In 1991 a devastating cyclone hit the district of Chakaria, in western Bangladesh. In the wake of the disaster, foreign aid and aid workers flooded into the region, bringing much needed food, drugs and other supplies. But – in what is still a very conservative, Muslim region – they also bred dependency and mistrust. What was needed, one Bangladeshi NGO resolved, was a real experiment in community participation – a project where the villagers themselves would decide what kind of health services they really needed, plan how they wanted them delivered – and then set about doing it themselves.
And so community doctor Moazzem Houssain, from ICDDR.B (the International Centre of Diarrhoeal Disease Research) took up residence in Chakaria to win round the villagers and get them to work with him on the construction of Chakaria’s first ever health centre. It takes a village tells the story of that experiment, the obstacles the project had to overcome, the successes it’s achieved, and the role that community health care provision can play in a national health care strategy.
In one of the poorest areas of one of the world’s poorest countries, there was a devastating cyclone in 1991. The community of Chakaria in Bangladesh has never really recovered, even today, more than 10 years later, and there is still malnourishment. Even before the disaster, Chakaria had a poor health record.
If the problems of health care were going to be solved long-term, then something new had to happen. So the ICDDRB (International Centre of Diarrhoeal Disease Research), which had been responsible for the relief effort, set up a community health project along the primary health care lines agreed at the WHO Alma Ata Conference on Health for All in 1978.
David Legge of La Trobe University, Australia, explains: “In 1978, 150 countries got together and said that we had to develop a model of primary health care which delivers generalist services locally – which uses appropriate technology, appropriate labour force models. But very importantly, which involves local communities in thinking about the problems they’re facing.”
What was needed was a scheme that at least demonstrated a community participation approach. Something that has the potential to reach the vast numbers of rural poor. If the Government of Bangladesh couldn’t do it then a non-governmental organisation was going to try. Here in Chakaria was a chance to try out a new way of doing things. It wasn’t the easiest of places to experiment with health care.
Most children – 60 per cent – were sick during any two week period. Most were malnourished. Less than half were immunised against measles. There was little family planning. There was high infant and maternal mortality. Diarrhoea was common. Dispensing medicine with unsterile needles was widespread. Few knew about food or water hygiene. There was rickets and endemic malaria.
The villagers were suspicious at first. But soon they learned to develop health awareness. They got to understand the causes of diarrhoea. They found they could buy latrine parts for about $3. Three hundred villagers subscribed – and saved nearly $850. Three hundred latrines were ordered and, overnight, public defecation disappeared, and the instance of diarrhoea decreased.
In 1998 the first of five health posts was built, and paramedics went to be trained. But paying for the service was a problem as Dr Mohamed Iqbal explains: “After one year of activity they found that only the rich people are coming and buying the health card at the cost of taka 50. So they made a list of the poor, the poor families of this area. And then decided they will give the poor families the health card at the rate of taka 10.”
Then they found that many poor people prefer to go to untrained quacks – although they are more expensive. Sometimes it’s because they simply don’t know that the health posts exist. The Chakaria Community Health Project isn’t supposed to be an alternative to Government health care. Right from the start, the project team worked with the nearest hospital and with other community organizations. Health awareness was top priority.
But women suffer particularly in this area. Dr Nandita Nazma of the project team says: “Women in this area, they are very much neglected. They are poor and also they have many children, – they cannot take proper health care for themselves.” Dr Iqbal adds: “The project found that the female health is neglected – so they selected some female health volunteers. They were trained about the female health – What are the health problems, what are the complications of the pregnancy, what to do when a complication arises?”
The Chakaria Health Project now has seven health posts and is setting up 17 ‘mini-posts’ in the isolated hamlets. The number of families buying into the scheme is rising and the annual fee has been reduced. Immunization has increased, there’s less diarrhoea, and health awareness is dramatically improved. So there have been real benefits.
But without running water, villagers have to risk water-borne diseases, caught from ponds. Skin infections, dysentery and malaria all result from the numerous ponds, streams and ditches. And more seriously, women in obstructed labour need to have access to proper operating facilities, and no amount of local involvement can achieve that.
Siobhan Peattie of Save the Children Fund thinks that poverty is the controlling factor, and that community participation can only do so much: “If everybody is very poor, then there is a limit to the amount of service provision that can come from that… So it is a model that can be scaled up, so it’s really an approach, that governments should look at. You really need a lot of input, financial input to make that happen at a population level.”
The Swedish International Development Co-operation Agency (SIDA) has made considerable investments in rural health development in Bangladesh.
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) is an international health and population research and training institute which was established in 1978 to address diarrhoeal diseases and related problems. It is also known as the Centre for Health and Population Research. It has recently published Lessons leaned from Chakaria.
Gonoshasthaya Kendra is an organization bringing health care to the poor of Bangladesh.
The British Government’s Department for International Development (DFID) has issued a Target Strategy Paper on Better Health for Poor People.
A useful source of links on poverty issues is the World Bank’s PovertyNet Web Guide.