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Family Planning Stories From the Field: Bangladesh
As advocates for international family planning assistance, the Global Population and Environment Program works to bring family planning stories from abroad home to our activists. It is imperative that we understand the intrinsic connections between women’s health and the health of the environment so that we can better advocate for the U.S. government to keep its promise to support family planning and reproductive health programs. EngenderHealth Founded in 1943, EngenderHealth is a nonprofit organization that works internationally to support and strengthen reproductive health services for women and men worldwide. EngenderHealth works worldwide to improve the lives of individuals by making reproductive health services safe, available, and sustainable. They provide technical assistance, training, and information, with a focus on practical solutions that improve services where resources are scarce. EngenderHealth believes that individuals have the right to make informed decisions about their reproductive health and to receive care that meets their needs. They work in partnership with governments, institutions, and health care professionals to make this right a reality. Read more about EngenderHealth at: http://www.engenderhealth.org.
Meeting New Challenges in Bangladesh
Still, the rates of maternal illness remain high, and some women must travel long distances to receive care in clinics where their rights to privacy and respect may be disregarded. The quality of care that is available to the wealthy far outstrips what others may obtain. Barriers to quality care continue to persist, and today, EngenderHealth and our partners in Bangladesh face an additional, unusual challenge. During the mid-1990s, the government of Bangladesh embarked on a mission to fundamentally change how health care services would be delivered. Historically, "health" and "family planning" were two separate branches under the Ministry of Health and Family Welfare. Each distinct branch was made up of parallel, vertical structures from the national level down to the smallest village. The system was inefficient, often redundant, and poorly coordinated between programs. Added to this mix were hundreds of nongovernmental organizations (NGOs) offering disparate health care and family planning services. A New Challenge, A New Chance
Management and Service-Delivery Issues The initial changes were introduced in 1998, and, if realized, full integration will eventually involve as many as 100,000 staff members at many different levels. These early efforts have created unforeseen challenges. According to EngenderHealth's Bangladesh Program Manager Dr. Abu Jamil Faisel, "The integration of services had not been well thought out. It began at the bottom level, at the thana or village level and below. There wasn't a clear indication about what would happen at the district level and above. This led to a great deal of confusion, tension, and chaos and was followed by a'wait-and-see' period. The integration has not yet been implemented at higher levels, partly because some of the officials of the new government are against integration and others are taking time to understand the dynamics and intricacies of integration." Early on, family planning officers worried that the experience of nontechnical staff and field workers, the backbone of the successful family planning program, would not be valued once services were integrated. As Dr. Faisel emphasizes, "when you combine two parallel systems, someone has to lose power. In this case it has been the family planning manager, who now must report to a health care manager. However, the health care person doesn't want to give preference to family planning issues. Reproductive health, including family planning, often focuses on preventive care, which is not the priority for most doctors who are often biased towards curative care. These doctors have a long list of conditions to treat and health issues to address. As a result, family planning services at the thana level become very low on the priority list, and the family planning workers began to feel that they have lost power."
EngenderHealth Activities For EngenderHealth, this juncture provides the opportunity to work in a number of key ways. First, our quality improvement tools and approaches are being used in new clinics and throughout the health care system to help ease the transition. These tools are being introduced to the thana-level managers to help the family planning and health staff reorganize and resolve problems proactively. The tools are indispensable for helping to alleviate conflicts between management and staff, enabling health care and family planning workers to voice their opinions, and training managers to listen, respond to, and value the expertise of all staff. Enabling all staff to take ownership of solutions will be especially important, given that reproductive health care workers have specific knowledge crucial to the success of the clinics. While these changes occur, EngenderHealth must also continue our day-to-day work in order to ensure the continuation of appropriate, high-quality reproductive health services. Capitalizing on our long-standing experience in Bangladesh and the opportunities provided by a more efficient service-delivery system, we have concrete, immediate goals. For example, EngenderHealth is working with the Ministry of Health and Family Welfare on a new project that addresses the social marketing of contraceptives. Dr. Faisel stresses the importance of continued emphasis on providing quality services for long-acting methods of contraception-including sterilization, Norplant implants, and IUDs. He explained that "new statistics are raising the alarm for those in the reproductive health care field. The total fertility rate has not decreased in the past six years in part because many women are relying on short-term methods, like pills, condoms, and injectables, which they often stop using after a year." "It remains true," explained Dr. Faisel, "that in the short term, if men and women are not happy with the way they are treated in clinics, they will go to the marketplace where a variety of contraceptives are advertised openly and distributed freely." In the marketplace, women can buy birth control pills, and will soon be able to get injectable contraceptives without ever seeing a doctor. Therefore, it is more important than ever to ensure that clinic-based reproductive health services are easily accessible and client-centered. As the health care landscape in Bangladesh continues to change and the challenges associated with integration continue to unfold, EngenderHealth remains at the forefront. By offering technical assistance at all levels, developing new programs, and directly helping the women and men of Bangladesh to maximize the use of their resources, knowledge, and commitment, we can continue to improve the quality of care for women and their families.
Bangladesh's Environmental Story Sitting at the delta of three mighty rivers-the Ganges, the Brahmaputra, and the Meghna-Bangladesh is an area rich with birds, fish, and endemic wildlife. Bangladesh is made up of tropical and subtropical forests, as well as one of the world's most precious mangrove forests, the Sundarbans. Recognized as a World Heritage Site, the Sundarbans is the world's largest mangrove forest and is the last mangrove that is able to support tigers, along with hundreds of other species of mammals, birds, and fish. Human pressures have taken their toll on Bangladesh's natural wonders; only 6% of intact forest remains in the country and more than 50% of seasonal and perennial wetlands have been encroached upon by agriculture and urban landuse. Floods are a common tragedy as population growth forces people to cultivate these flood-prone areas. The growing number of people born into poverty places yet another strain on natural resources as reliance on the environment for supplemental income activities and additional food sources, such as fish and wildlife, increases. The decline in natural resources devastates people that depend on their local environment to survive harsh times. Bangladesh's environment is not likely to improve until poverty is alleviated and public awareness of environmental devastation is heightened. Read more about Bangladesh's environment at usaid.gov and at panda.org. Read about Bangladesh's Green Umbrella Project at: http://www.green-umbrella.net/
photo of woman Courtesy jhuccp/Lutheran World Relief
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Women in Bangladesh have experienced vast improvements in their health during the past few decades-due in part to an increased nationwide commitment to family planning. When EngenderHealth began working in Bangladesh in the early 1970s, very few women used any form of contraception. Since that time, the contraceptive usage rate has skyrocketed from 3% to 54%. Likewise, the total fertility rate has declined from 6.4 to 3.3 children per woman. Today, when Bangladeshi women choose to use family planning, they no longer face social stigma. Through education, outreach, and commitment, contraception has become a social norm. As a result, women in Bangladesh are having smaller families and are better able to fully participate in their communities and society.
Beginning in 1998, the Ministry of Health and Family Welfare began a six-year reform plan to integrate the two programs. The plan was ambitious, with the promise of many welcome improvements. Early in the planning stages, EngenderHealth helped design the Essential Services Package, which under the new system would guarantee basic health services to all citizens. To increase access and streamline service delivery, the government would build 13,500 new community clinics in villages nationwide, or one clinic for every 6,000 people. Desperately needed in rural areas, these new facilities would bring health care closer to the people.