Pluralism in the Health System

3.1 Partnership Approaches

Supplementary

Government engages with one-two NGOs to address specific gaps in government service delivery
Leverage NGO reach to address limitations in service delivery

Complementary

Government partners with multiple NGOs to co-deliver basic services at scale
Extends and compliments government service delivery on a long term basis at national level

Contractual

Government outsources public sector services to NGOs
Fills major gaps in government service delivery

3.2 Public Health system

The public healthcare services are organized along four levels:

Community level healthcare
(provided by the domiciliary health providers and community clinics)
Primary level healthcare
(provided in Rural Health Centers, Union Subcenters, Union Family Welfare Centers, and Upazila Health Complexes)
Secondary level healthcare
(provided in District Hospitals, General Hospitals, Chest Disease Clinics, Tuberculosis Clinics, and Leprosy Hospitals)
Tertiary level healthcare
(provided in Post Graduate Medical Institutes, Specialized Healthcare Centers, Medical College Hospitals, and Infectious Disease Hospitals)

3.3 Private Health system

The private sector includes health facilities ranging from individual doctors’ offices to high-end tertiary (international standards) hospitals.

Formal Health Providers

Latest available health workforce data suggest 60% of health workers are located in the private sector, 36% are employed by the MoHFW, and other ministries account for about 4%. (However, these figures need to be treated with caution because many doctors work across both the public and private sectors.)

Figures from 2012 indicate there are 23 doctors for every 1.5 nurses and every 1 paramedic. This suggests far too few nurses and paramedics.

Informal Health Providers

Semi-qualified allopathic providers include providers who have received training of varying duration from a formal institution in the public or private sector such as the non-profit NGOs.

Para-professionals comprise of the medical assistants who completed a three-year medical assistant training programme from a public institution, mid-wives (family welfare visitor (FWV)) with 18 months training in midwifery and clinical contraception management from public/private institutions, and lab-technicians/physiotherapists
Community health workers (CHWs) from both public and non-governmental organisation (NGO) sectors. The CHWs in the NGO sector outnumber those in the public sector by a ratio of 2:1. CHWs have variable lengths of basic preventive and curative health care training, from various health care providing NGOs mainly, but also from the public sector.

Unqualified allopathic providers included in this category are village doctors and drug store sales people/drug vendors.

The village doctors (also known as rural medical practitioner, RMP) mostly received short training (from a few weeks to a few months) on some common illnesses/conditions, from semi-formal private institutions which are unregistered and unregulated and do not follow a standard curriculum. A negligible proportion of them received twelve months training from a short-lived government sponsored programme (the 'Palli Chikitsok' (PC) training programme, which followed the China's model of barefoot doctors) in the '80s.
Drug store salespeople: most of have had no training in dispensing, not to speak of training in diagnosis and treatment.

Last mile of health system_Bangladesh_ARC.docx

Traditional healers: 'Kabiraj', whose practice is based on diet, herbs, and exercise. They are mostly self-trained, but some may have training from government or private colleges of Ayurvedic medicine. Some of them combine ayurvedic, unani (traditional muslim medicine originating from Greece) and allopathic medicine to provide 'totka' treatment. This category also includes non-secular faith healers.

Traditional birth attendants: includes both trained and non-trained providers who deliver home-based services only.

Homeopaths: mostly self-educated, but some possess a recognized qualification from government or private homeopathic colleges.

To know more, read the attached document.

3.4 The Role of NGOs

A robust NGO sector has developed its own channel of supplementary and complementary CHW programming, matching in scale the government’s CHW cohort. Bangladesh has consistently harnessed such NGO expertise, staffing, and other resources in three ways.

Established and maintained as a result of the inability of the public and private sectors to reach the entire population.

The government has repeatedly and continually asked for NGOs’ assistance and encouraged developing, testing, improving, and expanding its own programming.

NGOs are mainly engaged in increasing service coverage and that with service quality. In terms of service coverage, their emphasis is on newborn health, maternal health, nutrition, health system strengthening, etc. at the PHC level. In terms of population coverage, their main focus is towards the hard-to-reach areas and the population therein. They are focusing on community engagement activities, which may go a long way to demand generation among the population for Universal Health Coverage and also decrease the financial burden for curative care

2239

NGOs are operating in Bangladesh
*as of 2019

255

Foreign NGOs
*as of 2019

8.35%

Total health expenditure originates from direct contributions by NGOs
*as of 2012

Pluralism in the Health System

3.1 Partnership Approaches

3.2 Public Health system

3.3 Private Health system

3.4 The Role of NGOs

Further Reading