of Bangladesh National Family Planning and MCH programme published its report, which identified some defects in the existing service delivery system. These included a relatively poor maintenance of the FWCs, lack of publicity of the FWC services in the community, inadequate supply of logistics at the FWCs and the satellite clinics, problems of funds and vehicles for logistics transportation from regional warehouses to district reserve stores and satellite clinics, weak counseling, treatment and follow-up of complicated cases of side effects of the use of contraception and of high risk pregnancies, and occasional shortages of emergency and life-saving drugs.

In 1994, an initiative was taken to transform the family planning programme into a reproductive health programme in pursuance of the recommendation of ICPD held in Cairo. Essential Service Package programme was planned in 1998. The programme provided a new approach for developing the tactics and standard of the family planning services. For example, it suggested introduction of a one-stop service for delivering both the health and the family planning services from one centre. It was assumed that instead of delivering services at the doorstep of the service receiver, the service receivers would come to the service providers. Special target population covers the women, children and the poor community. A static service delivery centre in the name of Community Clinic has been designed to be set up for every six thousand persons in both the rural and urban areas.

The expansion of the service delivery system to meet the needs of larger cohorts of women leads to escalation of costs. The government employed approximately 23,500 family welfare assistants and 4,500 family planning inspectors. The yearly expenses in salaries and benefits paid to these workers amount to over 22 million dollars. The costs will increase rapidly with increase in population if the current ratios of eligible couples to field workers and of field workers to supervisors are maintained. Approximately 3,000 Family Welfare Centres and 350 Maternity-Child/Health Family Planning Units now offer services at thana complexes. About 3,700 FWVs, 3,700 ayas, 3,000 medical assistants and 3,000 members of the lower subordinate services are working at FWCs, THCs and satellite clinics. The total annual expenses on salaries and other benefits paid to them account for over 7 million dollars. Escalation of costs in a situation of stagnating or declining donor funds calls for increasing effectiveness and efficiency in service delivery systems and striking a balance between the competing home service and clinic service systems. [Mustafa Hossain]