Community Led Sustainable Health Program (Second Phase)

VERC has been implementing Community Led Sustainable Health Program since 2006 with the financial and technical supported by SIMAVI, the Netherlands. At the closed of the CLSHP phase-1 activities, in July 2009, the project was assessed and recommended that the project be continued with revised design, emphasizing community empowerment. Accordingly, the second phase was so designed as to cover the entire upazila with the goal of institutionalizing an effective community managed sustainable health service accessible to all focusing on poor women and children.

Goal

Institutionalizing an effective Community Managed Sustainable Health Service accessible to all sections of people focussing on poor women and children in Lalmohan upazila enjoying better health and attaining improved hygiene practices.

Objectives

• To bring about long-term change in behavioural patterns by raising community awareness on health and hygiene issues and thereby improve the status of public health.
• To provide access to quality, affordable and sustainable healthcare services, responding adequately to the beneficiaries’ needs.
• To ensure that all members of the community, regardless of gender, age, disability or socio-economic situation have full access to the healthcare services available and participate fully and effectively in all community led initiatives.

Project Location

District	Sub-district	Unions/ Municipalities
Bhola	Lalmohan	Ramganj
		Lalmohan
		Poshchim Char Umed
		Lord Hardinge
		Dhali Gournagar
		Charvata
		Kolma
		Badarpur
		Farazgonj
		Lalmohan Municipality

Population Coverage

Direct Beneficiaries:
The entire population is expected to be the direct beneficiaries of the project interventions ultimately.  The project presently aims to cover at least 70% of the population, while it emphasises special focus on providing the women and children populations first with the services to be proffered. The demographic statistics indicate that a total 87,030 are females, that is, about 49.24% of the total 252,497 population constitutes females and 70% of the female population means 87,030 heads. Children number 97,729 of the total 252,497 population, of which 112,884 are aged over 18 years and the remainder are under 18, that is, they are all children. Of the children, 70% number 97,729, who are envisaged to be the direct beneficiaries of the VERC project interventions. While earmarking beneficiaries for the project, the poorest of the poor, the most vulnerable, marginalised, disabled, widows, female-headed households will be preferred.

Indirect Beneficiaries:
The male population of 128,168 of the total community population of 252,497 and another 400 government and NGO service providers living as community members will constitute the indirect beneficiaries.

Activities undertaken and accomplished to date

Rapport Building:
As VERC has been working in Lalmohan for a long time implementing safe water, sanitation and health related development activities, the organization has already become very popular with these communities. As the ongoing project is a rights based one and also because it follows and implements a new approach, the project staff have to meet with the Local Government representatives, government officials, NGO personnel and members of the local elite frequently, with a view to keeping close contact and building good working relationship based on cooperation.

CBO Formation:

In order to achieve sustainability, inculcate health seeking behaviour and practices among the community people and to establish easy access to the healthcare services made available at the governmental healthcare facilities and NGOs by their professionals, VERC has formed two types of community based organizations (CBOs), viz. Community Support Groups and  Health Watch Committees. This has been effected for community mobilization involving community members of different age groups, viz. groups of children, adolescent boys and girls and adult males and females.

The group formation is carried out by the local community people and the process is conducted and facilitated by the VERC field staff. All such groups, however, are not identical either in formation or their respective roles and responsibilities. Of the groups formed and envisaged so far, category one is an absolutely formal community based organization, that is, Community Support Group, one is a formal civil society organization, which is, in this case a Health Watch Committee and the remainder groups are informal working groups for performing issue based activities which should form parts of the community mobilization process.

The community based organizations formed under the project are described below.

Community Support Group (CSG): A CSG is by nature a formal community based organization consisting mainly of mothers and members of the community. The responsibilities of the members include carrying out analysis of the existing situation, identification of gaps in the healthcare service delivery system, developing plans of action, creation of supportive environment for accessing the services, breaking the cultural and behavioural barriers and raising an emergency fund for helping out distressed community people during delivery or emergency medical treatment. A CSG will also be responsible for sensitizing and motivating women who are usually victimized in various incidences of different kinds of violence through increasing awareness raising and capacity building initiatives. Each of such groups will comprise of 8-11 community members. A total of 33 community support groups will be formed. In addition to carrying out information dissemination and motivation sessions among the community members so that they are aware of and access the available healthcare services, community support groups will also support the community members to overcome barriers in the utilization of the available services. As a formalized CBO, it will have bylaws and CSG members will prepare yearly plans of actions for providing need based support to the communities with special focus on mothers and children. The details of the Community Support Group (CSG) formation, roles and responsibilities will be explained in the Community Empowerment Strategy. To date, 30 Community Support Groups have been formed. The CSGs are organizing monthly meetings on a regular basis and keeping the meeting minutes.

Health Watch Committee (HWC):  The HWC is a Civil Society Organization (CSO) comprising of local leaders, members of the elite, influential people, religious leaders and representatives from marginalized groups. Each HWC will have 11 members. The main responsibilities of the HWCs include carrying out negotiations with the service providers and their controllers for rescheduling the available healthcare in accordance with the needs of the community people and playing a watchdog’s  role so that the members of the communities are able to access the services as required in a sustainable manner. As a Civil Society Organization, the HWC will have formal bye-laws for guiding these organizations effectively through facilitating the Union Parishad (UP) Health Standing Committee and Upazila Management Committee. The HWC will also adopt a rights based approach through revitalization of the Union Parishad Health Standing Committee and the Upazila Management Committee. Also, for protecting women against violence and proper maintenance and improvement of their Sexual and Reproductive Health (SRH), the HWC will undertake and carry out advocacy programmes through mobilizing the Local Government Institutions both at the Union and Upazila level. The HWC will also lobby the government administration at the sub-district (Upazila) and central level with a view to promoting health and social protection rights of women as well as protecting women against all kinds of violence and violations relating to their health and social protection rights. The HWC will also try to create an environment for improving the existing healthcare services offered at the union and upazila level health facilities through involving the Local Government Institution bodies and concerned government administration and Health Management Committee. The details of the Health Watch Committee (HWC) formation, roles and responsibilities will be explained in the Community Empowerment Strategy.   Under the project, 11 Health Watch Committees have been formed and they are organizing regular meeting and document the meeting minutes.

Mobilization Group Formation:

Adult male and female, adolescent boys and girls and children’s groups: These groups will be treated as informal groups which will be formed for community mobilization and dissemination of health related messages among the community members. They are not to be considered as CBOs; rather they will act as issue based functional groups. These groups do not have any formal structure and bye-laws and will be directed by the team leaders. Adolescent male and female groups should mainly deal with the reproductive health and hygiene issues. In addition, the informal groups will motivate the backward communities to come forward to access the services available at the union and upazila level health facilities. They will also put the members of the community aware of the existing situation if the available services are not based on the needs of the local people. They will also raise a common voice demanding the improvement of the quality of the existing health services. Under the project, altogether 900 mobilization groups will be formed and 150 mobilization groups have been formed to date. These groups are currently engaged in organizing different events such as, the monthly meeting, rallies and marking occasions.

The 10 health messages which have been selected so far for dissemination among the community members cover the following:

1. Sexual and Reproductive Health
2. Family Planning/ Birth Control
3. Maternal Health-- ANC, Birth Planning, PNC
4. New-born care
5. Child Health – Immunization, Diarrhoea, Acute Respiratory Tract Infection
6. Nutrition – Breastfeeding, Supplementary feeding
7. Tuberculosis and Leprosy
8. Water, Sanitation and Environment
9. HIV/ AIDS
10. Information on Available Services at Facilities

 

Linkages between the groups:
Almost all the groups will play befitting roles both individually as well as collectively according to the locals’ needs and nature of intervention. The issues/ concerns are common to all but their degrees and dimensions vary with the variegated contexts/ groups/ actors. The mobilization group will be responsible for community ignition, awareness and mobilization. Community Volunteers will supervise and facilitate the mobilization groups directly.  The Community Support Group will function under the direct facilitation of a Health Motivator and in close collaboration with the Health Watch Committee. The HWC will play the key coordination role as the watchdog actor establishing and monitoring operational linkages between the Community Support Groups, other non-formal groups and the Local Government. Along with monitoring various practices promotion, activities such as carrying out campaigns, rallies and marking various days will be executed by the children’s groups will be overseen by the HWC. The HWC will act as an umbrella organization for all groups. It will also provide effective back-up to all groups while they carry out their respective roles and functions. The Health Watch Committee will be facilitated by a Program Organizer.

Capacity Building
Review and updating Training Module/ Manual:
A daylong meeting was organized for reviewing and updating the project training module/ manual by a team of nine professionals from among the VERC Training Cell personnel and senior staff members of the Community Led Sustainable Health Programme. Before finalization of the training module and manual, relevant training materials were gathered  from various different sources. The team reviewed and modified the existing training module and developed the course outline. At the same time, the team has set the time for oraganising and conducting the training during March-June 2010. The outlines of the following training programmes are given below:

1. Training in community mobilization and motivation techniques
2. ToT on prevention and promotion of healthcare issues

Project Orientation-cum-Training:
Health rights for all and ensuring access of all to the existing health services are the leitmotifs of the project titled “Community Led Sustainable Health Program (Second Phase)” which VERC is implementing in Lalmohan sub-district under Bhola district. In order to implement the project successfully, a 2-day project orientation-cum-training was organized during 3-4 February 2010. The project works on a wholly rights based approach. Therefore, the training sessions were designed and developed in such a way that both theoretical as well as group work were integral components of the training. The theoretical sessions discussed the conceptual aspects of the project such as the project goal, objectives, strategies, exit strategies and so on. The group work sessions mainly focused on sharing ideas about the formation of the CBOs, ways of achieving entries into and interaction with the communities and establishing and maintaining linkages between the groups.
Summing it all up, the training sessions seemed quite successful, as all the participants appeared to have received the messages about the project strategies and interventions clearly. 

Training in Community Mobilization:

VERC is recognized as a pioneering developer and innovator of new techniques for promoting sustainable development, particularly focusing on participatory methods whereby the community people are empowered through awareness raising to be able to take decisions on their own and implement actions themselves. VERC believes that only through community people taking up responsibilities for the improvement of their lot and situation, development initiatives can be made sustainable in the long term. VERC firmly believes that its dedicated staffmembers and community catalysts are the key actors in all its community-centred activities and achievements. In this regard, VERC has been continuously active in exploring and enhancing human potentialities through offering training and holding workshops, orientation and experience sharing sessions within the organization as well as consolidating learning from the community. VERC conducted a 5- day training course on “Community Mobilization” for Programme Organizers, Paramedics and Health Motivators during 21-25 March 2010 at Lalmohan, Bhola. A total of 30 project staff participated in the training. The objectives of the training course were to enhance

knowledge, skills and attitudes of the “Community Led Sustainable Health Program” project staff so that they should be able to act meaningfully and effectively promoting the leitmotifs of the new approach. The specific objectives of the training were to enable the trainees understand the community and community analysis, ways to communicate effectively, the importance of motivation, history and strategies of participation, CBO formation and facilitation and participatory monitoring, among other things. Ms. Laila Ishrat Jahan, Assistant Coordinator, Health Programme of VERC coordinated the programme from the headquarters. The training course was so designed as it earmarked 2 days for field practices and the remainder days were spent in in-house discussions and demonstrations. Mr. Subash Chandra Saha, Coordinator, Training and Communication Section of VERC and Khandoker Faisal, Assistant Coordinator facilitated the 5-day training course. 

Health Service Delivery
As per the new approach adopted, VERC will provide healthcare services through satellite clinics in the areas where governmental or NGOs services are hard to reach. The existing gaps in healthcare services are being located following enquiries and inventorying. It is expected that from April 2010 onward, the project will be able to set up and hold satellite clinics in the areas already earmarked. During the immediate past quarter, satellite clinics were held regularly in the previously selected areas. The description of satellite clinics commissioned is given below. 

-Satellite clinic
The project established 09 satellite clinics in different places of Dhali Gournagar, Char Vata and Ramganj unions of Lalmohan upazila. The project is committed to putting in its best efforts in establishing required number of satellite clinics in the areas. A satellite clinic provides health services from 10am to 4pm daily.

It is understood from the field experience accounts that all the satellite clinics are functioning properly and there is huge demand for services offered which asks for establishment of more satellite clinics for providing more services to the communities. The staff are working on identifying and finding out acceptable ways and means to increase their services in the project areas.

Under each satellite clinic, one paramedic and one health assistant are now effectively serving the community members. In order to make the satellite clinics more effective and operational, two more health motivators and five volunteers are mobilizing the local community of each catchment area under a satellite clinic. The work force is found to be providing adequate health services among the people in the community. From the current evaluation, it is perceived that people of the community expressed their full satisfaction about the quality of service provided by the team. But the beneficiaries require more and more health care services from the satellite clinics.

The satellite clinics are movable establishments and they are used to providing health services in most cases from the premises of some socially enlightened community leaders or some member of the local elite. Local elite consider it a symbol of prestige to serve the people in the community by offering to house the satellite clinic within the premises of their establishments. Therefore, finding a suitable place for establishing or operating satellite clinics is not a problem in the area. Therefore, the expansion of the service through commissioning more satellite clinics is not a problem and full utilization of the available limited resources is also ensured as the needs are great and pronounced.

During the period under review (October 2009 to March 2010), various types of services were provided to a total 2628 beneficiaries. The types of treatment and services received by the people through the programme are described below:  
From October 2009 to June 2010

SL	Services	No. Of Clients
1.	Antenatal checkup (ANC)	2053
2.	Postnatal checkup (PNC)	219
3.	Pelvic Inflammatory Diseases (PID)	50
4.	Fever, common cold and general weakness	293
5.	Gastric ulcer	217
6.	Skin diseases	21
7.	Diarrhea and dysentery	21
8.	Children under-5 (Acute Respiratory Infection)	05
9.	Children under-5 (diarrhoea)	04
10.	Family Planning method acceptance	-
11.	Counseling	18
12.	Other diseases	147
13.	Diagnostic services	434
Total		3482

Information regarding safe delivery:
From October 2009 to June 2010

Number of pregnant mothers			Delivery and others					Total no of pregnant mothers at the end of March 2010         (1-2)
At the end of October 2009	Newly detected during the period	Total pregnant mothers (1)	Delivery conducted by			Others	Total (2)
			Hospital, clinic, doctor, nurse	Trained TBA	Un-trained person
1198	1773	2971	216	531	751	02	1500	1471

 (*) Abortion  

Clients referred to Government health centres
VERC has developed good working relationship with the governmental hospital as well as NGOs active locally. In case the VERC staff come across any critical case which they are not able to handle or manage, they readily refer the mother to the government hospital and/ or NGOs, as appropriate. The records of all such referrals are maintained in specific registers. On the other hand, VERC is also used to practiseng resource sharing, seeking assistance from other NGOs.

Client Contribution
Although client contribution is a complementary as well as supplementary factor for achieving sustainability of the health programme, the initiation of the process has been kind of hampered as health cards distribution among the clients could not be accomplished during the reporting period because the task of new site selection for the satellite clinics has not been completed yet. Free treatment has been provided to 12 hardcore poor patients. The chart below depicts the client contribution picture at a glance during the period under review.

From October 2009 to June 2010

SL	Particular	October 2009 to June 2010
		Clients	BDT
1	Service charge	3032	30320
2	Pathological test charges	434	20622
3	Sale of medicine	--	74,694
4	Providing treatment without services	16	--
Total		3482	125,636

 
Advocacy
Advocacy constitutes the key activity carried out by VERC for ensuring everybody’s access to healthcare services. The major advocacy activities envisaged and undertaken by the organization are given below.

Collaboration and Coordination with Local Government & GO-NGO:
VERC continuously collaborate and coordinate with the local government and GO-NGOs for ensuring the health service delivery and improved access of the poorest communities.  Such lobbying is done in collaboration with CBOs (CGS, HWC) so that the targeted population get quality health services at free/ affordable cost. Besides, VERC regularly conducts GO-NGO collaboration workshops with a view to addressing the preventive and curative health service needs of people of the catchments areas. The project staff regularly hold meetings with government officers and other concerned officials and people as part of the lobby and advocacy activities. VERC also lobbies the local government institutions for ensuring the services for the poorest in collaboration with the CBOs in a sustainable manner. Marking various special days and occasions such as the World/ National Immunization Days, World AIDS Day, Environmental Days etc also form part of VERC’s advocacy work.   

Launching Workshop:
VERC has successfully organized the district level workshop cum Launching Workshop of Community Led Sustainable Health Project (second phase) at National Press Club on 16 June 2010 . The Chief Guest of the workshop was Mr. M Hafizuddin Khan, Advisor of the former Caretaker Government of Bangladesh. Mr. Mahamudul Kabir, Country Director, TDH-Netherlands and Dr. Dibalok Singh, Executive Director, DSK were present as special guests. The purpose of the workshop was to disseminate the project activities and how VERC hard to reach the hardcore people for health care services. More than 100 participants covering donors, International NGOs, NGOs, doctors and journalist participated in the workshop. Ten daily newspapers were published the news and 2 TV channels telecasted the news of the workshop. This workshop was highly appreciated by health practitioner, NGO personnel, civil society and donor communities.

Union Level workshops:
The project orientation workshop was organized at Ramganj union parishad office on 30 March 2010 with the former chairman of Ramganj Union Parishad as the chief guest. Around 60 people attended the workshop. The purpose of the workshop was to share the aim and objectives of the project, the role of the Community Support Groups and the Health Watch Committees and how these groups supplement and complement the Governmental Health Committees activities both at the Union and Upazila level envisaged to meet the basic community health needs.

A Case study

My savings are my support

Paschim Ramganj is a tiny village of Ramganj union under Lalmohan sub-district of Bhola district. It is 3 km away from Ramganj Bazar. Shahanaz is a 23 years old married woman who lives in this village with her husband Jashim, an electrician. When she conceived for the seventh time, it was settled at the family level that one of their neighbours would help deliver her baby. But when the time for her delivery neared, she started having pain and she was seen suffering from labour pain for three long days. Despite unbearable pain, there was no move for transferring her to the hospital as her financial condition was acutely distressful. Her husband was also working as a day labourer and could not afford to take Shahanaz to any health facility. In fact, they had no practical preparation or arrangements made for delivery of the baby. Suffering excruciating pain for three days, she suffered a stillbirth, that is, she gave birth to a dead child.

Having experienced all the pains and the sad losses, Shahanaz’s mind-set should have changed but unfortunately she was not so much changed because she was prejudiced and believed that it was what the almighty had kept in store for her and so it was irreversible. Shahanaz, however, was persuaded and motivated to attend the meetings organised and facilitated by the VERC staff, where she came to know about ANC, PNC, nutrition, sexual and reproductive health and preparatory arrangements for delivery etc. Eventually, she became a regular attending all the meetings. As an active group member, she started putting in 30 taka every week in a piggy bank (locally called ‘matir bank’, that is earthen bank). Her savings now stand at 800 taka. She has in the meantime conceived again and her expected day of delivery is in June. Shahanaz hopes that she will be able to deposit a good amount of money by June which will help her meet the emergency and other expenses during the child. Following her example and resolve, other pregnant women in the same village are also resorting to raise a little savings for the purpose.

VERC staff replicate these good practices throughout the project area. Shahanaz says she is grateful to VERC and she wishes VERC activities all success.

 

Md. Shahabuddin
Health Motivator
Ramganj

 

Significant document developed:  

Under the project period the there important documents were developed which are as follows:

1. Develop and share a detailed community empowerment strategy including the strategy on right based approach (see the detailed report-- annexure-A)
2. Develop and share community IEC/ BCC strategy including KAP and community monitoring tools (see the detailed report-- annexure-B)
3. Share baseline survey (see the detailed report-- annexure-C).

Constraints
The constraints experienced by the project personnel while initiating the project interventions in the area may be summarized as follows:

• While VERC has been awaiting NGO Bureau’s approval and clearance as regards the project’s funding, the organisation’s workers in the field bore the brunt of the delays as all planned activities could not be implemented as scheduled.
• Since to many project staff and the community volunteers, the project’s ‘rights based approach’ is a ‘new approach’, relevant motivational tools and training are a requirement to orientate and familiarize the field level implementers better with the ‘new’ concepts. 
• As the sites for the satellite clinics have not yet been finalized, health card distribution among the beneficiaries could not be accomplished.
• Due to widespread ignorance and religious prejudices,  people do not seem so willing to listen to, accept and practice the health messages and tips on sexual and reproductive health, safe sex etc.

 

Lessons Learnt
The lessons learnt by the project workers and the realizations dawned on the directing staff while implementing the initializing activities have been encapsulated as follows:

• Receiving health care services at the government healthcare facilities from the government employed medical professionals is among the basic rights of the people recognized by our constitution.
• It is a fact that most of the grassroots are not even aware of this ‘right’ and hence the widespread popular nonchalance and lack of interest in obtaining information about the available facilities and the services and tips on ways of accessing the same. The project, therefore, is moving in the right direction while it provides the communities assistance in establishing their ‘health rights’.
• Health services delivery centres being introduced under the project have to be so meticulously planned and carefully run that they may serve as models for other such service providers in the project area .
• It is imperative that in pursuance of the project’s the right based approach, the project workers carry on with their rapport building activities and hold motivation meetings regularly without fail, as such interventions are crucial to effect positive changes in the mindset of the community people.
• Project Community Support Groups and Health Watch Committees have proved effective in playing significant roles in the process of rendering the community people aware of their health rights and establishing people’s access to the healthcare services.