Real case studies of the national health care models and simulated projections can help visualise a probable model. The urban primary healthcare system in Bangladesh is a good proxy for this exercise because it is defined and information is available. We can easily study the two most significant entities -i the government and the NGO.
The new health policy update (August 2008) has given rise to some heated debates as to the universal right to Primary Health Care (PHC) and the open market approach through "non-state institutions" like the NGOs and the private sector operators. Real case studies of the national health care models and simulated projections can help visualise a probable model.
The urban primary healthcare system in Bangladesh is a good proxy for this exercise because it is defined and information is available. We can easily study the two most significant entities — the government and the NGO.
The government system
In Bangladesh, the publicly financed primary health facility in urban areas is quite poor. There are just 9095 Mother and Child Welfare Centers (MCWC) and 3540 urban dispensaries focusing entirely on primary care. By contrast, rural areas have almost 6,000 primary health care service delivery points.
The NGO system
The urban vacuum in non-commercial primary health care is mostly filled by NGO clinics. Approximately 19% of the total population receives services through an NGO clinic. Currently, two major networks funded by ADB and USAID provide comprehensive PHC (Essential Service Package/ESP) in the urban areas.
The United States Agency for International Development (USAID) has supported NGO service delivery for the past 30 years. The USAID network has evolved from separate rural and urban mechanisms in the first phase (1997-2002) to a unified program in the second phase (2002-2008), and now the Smiling Sun Franchising Program (SSFP: 2008-2011) aims to establishing a franchising network of NGO clinics.
"Franchising itself is a new concept and approach in Bangladesh. It is a system where individuals or businesses (franchisees) invest their assets in a system to utilise the brand name, operating system and ongoing support. Everyone (franchisee) in the system is licensed to use the brand name and operating system. The business relationship is a joint commitment by all franchisees and the franchisor, to get and keep customers. Legally, franchisees are bound use the prescribed marketing and operating systems of the franchisor."
SSFP will try to create an independent health franchise system, building on the existing national network of NGO clinics. This franchise will provide high quality health services generating sufficient income to support approximately 70% of the operational costs while maintaining access to those who cannot pay.
The project will underwrite/subsidise services for the poorest. It uses a build-operate-transfer (BOT) methodology to set a plan for developing the Franchise Manager into an operational entity so that it can assume franchise operations by the end of the project.
Currently, 30 NGOs are providing health care services to women, children and youth through 319 static (facility based) and 7,000 satellite (outreach) clinics in 61 districts of Bangladesh.
The USAID funding for the NGO Service Delivery is on a steady decline, corroborated by the final evaluation report of the 2002-2007 cycle program.
"USAID must make it clear to NGOs that, as of the end of the next project, it will no longer be supporting the operating costs of NGOs. Dependence on USAID must end. The NSDP network will be critical in the long-run since the large urban NGO's should eventually become sustainable, and able to cross-subsidise the rural NGOs."
It is clearly evident that USAID will discontinue funding to the NGO clinics either at the end of the current program or sometime soon thereafter. This is a radical shift from all previous approaches, and will greatly impact the PHC scenario in Bangladesh.
It is important to note that franchising is a new system in Bangladesh and franchising PHC service delivery, which is either a free or largely subsidised service in even the developed world, is going to be a formidable challenge.
In order to make the urban-rural network viable, the rural counterparts will need to be subsidised in varying degrees with the profit made by the urban side. This will substantially reduce the business drive of the successful profit centers (SSFP network clinics).
If this situation lasts for a long period, there is a possibility of successful franchisees dropping out of the network. How the SSFP as a PHC franchising network, and the NGOs as individual organisational entities, deals with this complex transition is a matter for full scale study by itself. The Asian Development Bank (ADB) started its first Urban Primary Health Care Project (UPHCP I) in 1999' The project provides services through a combination; of facility-based (static) and outreach (satellite) clinics^ UPHCP I covered the six city corporations -• Dhakas Sylhet, Chittagong, Barisal, Khulna and Rajshahi.; UPHCP II is ongoing (2005 -2011) and has added five municipalities -- Bogra, Comilla, Sirajgonj, Madhabd) and Savar.
UPHCP II is in expansion with an initial $ 90 million budget, and the objectives are to improve:
• Access to and use of urban PHC services in the pro jectarea;
• The quality of urban PHC services in the project area; and
• The cost-effectiveness, efficiency, and institutional and financial sustainability of urban PHC.
The network consists of 162 Primary Health Care Centers (PHCC) and 19 Comprehensive Reproductive Health Care Centers (CRHCC) offering safe delivery1 and caesarian section. There are an additional 2< Voluntary Counseling and Confidential Testing Centers (VCCTC) and 24 Primary Eye Care Centers (PECC).
The VCCTC provides free HIV counseling and testing and also STI/RT1 diagnosis and treatment. The PECC offers full range of primary eye care including eyesight correction with glasses (optometry). Currently, on an average, the network provides services to 3 million people yearly - mostly the urban poor women and children.
The differences between UPHCP and its USAII> counterpart are:
• The clinics are planned to be housed in own facilities built on land owned by the city corporations or donated by people;
• The service mix includes provision of profit generating components in demand by the local community (ESP+);
• The projects are owned and managed by CCs or municipalities, which forms a basis for sustainability and
• New innovative approaches like public-private partnership with a profit sharing arrangement etc. are encouraged, which has a greater chance of producing a sustainable model.
Considering the current national urban PHC portfolio, UPHCP II seems to combine all essential PHC service elements in a collaborative arrangement between an existing government, structure (Local Government Division of MoLGRD&C), autonomous bodies (CC or municipality), NGOs and private sector.
The government provides the required policy guidance and stability whereas the other components (autonomous bodies, NGOs and private sector) offer vital flexibility in design and operations.
The resulting public-private partnership can be a flagship for the global urban PHC designers and opera -
As a matter of national interest, the civil society and the government policy makers should follow up and facilitate the modeling of SSFP and UPHCP II for adopting the better one. or use a combination approach in future.
Dr. Ishtiaq Shahriar Joartier is the national HIV specialist in UPHCP II.