The Annual Report for the Kailakuri Health Care Project (KHCP) for the year 2009
Aim: Health Care for the poor by the poor (in difficult circumstances).
Contents:
1. Introduction. 2. 2009 Statistics at a Glance. 3. Low-Cost Health Care at a Glance. 4. Annual Account for 2009. 5. Donor List. 6. Financial Situation and Budget. 7. Developments and Priorities. 8. The Mother and Child Village Programme. 9. The TB Programme. 10. General Patient Care. 11. The Diabetes Programme. 12. Staff, Training and Health Education. 13. Tribute to Two Stalwarts. 14. Conclusion.
1. Introduction:
Recent reports, surveys and news items present the following information: i) Bangladesh now has a population of 170 million of whom 30% (51 million) live in extreme poverty. ii) Despite enormous expenditures by government and NGOs poverty is not decreasing. iii) The poverty probably derives from a cluster of causes: history and culture, climate and natural disasters, extremely high population, competition for resources, extortion and corruption, landlessness, agricultural and business failures, inability to repay loans, extreme disparity of opportunities, non-availability of work, low incomes, rising prices and exorbitant medical bills. iv) The cost of living has gone up 10% in the last 12 months and rice prices 30%. v) Food, essential commodities and medical care are priced outside the range of the poor. vi) With the expansion of middle classes and purchasing power in India and China prices will continue to increase.
After two years of military backed caretaker government rule elections were held at the end of 2008. There was a return to democratic government with an overwhelming majority supporting the popular Awami League, unfortunately followed by a resurge of corruption, violence and price rigging. The Kailakuri project has sustained its commitment, ideology and activities of health for the poor by the poor. There has been increasing stability of staff expertise, organisation and project administration, and of cohesion between committees, staff, leadership and head office, all committed to the project’s aim and philosophy.
(Last year’s annual report presented an extensive internal evaluation to be found on the project’s website http://sites.google.com/site/kailakurihealth/. This year’s report is therefore shorter).
1. The Village Mother-Child Health Programme (VHP):
Number of villages 17 0% increase End of yr. under 4y children under care 1,139 - 5% Number of women given antenatal care 317 - 44% Number of assisted deliveries 44 - 46%
2. No. of Persons receiving Health Education: appr.25,000 appr. 7%
3. Outpatient Visits: General 18,510 20% increase TB 1,781 - 2% Diabetes 11,483 -1% Total 31,774 7% 4. Inpatient Admissions: General 615 -1% Diabetes 250 -15% Total 865 - 5% 5. End of Year Diabetes Patient No. 1,048 ? 4%
6. No. of TB Patients Treated: 89 3%
7. No. of Surgical Transfer Patients: 40 - 44% 8. Total No. of Staff: 87 - 1% 9. Total Expenditure : Tk. 11,047,000 12% (USD 161,000, NZD 237,000)
3. Low-Cost Health Care at a Glance:
1. Antenatal care in the home for one mother, or 12 months’ health-nutrition care in the home for one child: BDT 550 (USD 8, NZD 12). 2. Six months’ multidrug treatment course for one TB patient (cost to KHCP BDT 1,100 (USD 16, NZD 24) 3. One general outpatient visit (incl. medications): BDT 43 (USD 0.60, NZD 0.90) 4. Cost of keeping one inpatient admitted for one day (incl. medications, food for patient and attendant, etc): BDT 365 (USD 5, NZD 8) 5. Cost of supervision and treatment of one diabetic patient for one year (cost to KHCP): BDT 2,300 (USD 33, NZD 49)
6. Staff pay for 87 staff for one year (incl. doctor): BDT 3,658,000(USD 53,000,NZD 78,000)
7. Average pay for one staff member for one month: BDT 3,500 (USD 51, NZD 75) 8. Total project expenditure for one year: BDT 10,917, 000 (USD 159,000,NZD 234,000) 9. Appr. Cost per Person Touched (appr. 25,000 persons): BDT 425 (USD 6, NZD 9) 10. Fixed Expenditure (total salary bill) per Person Touched: BDT 129 (USD 2, NZD 3).
The KHCP successfully provides health care for the poor by the poor at extremely low-cost. This is possible because actions are simple, investigations minimal, staff non-professional and there is close co-operation with other organisations for cost sharing.
4. Annual Account for the Year 2009-10: (15th February 2009 to 14th February 2010)
Notes:
1. Expenditure Breakdown according to Programme:
2. Approximate Exchange Rates: USD 1 = BDT 68.7, NZD 1 = BDT 46.7, Brit. Stg 1 = BDT 104, Euro 1 = BDT 87.1 (July 2010). 3. Income, receipts and expenditure relate to the project not to the IIRD Head Office. 4. Numbers are rounded. 5. Differences from the official audit are due to i) audit presentation in format of government authorised project budget, ii) annual account’s including of rotating fund, etc. 6. Total expenditure is 11% more than previous year which correlates with the cost of living increase.
5. 2009 Donor and Supporters List:
I. Overseas Donors and Supporters
1. Many American donors giving via the late Fr. Douglas Venne and the Maryknoll Fathers (including several very large private donations). 2. Many New Zealand donors giving via the New Zealand Link Group and the New Zealand Anglican Mission Board (including several very large private donations). 3. The Morgan Family Foundation (New Zealand). 4. The late Fr. Douglas Venne. 5. The late Mrs. Libby Laing and members of the New Zealand Link Group. 6. Asia Connection Incorporated (USA). 7. General Surgical Association, Dunedin (NZ). 8. S. Patrick’s Catholic Church, Lincoln (NZ). 9. The Rotary Club of Newmarket, Auckland (NZ). 10. The Rotary Club of Half Moon Bay, Auckland (NZ). 11. CMS group, Wanganui (NZ). 12. The Rotary Club of Kapti (NZ).
13. The Quail Roost Foundation (USA). 14. American donors giving via Mr. Nicholas Tseffos. 15. The Lions Club of Ohope. 16. S.Luke’s Mission Guild, Havelock North (NZ). 17. A British private donor. 18. An Italian private donor. 19. Korean Presbyterians, Hamilton (NZ). 20. The Rotary Club of Tekuiti (NZ). 21. The New Zealand Bangladeshi Association. 22. Many New Zealanders and groups gave hospitality, transport and support to Dr. Baker during his fund-raising tour are in 2009. 23. The Baker family for their generosity, hospitality and patience. 24. The New Zealand CMS, AAW and CWS for friendship, advice and prayer support.
II. In-Country Support:
1. The Institute of Integrated Rural Development (IIRD, our Parent NGO) provides government authorisation and liaison, the project manager’s salary and other support. 2. BIRDEM Hospital (Diabetes Association of Bangladesh) gives support to our poor diabetics and channels very considerable government aid in the form of concession priced insulin. 3. The Government of Bangladesh gives authorisation, support through BIRDEM and Damien Foundation and local support at Thana level. 4. Damien Foundation provides free investigations and medicines for TB patients. 5. The Bangladesh National Society for the Blind Eye Hospital in Mymensingh provides free or low cost eye surgery for cataract and other eye patients. 6. Notre Dame College, Dhaka provides almost free accommodation for our diabetes and other patients. 7. The Pirgacha Mission, the Maryknoll Fathers and Sisters, the Taizé Brothers and the Marist Brothers and Sisters give various kinds of help including important advice when needed. 8. Prominent Bangladeshi friends in Dhaka city and Modhupur give important advice, encouragement and promotional assistance.
6. Financial Situation and Budget:
I. Income, Expenditure and Balances for 2009-10 and 2010-11 (projected)
II. Income Breakdown: 2009-10 2010-11
III.Foreign Donations:
Notes: 1. The KHCP financial year is 15th February to 14th February. 2. Opening balances are incountry balances. 3. 2009-10 income refers to amounts received in Bangladesh. 2010-11 income is expected global income. 4.
5. The project is a health-medical project. If the medical officer in-charge does not give sufficient time to active fund seeking then the project will have to cut essential activities. If he does give sufficient time then medical supervision is in jeopardy. 6. The quickest may out of the dilemma is to bring in an English speaking person skilled in fund-monitoring, correspondence and fund seeking.
7. Developments and Priorities:
Over the past year the project has sustained its vision, commitment and activities, staff are stronger, management better and patient number increases less. Medical supervision however is weaker, running costs greater (and expected to increase with increasing market prices), funding uncertain, the medical officer in-charge older and future leadership unclear. Two of our key promoters (Fr. Douglas and Sr. Libby) have died. However two new funding avenues may open up: i) donations from Rotary Clubs and the commercial sector in Dhaka City (through the kind help of Md. A.F. Nesar Uddin and Md. Mintu Mahmud), although a lot of work will probably be required. (Already KHCP has appeared on two television channels and been reported in the leading national newspaper.) ii) American donors from Wisconsin through the help of Mr. Nicholas Tseffos a medical student who visited in January 2010. We are very grateful to these three friends. The project has gained an energetic new project manager, Mr. Pijon Momin, a Mandi tribal, and a devoted lady doctor from Japan, Dr. Mariko Inui. Both are quickly learning the ways of Kailakuri (and the language in the case of Dr. Mariko) and are a great hope for the future.
The present top priorities for sustainability are: i) to find an English speaking correspondent-fund seeker-management upgrader. ii) to find a long term doctor who will in due course take over medical supervision of the entire project. When a person is found for the first position then the present medical officer in-charge will be able to prioritize medical supervision, problem solving and hunting for a long term doctor.
8. The Mother, Child Village Health Programme (VHP):
Realistic effective mother child health activity is essential to community health upgrade and one of its most effective components.
Statistics for 2009:
Number of Villages: 17 (population about 12,200).
Staff: 17 (6% drop): Village workers 11, supervisors 6.
Under-4 yr. Child Care: 1139 children (5% less than 2007) were under growth-health supervision at year’s end. Weight chart survey showed nutrition problems in only 3%! (failure to gain weight over three consecutive months, drop of 0.8 kg not yet regained or below 3rd centile on weight chart).
Immunisations: Staff continue to support the government E.P.I. programme.
Antenatal Care: 312 mother were given antenatal care (45% less than 2008, 34% due to loss of Shulakuri mothers due to take over of the area by another NGO, 11% probably due to mothers having fever pregnancies).
Delivery Care: 25% of antenatal care mothers had staff assisted deliveries; many of the others were assisted by government or NGO trained birth attendants. Altogether 44 deliveries (46% less than 2008) were assisted by KHCP staff, 32 in their homes (36% drop) and 12 at the clinic (63% drop). Most of the latter were non-antenatal care mother from outside the area.
Family Planning: VHP staff motivate for work done by government although 41 couples received oral contraceptives from the VHP. 27% of these stopped during the year, most to change to another family planning method.
Nationwide the efficacy of family planning population control activities depends on government commitment and the availability of free components through government programmes or at low cost commercially. Two child families have become the norm in our area. Family, community and national needs for spacing and number planning have to be weighed up against ethical aspects and effects on population structure.
Religio-ethnic Breakdown (relevant because of the very distinct division into different communities)
The total cost of the VHP for 12 months was BDT 1,000,000 (USD 15,000, NZD 21,000), about BDT 550 (USD 8, NZD 12) per mother or child cared for. In terms of cost-patient benefit the VHP is thus KHCP’s top priority. Restructuring and increasing the areas covered would make the cost benefit even greater.
9. The TB Programme:
Worldwide TB is still an enormous problem and the third highest cause of adult death. Bangladesh is rated sixth amongst the world’s 22 worst countries and has the fifth greatest problem of multiple drug resistance. Reasons for the very high prevalence are poverty, malnutrition, high population density and poor working conditions in factories. TB is a major obstacle to poverty eradication.
The most realistic means of prevention is to decrease the number of infectious (sputum positive) cases in the community. (BCG is effective for preventing childhood TB but does not prevent adult cases or affect community prevalence). In 1993 WHO declared TB a global emergency and introduced the direct observation treatment short term (DOTS) programme which is now active in all districts of Bangladesh. The country is considered to produce 300,000 new cases and year. With 92% treatment success but only 72% detection rate action is now needed to increase the latter to 90% as quickly as possible.
The most important causes of multiple drug resistance are irregular treatment and default. In Bangladesh the reasons are: the long duration of treatment needed, the large number of patients going to private doctors with no system of follow-up, drug side effects and problems within TB health services.
Kailakuri Results
I. Success Rate: 63 sputum positive patients started treatment between October 2008 and September 2009. 13 were subsequently transferred to other centres. Of the remaining 50, 47 were cured (ie: 94%, excellent results).
II. 2009 Statistics:
Total number treated 89 No. continuing from 2008 25 Started in 2009 + 60 (19% less than 2008)
Transferred - 8 Defaulted - 0 - 58 Died - 0 Continuing into 2010 27 (Preventive treatment 4)
III. Patient Analysis: Category 1 (new sputum positive) 82 (96%) Category 2 (retreatment) 3 (4%) Category 3 (non-pulmonary) 0 (0%) 100% followed treatment regularly. 4% also had diabetes. 69% lived within five miles (21% within two miles). 42% were under 30 years’ age. (Male 72%, female 28%; Muslim 80%, Christian 14%, Hindu 6%). 16 patients (19%) were hospitalised (eight at Kailakuri and eight at Jalchatra).
The total cost of the TB programme to KHCP for the 12 months was BDT 100,000 (USD 1,500, NZD 2,000). The cost per patient was BDT 1,100 (USD 16, NZD 24).
10. General Patient Care:
General patient care although appearing as the apparently cheapest intervention (in terms of cost of one visit and one day’s admission) in the KHCP, this is a bit deceptive in that the measures are not in numbers of patients.
2009 Statistics
I. Outpatients:
Total number of patient visits: 18,510 (20% more than in 2008). Muslim 86%, Mandi 12%, Hindu 2%. Male 37%, female 63%. Under 5 yr. children 14%, Distance of home 0-2 miles 38%, 3-5 miles 47%, over five miles 15%. Top ten problems: peptic ulcer, pains, asthma, gynecological problems, weakness, anaemia, epilepsy, otitis media, hypertension, urinary tract infections (followed by worms, skin infections and sores, fevers and diarrhoeal diseases).
The cost of running the general outpatient department for 12 months was approximately BDT 790,000 (USD 11,500, NZD 17,000) making cost per visit BDT 43 (USD 0.60, NZD 0.90) which includes staff salaries, medicines, stationary, etc.
II. Inpatients:
Total number of admissions (general plus diabetes) 865 (5% less than 2008). General patients 615 (1% less than 2008). Diabetes patients 250 (18% less than 2008). The average number of admitted patients (general plus diabetes) was 31 and the average duration of stay was 11 days. (Muslim 72%, Mandi 21%, Hindu 7%; male 51%, female 49%, under 5 years 25%).
Top Ten Problems (for general patients): pregnancy-delivery-newborn problems, diarrhoeal diseases, malnutrition, fevers, genito-urinary problems, injuries and burns, respiratory infections, poisoning, bronchitis/asthma, neurological problems (followed by peptic ulcer and its complications, anaemia, skin problems and psychiatric problems).
The cost of running the inpatient department (general plus diabetes) for 12 months was BDT 3,570,000 (USD 52,000, NZD 76,000). This comes to BDT 4,000 (USD 60, NZD 86) per patient. With average stay of 11 days that is BDT 365 USD 5, NZD 5) per day.
Surgical Transfer: 40 (44% less than 2008)
11. The Diabetes Programme:
Diabetes patients are traditionally considered to be Type 1 (insulin production problem) or Type 2 (insulin action problem). Type 1s are usually a younger age group presenting early with florid symptoms (passing huge amounts of urine with severe weakness and wasting) while Type 2s are usually older with few symptoms and presenting late. Type 2 numbers in Bangladesh have exploded perhaps mainly due to life style change although recent research suggests that machine husking of rice may be highly significant. The prevalence of diabetes in Bangladesh is now much greater than that of active TB. TB is curable. Diabetes is life-long but controllable. Diabetes accounts for about a third of the work and expenditure of the Kailakuri project. Kailakuri Statistics for 2009 Total number of patients treated ? 1255 (Uncertainty relates to tablet patient numbers, see below) End of Year Patient Analysis: Total number: 1048 (? 4% increase on 2008, insulin 3%, tablet patients ? 6%). Treatment: Insulin 639 (61%), tablets 409 (39%) Religio-ethnic breakdown: Muslim 96%, Hindu 3%, Christian 1%. The overwhelming majority is Muslim, in excess of their proportion in the population, probably due to word-of-mouth information about Kailakuri services.
Type 1 patients require insulin for survival. Type 2 patients are usually controllable for a long time with diet and tablets but later frequently need insulin for diabetes control. Kailakuri tablet patients are probably all Type 2. Probably at least a third of the insulin patients are also Type 2. Because the records of the insulin patients are retained at the project centre their statistics are fairly reliable. Tablet patients are registered but hold their own records. Hence their statistics are less reliable. Insulin Patients Total number treated in year 690 (17% increase) Continuing from 2008 618 Started in 2009 +72
Defaulted - 18 Died - 21 - 39 (6%) Continuing into 2010 639 (3% increase) (12 less-poor patients were transferred to BIRDEM district branches, too costly for the others).
End of Year Insulin Patient Analysis Total number of patients 639 (3% increase) Regular outpatient attendance 83% Diabetes control (Benedict): good 85%, fair 11% Distance of home from nearest sub-centre: Within 15 miles 63% (0-5 miles 26%, 5-10 miles 21%) Functional literacy 65% Under 30 y age 52% (under 21y 21%) Economic status: very poor 41%, extremely poor 13% (based on home visit assessment) Male 52%, female 48%
Regular Tablet (Glibenclamide) Patients Total number treated ? 565 Continuing from 2008 ? 385 Started in 2009 +180 Transferred out -13 (? 2%) Irregular, defaulted or died (lost to the project) - 143 (? 25%) Continuing into 2010 409 (? 72%) (13 less-poor patients were transferred to BIRDEM district branches). End of Year Tablet Patients Total number 800 Regular 409 (49%) Analysis of 409 Regular Outpatient Attenders Diabetes control (Benedict): good 82%, fair 12% Distance of home from nearest sub-centre: Within 15 miles, 68% (0-5 miles 20%, 6-10 miles 24%) Functional literacy appr. 75% Under 30y age 5% (under 21y 1%) Economic situation: Very poor 49%, extremely poor 26% (assessment made without home visits). Male 28%, female 72%. Diabetes Patients Admitted at Kailakuri: Total 250 (18% less than 2008, probably due to fewer new patients plus efforts to keep numbers down). The main reason for admission was for diabetes teaching and control together with the need for health build up (46%, almost all insulin patients before or after going to Dhaka for registration). Other problems were: diabetic ulcers, cataracts going for surgery, pregnancy, etc.
Notes: i) Over half the tablet patients attend irregularly and are either discharged or lost to the programme. A considerable proportion of the insulin patients are flagrant Type 1s requiring costly insulin for survival and supervision to prevent life-threatening acute complications. They are given initial hospital admission at Kailakuri and intensive teaching and follow-up. There are few drop-outs. The regularly attending tablet patients are quite comparable to the insulin patients in distance from sub-centres and quality of diabetes control. They are very distinctly an older group and the female proportion is dramatically greater than the male (even more so than for general out-patients. The KHCP is patient friendly and woman friendly. It may be that males are less willing to give up time coming for problems they feel to be less threatening). ii) The danger of chronic complications (ulcers, kidneys, strokes, eyes, etc.) is the same for Type 1 and Type 2, However Type 2 patients being relatively symptom free are likely to have been living with diabetes for a number of years before presentation and therefore develop complications sooner. At the present time the Kailakuri project is severely stressed caring for its existing number of diabetes patients and is not in a position to try to retain more Type 2s.
New Insulin Patients sent for concession insulin registration to BIRDEM Hospital, Dhaka Number of patients sent 72 (11% less than 2008) Travel cost BDT 105,000 (USD 1,500, NZD 2,000), 52% increase Average cost per patient BDT 1,500 (USD 22, NZD 32), 70% increase The high cost of sending the patients to Dhaka is quickly recovered by the insulin price co-cessions.
Estimated Cost of the Diabetes Programme (to KHCP)
The cost to the project was BDT 2,927,000 (USD 42,000, NZD 63,000) about 27% of the KHCP expenditure for the year and about BDT 2,300 (USD 33, NZD 49) per patient. If the BIRDEM subsidy is added it becomes about BDT 4,600 (USD 66, NZD 99) per year. Diabetes patients are rehabilitated and able to live normal lives and the cost is extremely low.
12. Staff, Training and Health Education:
KHCP has 89 staff led by the medical officer in-charge and the project manager.
I. The Health Action Team 66 (73% of staff). i) Paramedics and health educators 29 (26% of staff) (They are supported by the two qualified doctors but this is still not satisfactory because most of the medical officer in-charge (MOIC)s time goes to fund raising, correspondence and administration and the new doctor although making a significant start on patient care is still immersed in language study) ii) Health assistants 12 (13%) iii) Village child health staff 17 (19%) iv) Cooks 7 (8%) (Of the health action team 37% work with general patients, 34% with diabetes, 26% village mother child care and 3% TB)
II. Support Staff: i) Administration staff 11 (12% of total), including the MOIC. ii) Workers on garden, compound, building, market, etc. 13 (15%).
The project is labour intensive. All staff are payed by the project but for the project manager (by head office) and the new doctor (by Japanese Overseas Christian Service). Staff pay comprises 34% of all costs. Present problems are to find a fund seeker/correspondent and a new long term doctor to replace the MOIC. Four senior paramedics have been through a six month training course in Mymensingh. Even though they only attended one third of classes they still topped their groups. The teaching closely parallels that at Kailakuri and the course allows them to concentrate and systematize their knowledge. Senior paramedics give ongoing training to the rest of the staff. The five health educators give regular teaching in the inpatient and outpatient departments and the diabetes sub-centres. Village staff give regular teaching in the villages.
13. A Tribute to Two Stalwarts:
Fr. Douglas Venne (American Maryknoll) and Sister Libby Laing (New Zealand CMS), our two key funding promoters have died. Fr. Doug was totally committed to the poor. For many years he was an ardent supporter of our work. He gave us thousands of American dollars which had been given to him. He edited our newsletter and encouraged American support for us. He himself lived a life of poverty with the poor in a village near Tangail. Libby served with us for four years developing and stabilising the village mother child programme and training the staff. After completing she continued to visit each year, coordinated the New Zealand Link Group and took an active part in seeking New Zealand support. Many many thousands of poor people have benefited from the labours of these two devoted workers. We honour them and all that they have done. Their work must continue.
14. Conclusion and Sustainability:
Approximately 30% of Bangladesh’s 170 million people are in extreme poverty and often unable to access basic health services without expenditures that either throw then into debt or require them to sell off essential resources. Either way they are driven further into poverty.
The KHCP successfully provides basic health care for the poor by the poor at extremely low cost. Even so funds have to be found. Health for the poor by the poor cannot be self-supporting because it is not possible to get costs low enough. This however is just a reflection of the root problem which is world wide. Poverty is vast and increasing. Those enmeshed are often unable to access even minimal basic necessities. They have to get themselves out of the situation by their own efforts but cannot do so without external facilitation and support (and maybe community structural changes). How this problem is managed affects the human race as a whole in terms of its readiness to acknowledge problems, how it analyses them, formation of attitudes and values, relationships, decision-making, actions and reactions. By its decision making the species develops its characteristics and determines its evolution, determining not only its external but also its internal ecology.
Almost all the KHCP’s funds come from overseas (apart from the very substantial support of BIRDEM Hospital, Damien Foundation, Mymensingh Eye Hospital and others). Costs are rising and the international economic situation is in difficulties. The project’s sustainability depends on:
I. in the short term: i) limiting size ii) finding an English-speaking person for fund-monitoring, correspondence,fund seeking, etc. iii) finding another doctor for overall medical supervision of the whole project (to eventually replace the present medical officer in-charge)
II. in the long term: i) appropriate promotion so that a significant portion of funding comes from within the country. ii) finding a suitable totally committed national doctor. We believe that concern for the poor, advocacy and making their basic needs accessible are absolutely essential. This is the light in which we see the work of health for the poor by the poor. We are enormously grateful to Almighty God and to all our friends who have made it possible and we pray that in these difficult times it will not cease.
Edric S. Baker Medical Officer In-Charge July 2010.
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