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Support to the Health, Nutrition
and Population Sector Programme
in Bangladesh
BMZ-No.: 2003 66 237 / 2005 70 424 Health Financing Component
Baseline survey:
to assess the existing capacity of human and other resources for health service
delivery at all levels of the health care system in one upazila from each of 3
selected pilot districts
Presented to: Ministry of Health and Family Welfare KfW Entwicklungsbank Health Economics Unit Palmengartenstr. 5-9 60325 Frankfurt am Main Germany Baseline survey: to assess the existing capacity of
human and other resources for health service delivery
at all levels of the health care system in one upazila
from each of 3 selected pilot districts
Rumana Huque Ph.D. Sushil Ranjan Howlader, Ph.D. Azaher Ali Molla Sharmeen Mobin Bhuiyan
Report prepared for the Health Economics Unit, Ministry of Health
and Family Welfare, Government of Bangladesh, by Institute of
Health Economics, University of Dhaka

June 24, 2012
The research team expresses sincere gratitude to the Health Economics Unit (HEU), Ministry of Health and Family Welfare (MOHFW) for initiating the present and for giving us the opportunity to contribute to the process of implementing the SHASTHYO SHUROKHSHA KARMASUCHI (SSK). We express our sincere thanks to Mr. Md. Ashadul Islam, Joint Chief of HEU and Mr. Abdul Hamid Moral, Senior Assistant Chief of HEU, for facilitating the study and making valuable comments and suggestions at different stages of the work. We would like to take the opportunity to thank Dr Lars Chr. Kyburg, Mr Azmal Kabir and Pulak Priya Mutsuddy, Health Financing Technical Assistance, GFA Consulting Group for their support. We are highly grateful to Prof Shamsuddin Ahmad for providing academic inputs and the necessary managerial support at all stages of the assignment. We are also thankful to Dr. Syed Abdul Hamid for the contributions he made at certain stages of the work. We acknowledge the support of Civil Surgeons, Upazila Health and Family Planning Officers, and other personnel in the three pilot upazilas for providing us required cooperation. We express our thanks to the quality control officer and field investigators for their hard work. Our thanks are specially due to Md. Mojibur Rahman for processing of data. However, we alone are responsible for any error and omission still remaining in the report. EXECUTIVE SUMMARY
Background and general objectives
The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare
(MOHFW) has developed a social health protection scheme termed as Shasthyo
Shurokhsha Karmasuchi (SSK) with the assistance from KfW (German Development
Bank) and GFA Consulting Group. The SSK scheme will focus initially at Upazila
level, it will be scaled up in all districts upon the lessons learned to aim for Universal
Coverage within the Vision 2021. The main objectives of SSK project are to improve
access of the poor to hospital inpatient care, to decentralize hospital activities to
introduce modern Information and Communication Technologies for increased
efficiency and transparency in the health sector.
This study was conducted to assess the overall existing competence of health facilities
at primary levels to meet the needs of the SBP (SSK Benefit Package). The specific
objectives were to assess the existing capacity of the public health care facilities in
terms of availability of personnel and their qualifications, availability of physical
infrastructure, availability of medicines and logistics; to identify the requirement of
additional health service providers, level of staff competence, level of human skills/
training, and the data/ information need to meet the needs of the SBP. It also explored
some management issues including the referral mechanism, financial management
systems, and monitoring and supervision mechanism.
Methodology
The study adopted quantitative techniques including observation checklist and
compilation of service statistics. Further, qualitative techniques including Key
Informant Interview (KII) and document review were employed during the study. The
study was conducted in 3 pilot upazilas: Rangunia (in Chittagong), Debhata (in
Satkhira) and Tungipara (in Gopalganj). These three upazilas have a total of 25 Unions.
All the public facilities- 3 Upazila Health Complex (UHC), 25 Union Health and
Family Welfare Centres (UHFWC)/ Rural Dispensary (RD) and 64 Community Clinics
(CC) providing services in these areas were recruited for the study. Private clinics and
NGOs for the study with at least three beds were also included in the design of the
survey. However, only four private clinics in three areas met this criterion, and no NGO
was found with inpatient department in any of the areas.

Findings

Capacity at different levels:
If we consider the sanctioned post, existing equipment and
infrastructure, then it appears that adequate capacity exists in all the UHCs, not only to
provide services to the existing number of patients but also to provide services in a
situation where number of patient increases by 20% to 30%. UHFWCs have not been
established in some unions of Rangunia. In each upazila some CCs are yet to be
established and some among the established CCs are yet to start functioning.

Human resource:
Underutilisation of human resources is a common phenomenon in
the UHCs in three upazilas. It was evident that 24% of the total sanctioned posts
remained vacant in the three UHCs. However, among them, the proportion of vacant
posts in total posts was highest in Tungipara (45%). It was observed that only 40% of
the employed providers provide services and works for maximum of five hours a day in
all three UHCs. The average number of patients seen per day by a doctor in the
outpatient department in UHC was 45, which implies that on an average a doctor
allocates only four to five minutes per patient. Inappropriate skill-mix was also
common among the three UHCs. Though there were sanctioned posts for anaesthetist,
dental surgeon, store keeper, and statistician, many of these posts were vacant in a
UHC during the survey period. The ratio of nurse to doctor was 1.25 in Debhata, 1.1 in
Tungipara and 0.76 in Rangunia UHC. There was no female doctor in Tungipara UHC.
The ratio of physician per 10,000 population was 0.66, 1 and 0.65 in Debhata,
Tungipara and Rangunia respectively.

Equipments:
The proportion of equipments in the inpatient department remaining out-
of-order is 93% at Rangunia UHC, 56% in Debhata UHC and 62% in Tungipara. A
number of equipments remain unused due to non existence of persons to operate those.
The managers in UHC also faced the problem of inadequate fund available for repair
and maintenance of equipments.

Drugs and logistics:
While supplying drugs and logistics to the UHC, the ‘actual local
need
' is not considered. Drugs are sent from the central level based on the number of
beds. While there remains excess supply of some drugs, a number of drugs are supplied
in inadequate amount. Drug registers are maintained in such a way that disaggregated
numbers of drugs used in the inpatient department and the outpatient department cannot
be obtained. At the end of 2011, 15% of the drugs received were unused at UHCs.
Among the three UHCs, drug usage as a proportion of total drugs received was higher
in Rangunia and lowest in Debhata.

Referral mechanism
: Referral mechanism is almost non-existent in the facilities. The
UHC does not appropriately maintain patient record by name, address, age, gender,
disease condition, diagnosis or treatment protocol. The manual paper-based record
keeping system is time consuming and increases the possibility of error in data
compilation.

Conclusion and recommendations
The existing capacity if assessed in terms of human resources, equipments and
infrastructure is adequate for proving care not only to the current number of patients
but also in a situation when the number of patients increases by 20% or 30%. However,
for proper and efficient utilisation of these inputs, the supply of drugs and logistics
should increase, some equipment should be repaired and some replaced, and input mix
should be made more appropriate. On the basis of the above findings, it is
recommended that:
 Measures need to be taken to ensure that all the employed staff works in the facility for full time, there needs to be adequate number of personnel available for emergency care for 24 hours. An incentive mechanism needs to be devised for providers. Part of the fees collected at upazila level can be retained at local level and paid to the providers.  Supply of drugs and logistics should be based on local need. The amount of drugs and logistics received and utilised and the additional requirement for every three months need to be assessed regularly.  Training of health care providers and support staff is required on issues related to SSK, financial management, Management Information System (MIS), store management, and local level planning.  A comprehensive health information system should be introduced in order to maintain records, to efficiently maintain information flow among the tiers, and for adequate monitoring and evaluation.  Monitoring and supervision at all levels should be strengthened. The same indicators should be used in all the three pilot upazilas to monitor the activities of the insurance scheme. Besides regular monitoring, mid-term project evaluation should be undertaken to assess the impact of the insurance scheme.  The UHFWCs and CCs should be established in all the unions and wards. Besides, the UHFWCs and CCs that have already been established should properly function. This is needed for providing basic outpatient care, for creating demand for health care from the formal sources, and for enforcing referral mechanism. A strong referral mechanism needs to be maintained among different tiers. Table of Contents
Contents
ACKNOWLEDGEMENT .3
EXECUTIVE SUMMARY .4
Table of Contents .7
List of Tables .8
List of Figures .10
List of abbreviations .11
1. INTRODUCTION .13
1.1. Background .13
1.2. Objectives of the study .14
1.3. Organization of the report .14
2. METHODOLOGY .15
2.1. Study design .15
2.2. Data collection methods .15
2.3. Implementation of the study .17
2.4. Data analysis .18
3. FINDINGS IN DEBHATA UPAZILA .19
3.1. Capacity of Debhata UHC .19
3.2. Capacity of the UHFWC .32
3.3. Capacity of Community Clinics .38
3.4. Capacity of the private sector .41
4. FINDINGS IN TUNGIPARA UPAZILA .43
4.1. Capacity of the Tungipara UHC .43
4.2. Capacity of the UHFWC .53
4.3. Capacity of CC .58
4.4. Capacity of the private sector .60
5. FINDINGS IN RANGUNIA UPAZILA .61
5.1. Capacity of the UHC .61
5.2. Capacity of the UHFWC/RD .69
5.3. Capacity of CC .72
5. 4. Capacity of the private sector .75
6. FINDINGS FROM THREE PILOT UPAZILAS: A COMPARATIVE ANALYSIS .76
7. CONCLUSION AND RECOMMENDATIONS .82
REFERENCES .84
ANNEXURE .85
List of Tables
Table 2.1:
Number of unions and public facilities in pilot upazilas List of data collection methods and data collection instruments Groups of variables and sample covered Existing and required human resources at UHC of Debhata Upazila Human resource management indicators in Debhata Educational qualification of he physicians in Debhata UHC Important equipments at UHC of Debhata Upazila Important furniture and fixture at UHC of Debhata Upazila Amount of land and space of UHC of Debhata upazila Drugs received in 2011 by UHC of Debhata upazila Number of patients who visited the UHC by disease and year Existing and required human resources in UHFWCs of Debhata Upazila by designation Important equipments at UHFWC of Debhata Upazila Important furniture and fixture at UHFWC of Debhata Upazila Existing and required infrastructural inputs in UHFWCs of Debhata Upazila Average amount of important drugs received in 2011, inventory, and required amount in UHFWCs of Debhata upazila Average number of patients in the UHFWCs of Debhata upazila in the last three years by disease/condition Number of patients in 2011 by month and UHFWC Existing and required human resources in CCs of Debhatat upazila Important equipments at CCs of Debhata Upazila Important furniture and fixture at CC of Debhata Upazila Existing and required infrastructural inputs in CCs of Debhata Average quantity of drugs received in 2011 by CCs of Debhata Total number of patients in the 12 CCs of Debhata upazila Table 3.4.1 Important equipments at private clinic of Debhata Upazila Table 3.4.2 Important furniture and fixture at private clinic of Debhata Upazila Table 4.1.1 Existing and required human resources at UHC of Tungipara Upazila Table 4.1.2 Human resource management indicators in Debhata Table 4.1.3 Educational qualification of he physicians in Debhata UHC Table 4.1.4 Important equipments at UHC of Tungipara Upazila Table 4.1.5 Important furniture and fixture at UHC of Tungipara Upazila Table 4.1.6 Amount of land and space of UHC of Tungipara upazila Table 4.1.7 Drugs received in 2011 by UHC of Tungipara upazila Table 4.1.8 Supplies and logistics received in 2011 by UHC of Tungipara upazila Table 4.1.9 Number of patients by disease and year in Tungipara UHC Table 4.2.1 Existing and required human resources in UHFWCs of Tungipara Upazila by designation Table 4.2.2 Important equipments at UHFWC of Tungipara Upazila Table 4.2.3 Important furniture and fixture at UHFWC of Tungipara Upazila Table 4.2.4 Existing and required infrastructural inputs in FWCs of Tungipara Table 4.2.5 Average amount of important drugs received in 2011, inventory, and required amount in UHFWCs of Tungipara upazila Table 4.2.6 Average number of patients in the UHFWCs of Tungipara upazila in the last three years by disease/condition Table 4.2.7 Number of patients in 2011 by month and UHFWCs Table 4.3.1 Existing and required human resources in CCs of Tungiparat upazila Table 4.3.2 Important furniture and fixture at CC of Tungipara Upazila Table 4.3.3 Existing and required infrastructural inputs in CCs of Tungipara Upazila Table 4.3.4 Drugs received in 2011 by UHC of Tungiparat upazila Table 4.3.5 Average number of patients in the CCs of Tungipara upazila during 2011 Table 5.1.1 Existing and required human resources at UHC of Rangunia Upazila Table 5.1.2 Human resource management indicators in Rangunua Table 5.1.3 Educational qualification of he physicians in Rangunia UHC Table 5.1.4 Important equipments at UHC of Rangunia Upazila Table 5.1.5 Important furniture and fixture at UHC of Rangunia Upazila Table 5.1.6 Amount of land and space of UHC of Rangunia upazila Table 5.1.7 Drugs received in 2011 by UHC of Rangunia upazila Table 5.1.8 Number of patients who visited the UHC by disease and year in Rangunia Upazila Table 5.2.1 Existing and required human resources in UHFWCs of Rangunia Upazila Table 5.2.2 Important equipments at UHFWC of Rangunia Upazila Table 5.2.3 Important furniture and fixture at UHFWC of Rangunia Upazila Table 5.2.4 Existing and required infrastructural inputs in UHFWCs of Rangunia Table 5.2.5 Average amount of important drugs received in 2011, inventory, and required amount in UHFWCs of Rangunia upazila Table 5.2.6 Average number of patients in the UHFWCs of Rangunia upazila in the last three years by disease/condition Table 5.2.7 Number of patients in 2011 by month and UHFWC Table 5.3.1 Existing and required human resources in CCs of Rangunia upazila Table 5.3.2 Important equipments at CCs of Rangunia Upazila Table 5.3.3 Important furniture and fixture at CC of Rangunia Upazila Table 5.3.4 Average amount of important drugs received in 2011, inventory, and required amount in CCs of Rangunia upazila Table 6.1.1 Selected indicators of human resource management Table 6.1.2 Cost per patient and population Table 6.1.3 Performance of UHC, UHFWC and CCs in three upazilas List of Figures

Figure 1
Proportion of inpatient and outpatient in Debhata UHC, 2010-2011 Percentage distribution of total patients (inpatients and outpatients) by type of disease/condition in 2011 in Debhata UHC Percentage distribution of the inpatients by type of disease/condition in 2011 in Debhata UHC Percentage distribution of the outpatients by type of disease/condition in 2011 in Debhata UHC Number of outdoor and indoor patients by month for 2011 in Debhata UHC Percentage distribution of the patients by type of disease/condition in 2011 in Debhata UHFWCs Proportion of patients in UHFWCs by quarter (2011) Percentage distribution of patients referred to UHC by disease/condition Proportion of inpatient and outpatient to total patient Percentage distribution of total patient (both inpatient and outpatient) by type of disease/condition in 2011 Percentage distribution of inpatient by type of disease/condition in 2011 Percentage distribution of outpatient by type of disease/condition in 2011 Number of outdoor and indoor patients by month in Tungipara UHC in 2011 Average number of patients per month in Tungipara UHFWCs in 2011 Proportion of patients in UHFWCs by quarter in 2011 Proportion of inpatient and outpatient in total patient, 2010-2011 Percentage distribution of inpatient by type of disease, 2011 Number of outdoor and indoor patients by month in 2011 in Rangunia UHC Proportion of patients in UHFWC/RDs by quarter (2011) Proportion of filled-in and vacant posts in total posts in UHC by area Proportion of vacant posts to sanctioned posts by staff category and by area in UHC Percentage distribution of important equipment in IPD in UHC by condition and by area Percentage distribution of drugs by use at UHCs in 2011 Percentage distribution of drugs by use and by area in UHC Bed occupancy rate in three UHCs List of abbreviations
ADP
Annual Development Programme Acute Respiratory Infection Bangladesh Association of Voluntary Sterilization Bachelor of Dental Surgery Community Clinic Communicable Disease Community Health Care Provider Data Collection Instrument Diploma in Child Health Diploma in Dermatology and Venereal Diseases Dilatation and curate Dialysis Association of Bangladesh Directorate General of Health Services Directorate General of family Planning Diploma in Gynaecology and Obstetrics Electro Cardiograph Emergency Obstetric Care Eye, Nose and Throat Expanded Programme of Immunization Field Investigators Fellow of College of Physicians and Surgeons Family Welfare Assistant Family Welfare Centre Family Welfare Visitor Health Assistant Health Economics Unit Health Inspector Institute of Health Economics Integrated Maternal and Child Health Inpatient Department Intra-uterine Device Local Level planning Medical Assistant Bachelor of Medicine and Surgery Management Information System Ministry of Health and Family Welfare Menstrual Regulations Medical and Surgical requisite Non-Communicable Disease Non Scalpel Vasectomy Outpatient Department Operation Theatre Rural Dispensary Residential Medical Officer Reproductive Track Infection Sub Assistant Community Medical Officer Shasthyo Shurokhsha Karmasuchi Benefit Package Shasthyo Shurokhsha Karmasuchi Sexually Transmitted Disease Upazila Health and Family Planning Officer Union Health and Family Welfare Centre Upazila Health Complex Venereal disease 1.1. Background
In the last three decades, Bangladesh has achieved commendable progress in
development issues. Bangladesh has made significant progress in health indicators in
recent years – infant, child and maternal mortality rates have declined, immunisation
coverage has increased, a number of epidemic diseases have been eradicated, and
overall morbidity has declined. Life expectancy at birth for both males and females has
gone up since the 1980s. Fertility rates have also declined considerably.
Despite the achievements, the health sector face some challenges to meet the
objectives, such as, universal access to basic healthcare and services of acceptable
quality; improvement in nutritional status, particularly of mothers and children;
prevention and control of major communicable and non-communicable diseases;
supply and distribution of essential drugs, vaccines, increase in overall life expectancy
of the population, survival and healthy development of children, the health and well
being of women, and the adoption and maintenance of healthy lifestyles.
The widening financing gap of the sector has for long become a matter of serious
concern to the policy makers. Bangladesh lacks adequate fiscal resource because of
relatively small tax base. Hence, additional mechanisms and sources of financing such
as health insurance schemes need to be adopted. Health insurance has many benefits. A
gamut of literature exists to suggest that there are three main benefits of insurance
(Abel-Smith, 1992; Normand, 1999). First, to expand the revenue base either for
improving quality of existing services or to extend coverage to a greater proportion of
the population. Second, to provide protection against high out-of-pocket expenditures
incurred for health care. Finally, to develop capacity of the clients to receive health
services in a cost-effective way. In this context, the Health Economics Unit (HEU) of
the Ministry of Health and Family Welfare (MOHFW) of Bangladesh plans to
implement a social health protection scheme termed as Shasthyo Shurokhsha
Karmasuchi (SSK) with the assistance from KfW (German Development Bank) and
GFA Consulting Group. The SSK scheme will be piloted in three upazilas soon, and
then it will be scaled up in all districts using the lessons learned from the pilot areas so
as to achieve Universal Coverage of health care as aimed in the Vision 2021. The main
objectives of SSK project are to improve access of the poor to hospital inpatient care by
reducing financial barriers, to decentralize hospital activities for functional
improvement in the health sector in phases as a part of Local Level Planning (LLP),
and to introduce modern Information and Communication Technologies for increased
efficiency and transparency in the health sector.
A list of reimbursable benefits will be defined, which will be known as SSK benefit
Package (SBP). This will evolve over time and shall be regularly updated. The benefit
package could include in-patient care which is manageable at Upazila and District
level, free physician's consultation, free drugs and diagnostic facilities, structured
referral to the secondary and tertiary level hospitals, transportation cost for referral
cases and a mobile ‘camp clinic' with a mixed specialized team will be conducted in
each union at least once a month for screening and treating at, and referring for
inpatient care to, the appropriate facilities.
In order to design the SSK scheme and implement it, information is required on issues related to costs of services, the existing and the required capacity of health care facilities to provide services, and demand for services. For smooth functioning of the scheme, stakeholders need to be fully informed about how organizations respond to the adjustments required for financing and delivering the benefit package through an insurance scheme. It is therefore crucial to have detail information on availability of human resources, their competencies, availability of physical infrastructure, medicines and logistics and the existing referral system of health facilities at different levels to meet the needs of the benefit package offered by the insurance scheme. In this context, the Institute of Health Economics (IHE), University of Dhaka has been awarded to carry out a study to assess the existing capacity of human and other resources for health service delivery at all levels of the health care system in one upazila from each of 3 selected pilot districts. This report presents the findings of the study. 1.2. Objectives of the study
The General objective of this study is to assess overall existing competence of health
facilities at all levels to meet the needs of the SBP (SSK Benefit Package).
The specific objectives are:
 To assess the existing human resources and physical infrastructure for health service delivery at the primary levels of the health care system in the public sector  To assess referral facilities at secondary level  To assess the availability of medicines and logistics management system  To review the existing health information system flows at all levels  To review the existing staff and financial management systems  To explore the need for additional health service providers who could strengthen service delivery at all levels of the health care system  To assess the availability of private sector facilities to provide SSK services 1.3. Organization of the report
The report has been organised in six chapters. Chapter one presents the background
information, and the specific objectives of the study. Chapter two discusses the
methodology adopted for the study while chapter three presents findings from Debhata
upazila. Chapter four and five outlines the findings from Tungipara and Rangunia
upazila respectively. Chapter six presents a comparative analysis of the capacity of all
the upazilas followed by chapter seven which draws conclusion and recommendations.
2. METHODOLOGY
The study adopted quantitative techniques to collect data including observation checklist and compilation of service statistics. Further, qualitative techniques including Key Informant Interview (KII) and document review were employed during the study. This section discusses the important aspects of the methods, which had been used for conducting the study. 2.1. Study design
The study was conducted in 3 pilot upazilas: Rangunia (in Chittagong), Debhata (in
Satkhira) and Tungipara (in Gopalganj). These three upazilas have a total of 25 Unions.
All the public facilities- Upazila Health Complex (UHC), Union Health and Family
Welfare Centre (UHUHFWC)/ Rural Dispensary (RD) and Community Clinics (CC)
providing services in these areas were recruited for the study.
Table 2.1: Number of unions and public facilities in pilot upazilas
Upazila

Number of
Number of
Number of
UHFWC/RD
facilities
One of the objectives of the study was to assess the capacity of private sector: private clinics and non-governmental organisation (NGO). As the proposed insurance scheme puts greater emphasis on inpatient care, the inclusion criteria to recruit private clinics and NGOs for the study was facilities with inpatient department having at least three beds. However, only three private clinics in three areas met this criterion, and no NGO was found with inpatient department in any of the areas. Hence, the NGO clinic was excluded from this survey. 2.2. Data collection methods
The specific data collection methods of the study included:
Collection of service statistics: The study collected service statistics, such as,
number of patient by case mix, bed occupancy rate, bed turn-over rate, number of patients referred to secondary level, the number of allotted and vacant posts, input mix, space, availability of medicine, equipments, logistics, furniture, and vehicle. Information was collated from patient registers, procurement slip, expenditure records, stock record, referral slips and the available data base. A service statistics collection form was used for collecting the information. Relevant personnel and administrative staff in the health care facility at different levels, including Upazila Health and Family Planning Officer (UH&FPO), Residential Medical Officer (RMO), Medical Officer (MO), store keeper, pharmacist, Health Assistant (HA), Family Welfare Assistant (FWA) and Community Health Care Provider (CHCP) were approached to help in filling the form. Observation: The Field Investigators (FI) and the core research team observed a
number of issues including, number of patients seen by provider per day, number of provider actually proving services and their working hours, doctor-nurse ratio, type of service provision, the available number of equipments, logistics, vehicles and their current condition, and the referral mechanism followed. An observation checklist was prepared to collect information from all the facilities. Key Informant Interview: The managers and selected health care providers
including UHFPO, MO and RMO in each facility were interviewed to assess the
existing capacity of the facility (including numbers, qualifications- academic/ on the
training, and place of work of providers), the number of patients can be treated with the
existing capacity, the referral mechanism followed, human and financial management
system, the monitoring and supervision system, how the insurance will affect the
patient flow, what additional providers and other logistics will be required to meet the
additional health care need, what additional data is required for smooth functioning of
the scheme and what training is needed. A pre-tested semi-structured questionnaire was
used to carry out the interviews.
Table 2.2: List of data collection methods and data collection instruments
Data collection

Source of information
Data collection
instrument
Collection of service Patient registrar, procurement slip/record, stock record expenditure record, referral slip and existing data base Observation checklist Informant UHFPO, MO, RMO, HA, FWA, Semi-structured
The groups of variables, sources of information and data collection methods and
sample covered of the study are outlined in Table 3.
Table 2.3: Groups of variables and sample covered
Groups of
Source of
Data collection
Sample covered
information
service  25 UHFWC/RD  Available NGO medicines, logistics Management issues:  3 in UHC (3*3) referral mechanism management system  1 in CC (1*64) financial management system medicine and logistics management system health information system  3 in UHC (3*3) service providers  1 in CC (1*64) additional investment infrastructure, logistics additional training 2.3. Implementation of the study
Draft questionnaire was prepared and shared with Health Economics Unit (HEU) and
GFA representatives. Questionnaire was revised based on the comments and
suggestions received. Pre test of questionnaire was done to explore the availability of
service statistics, the record keeping procedure in public facilities, the sequencing of
questions, the technique/method/ options for documenting responses, and providing
appropriate skips in the questionnaire. The questionnaire was revised again based on
the experience and findings of the pre-test. Data was collected over the period of April
and continued till first week of May, 2012.
Institute of Health Economics (IHE) maintained the uppermost quality at all stages of
the study including research design, data collection and analysis. Employing
interviewers with adequate experience was one of the norms of the operational policy
of IHE. Adequate records were kept in a computerized database about each individual
to track him or her for maintaining field management standards. PI, public health
expert, health economist, and supervisors visited the sites and reviewed interviewer
forms. All filled in questionnaires had been scrutinized. Completed interviews had been
randomly cross-checked by the researchers.
It may be noted here that IHE was awarded two studies, one for situation analysis (the
present one) and the other for estimation of costs of health services, to be conducted
simultaneously. The studies were conducted by two separate teams. As was expected,
teams worked in close coordination and through continuous interaction and followed
the same conceptual framework, while each maintaining adequate amount of academic
and operational independence. Two studies used two sets of data collection instruments
and had different groups of respondents for several issues. But for the sake of
convenience and to complete work within the strict time frame, both teams of field
investigators were trained together to administer all data collection instruments, and in
the study areas each team collected data using both sets of Data Collection Instruments
(DCI) in the lower level facilities (UHFWCs, CCs, Private Clinics) deliberately
allocated to it. Furthermore, each study used the information of both data sets as and when considered necessary and appropriate. The study team faced a number of challenges while collecting data. During the field work, training of CHCP was going on. Many CCs remained open only on selected days, while some were yet to be functional. All these made it difficult to collect information from CCs in stipulated time. As stated earlier, the type of NGOs and private clinics required for the study was not available in the study areas. Moreover, some private clinics were reluctant to provide data 2.4. Data analysis
The study collected service statistics. The information was analysed using spread sheet
in Microsoft Excel. The quantitative data was analyzed by using both descriptive and
analytical statistics. Proportion, frequencies, rates and ratios had been calculated.
Qualitative data was analysed using a thematic approach. The broad thematic areas and
the core dimensions of analysis for the study are summarized below:
 Capacity of facilities at present: numbers and qualifications of staff, their place of
work in the public and private sectors, physical infrastructure, availability of medicines and logistics, data availability and its quality  Management issues: referral mechanism, health information system, staff and financial management systems, monitoring and supervision mechanism  Need assessment: requirement of additional health service providers, level of staff competence, level of human skills/ training, the data/ information need to meet the needs of the SSK  Gap identification and strategies to close the gap: the gap between existing competence of public health facilities and required level of competence. The study calculated the density (per 10000 population) of doctors, nurses and health assistants. However, no standard or norms on issues related to human resource management or availability of equipments, furniture and drugs are followed in Bangladesh. The study therefore cannot compare the current capacity of the pilot upazilas to the national standards. 3. FINDINGS IN DEBHATA UPAZILA
Debhata is one of the seven upazilas in Satkhira district. This upazila has a total area of 174.33 sq km with a total population of 122,097 of which 51% is male and 49% female. One Upazila Health Complex (UHC), four Union Health and Family Welfare Centres (UHFWCs) and 14 Community Clinic (CCs) provide health care in Debhata. This section presents the findings of the survey carried out in Debhata upazila. The section has been divided into four subsections: capacity of the Upazila Health Complex (UHC), capacity of the Union Health and Family Welfare Centres (UHFWCs), capacity of Community Clinics (CC) and capacity of Private Clinic in the upazila. 3.1. Capacity of Debhata UHC
The capacity of both inpatient and outpatient departments of Debhata UHC has been
assessed in terms of availability of personnel and their qualifications, availability of
physical infrastructure (land, equipment and furniture), availability of medicines and
logistics, data availability and whether there remains appropriate input mix in the
facility. Some management issues including the referral mechanism, financial
management systems, and monitoring and supervision mechanism are also analysed.
The study also explores requirement of additional health service providers, level of
staff competence, level of human skills/ training, and the data/information need to meet
the needs of the SSK.
As stated in the methodology section, the study calculates the density (per 10,000
population) doctors, nurses and health assistants. However, as no such norms are
followed in Bangladesh, the study cannot assess the gap between existing capacity and
the desired level of capacity in the pilot upazilas.

Human resources
A crucial component for building an effective and responsive health system is the
health workforce which includes physicians, nurses, public health workers, policy
makers, administrators, educators, clerical staff, scientists, pharmacists and health
managers amongst others (WHO, 2007). The performance and the benefits the
insurance scheme can deliver depend largely upon the knowledge, skills and motivation
of those individuals responsible for delivering health services.
The managers in the Debhata UHC suggested that for efficient service provision in the
facility, the number of persons employed in the facility, the number of persons who
really work in the facility and their actual working hours are important. It was found
that the UHC in Debhata had a total of 101 sanctioned posts, of which 92 persons were
employed and 9 posts were vacant. Eight doctors and 10 nurses were employed in the
UHC (Table 3.1.1). In every UHC, each doctor is assigned to work for both inpatient
and outpatient departments round the clock in rotation. Among the physicians, one
Junior Consultant (Surgery) was mainly responsible for inpatient department, while
three physicians worked in both inpatient and outpatient departments.
Table 3.1.1: Existing and required human resources at UHC of Debhata Upazila
Designation
Number of
Number of
Number of
sanctioned
employed
Vacant posts
Clinical staff responsible for both inpatient and outpatient department
UHFPO
Jr Consultant (Gynaecology) Nurse (senior and assistant) Medical technologists Clinical staff responsible for inpatient department
Jr Consultant (Surgery)
Jr Consultant (Anaesthetist) Clinical staff responsible for outpatient department
Jr. Consultant (Medicine)
Medical Assistant Health Assistant Administrative staff
Statistician
Head assistant cum Accountant Health Inspector/ Assistant HI Family Planning staff providing outpatient care
UFPO
Another crucial issue is the appropriate skill-mix of personnel working in the facility. It was evident that there was inappropriate skill-mix in the UHC in Debhata. Though there were sanctioned posts for anaesthetist and dental surgeon, these posts were vacant during the survey period. These two posts cannot be substituted and are very crucial for delivering essential services in the upazila. There was no sanctioned post for pathologists in the UHC, and there was no designated officer available at emergency department. In Debhata, the ratio of nurse to doctor was 1.25, while the number of doctors and nurse per 10,000 population is only 1.47 (Table 3.1.2). The ratio of health workforce (doctors, nurse, medical assistant, health assistant, health inspector, assistant health inspector, UHFPO and FWV) per 10,000 population is 3.77. Table 3.1.2: Human resource management indicators in Debhata UHC
Indicators

Ratio of nurse to Doctor Ratio of physician per 10,000 population Ratio of nurse per 10,000 population Ratio of physician and nurse per 10,000 population Ratio of health assistant per 10,000 population Ratio of health workforce (physician, nurse and health workers) per 10,000 population Percentage of female physician among total physicians Ratio of inpatient bed per 1,000 population
The study explored the actual working hours (work load) of the employed persons and
the allocation of their time between patient-contact and managerial activities. The Field
Investigators (FIs) of the study reported that despite being employed in the UHC, some
of the health care providers do not regularly work in the facility in reality. The FIs
observed that only 40% of the employed providers generally provide services in the
facility and a health care provider works for maximum of five hours a day in Debhata
UHC (the same was found in other upazilas as well). The costing study used three
different methods to explore the allocation of time of the employed health care
providers for service provision- diary method, time motion and observation. Though
the results of these three methods greatly varied, it was apparent that on an average, a
health care provider treats patients for three hours only in the outpatient department
(OPD). Those who are responsible for both inpatient and outpatient department provide
care in the inpatient department for one hour per day. S/he also accomplishes other
managerial activities such as record keeping, reporting, and monitoring and supervision
for one hour. They also had to attend different training sessions and non-medical
meetings at regional and central levels. As a result, pressure on the providers who are
present on a day becomes high; sometimes one provider has to attend as many as 40-50
patients during the three hours they work for patients in the OPD. This implies that on
an average, a doctor spends four minutes per patient. This has been considered as
inadequate by a number of respondents.
The managers said that around 70% of the capacity of the UHC is currently being
utilised in the facility. If all the employed persons work in the UHC and work for full
time, the number of patients they serve will be double. This also emerged from the
interview of the managers and health care providers in the UHC. Managers of the UHC
were asked about the additional number of patients they expect after the
implementation of the SSK. They predicted that after the introduction of SSK, the
patient would increase by 20%. The managers and health care providers were also
asked whether they need any additional posts at present to provide services efficiently
and after the introduction of SSK to meet the increased demand for services. They
suggested that they do not need to create any additional posts of health care providers;
rather if the employed persons work in the UHC, they can provide services efficiently
at present and even after the SSK.
Expertise and experience of the health care providers
Another crucial factor for quality of service provision is the expertise and experience of
the health care providers. It needs to be acknowledged that since the health care
providers have to apply their knowledge and acumen in different stages of treatment
protocol for the patients, having experience is quite important for them. However, it
was apparent that a considerable proportion of health care providers in Debhata UHC
were young with less experience and inadequate specialised expertise. They had only
MBBS degree, and no specialized expertise.
Table 3.1.3: Educational qualification of the physicians in Debhata UHC
Designation
Educational
Year of joining
Issues of basic
present service
training received*
(highest degree)
01-Jul-10 General Surgery, Basic Service Management Jr Consultant (Medicine) 01-Jul-10 Diabetes Jr Consultant (Surgery) 01-Dec-84 ARI, EPI, DIAB (Gynaecology) Medical Officer 06-Nov-85 BAVS, EPI
It appeared that all the health care providers and important staff at UHC received basic
training on several issues including reproductive health, child health, communicable
and non-communicable disease. Examining the exact duration of the training
programmes, the level of competence of the trainers, curriculum of the training
sessions, and methods of conducting training courses were beyond the scope of the
study. However, during discussion, the health care providers informed that they need
training on midwifery, managerial (recording, reporting, data management) and
financial (book keeping, accounting and auditing) issues, and local level planning
(LLP) so as to improve performance of the facility. They also suggested that they
would require orientation/training on SSK, especially on issues related to what is
insurance, what services would be provided under the benefit package and to whom,
what would be the payment mechanism, how to provide health cards to the recipients,
and how to maintain patient records. They added that refresher training should be
organised on regular interval.
During field trips of the core research team, respondents stated that a number of factors
including frequent transfer of officers and staff, the process of sabbatical and existing
vacant posts of medical personnel adversely affect performance of the facility. A few
respondents reported that non-coordinated training programme for the staff and officer
from the national level impede regular activities of the facility.
Managers and health care providers in the UHC also raised the issue of lack of co-
ordination between DGHS and DGFP. Respondents suggested that if SSK starts
functioning, health personnel from DGHS and DGFP might need to operate together to
some extent. A unified command would therefore be crucial for sustaining SSK.

Equipments, furniture and fixture
It was found that the inpatient department of Debhata UHC had important equipments;
however, a number of equipments were not functioning at the time of survey (out of
order). Minor repair of some of these would make them functional. A considerable
amount of the equipments, although some are functioning at this moment, has exceeded
their expected life years and therefore require replacement. For example, the oxygen
cylinders were procured in 1986. Given the average life expectancy of five years, all
the oxygen cylinders need to be replaced now (Table 3.1.4). It was evident that minor
repairing of equipments was constrained due to inadequate budgetary allocation for
repair and maintenance, and complex fund approval procedure. It was also evident that
there remained inappropriate input mix in the UHC. Though there were equipments for
dental care, such as, dental chair, dental light, air compressor, suction machine and
ultra sonic scalar, there was no dental surgeon in the UHC.
In Debhata UHC, a total of 161 important equipments were functioning in inpatient and
outpatient departments. This implies that there exist 13 important equipments per
10,000 population.
Table 3.1.4: Important equipments at UHC of Debhata Upazila
Number of
Additional
equipment
number of
Name of the equipment
equipment
replacement
required for
Inpatient department
Diathermy machine O.T. Light, Ceiling 9 bulb Obstetric Delivery Table Oxygen cylinder trolley Oxygen flow meter Sucker machine 250 w/400 watt B.P. machine Aneroid Instrument tray 10"-12" Mouth gag rubber Sponge holding forceps Boiling water sterilizer Patient stretcher Outpatient department
Refrigerator 10cft B.P. machine Aneroid Examination table Patient stretcher Health care providers were asked whether they need additional number of equipments
after the introduction of SSK to cope with the increased number of clients. They
suggested that they would require a number of additional equipments for SSK, such as,
X-ray machine, X-ray view box, D & C set (Table 3.1.4). They also stated that the
scheme would create some expectation among the clients who would pay premium for
the benefit package. It would therefore be crucial to maintain quality of care to meet
clients' expectations. In this connection, managers expressed their concern to the
frequent power failure at the upazila level. They suggested that availability of generator
with continues supply of fuel would be essential for the smooth functioning of the UHC
after the launching of SSK.
Debhata UHC has 31 inpatient beds. The ratio of inpatient bed per 1,000 population in
Debhata is 0.25, which is relatively low as compared to a number of countries in Asia.
The ratio was 3.1 in Sri Lanka in 2002, 2.2 in Thailand in 1999 and 0.9 in India in 2003
(GOI, 2006).
Debhata UHC has important furniture in adequate quantity in the inpatient department.
However, it was found that a number of furniture in the UHC was procured long ago,
though they are still being used. We can take the example of patient table. Four patient
examination tables were procured in 1984 which need to be replaced. Respondents
suggested that they do not need additional number of furniture/fixture at present;
however, the broken furniture/fixture needs to be replaced. However, the managers
suggested that for SSK, the UHC needs to be upgraded to 50-bedded complex.
Table 3.1.5: Important furniture and fixture at UHC of Debhata Upazila
Name of the furniture
Total number
Number of furniture
need replacement
Inpatient department
Cabinet (Almirah) steel Patient examination Table Bed Guide Locker Temperature Chart Holder Medicine Trolley Sub Total
Out patient department
Patient examination Table Dispensing Table Medicine Trolley Medicine Cabinet Cabinet (Almirah) -Steel Emergency Duty Roster Sub Total

Land and space
The total amount of land of the UHC is 3.31 acre. There are seven buildings in Debhata
UHC. Respondents stated that adequate land and space exists in the UHC in Debhata.
There were 10 rooms available for doctors each with an average space of 300 square
feet. Inpatient department has a total space of 6.080 square feet, which included ward,
operation theatre, post operative care unit, and labour room. Managers in the UHC
informed that they would not need any additional space for running the insurance
scheme (Table 3.1.6).
Table 3.1.6: Amount of land and space of UHC of Debhata upazila
Land and space

Total number
Total space
17500 square feet Inpatient department
Total number
Total space (in square feet)
Post operative care unit Sub-total
Outpatient department
Total number
Total space (in square feet)
Corridors and halls Sub-total

Drugs, supplies and logistics
Appropriate supply of drugs, supplies and logistics is seen as critical factor for
providing quality health care by the managers and health care providers in Debhata
UHC. They stated that while supplying drugs, supplies and logistics to the UHC, the
actual local need' should be considered, and therefore the number of patients and case
mix in the facility, the seasonal variation of disease and number of patients, and trend
of patients in outdoor and indoor departments can be considered to assess ‘actual need'.
However, providers at UHC informed that they receive medicine from the central level
as a ‘push method', which is not associated with the ‘actual need' for drugs and
supplies. They added that medicine is not supplied for outpatient and/or emergency
departments; rather medicine is sent by the central level based on the number of beds.
Though 350/400 patients come to the outdoor department per day, no direction is given
on how to run outpatient department.
It is to note that drug registers are maintained in such a way that disaggregated numbers
of drugs used in inpatient department and outpatient department cannot be presented.
Respondents suggested that among the total drugs received, 60% drugs are generally
used in outpatient department, 10% in emergency unit and 30% in inpatient
department.
Table 3.1.7: Drugs received in 2011 by UHC of Debhata upazila
Name

Quantity received in The amount of inventory
2011 (in number)
at the end of year 2011
(in number)
Tab Metronidazole 400 mg Tab Hyoscine N Butyl Bromide Tab Ranitidin 150 mg Tab Cotrim 400 mg Cap Tetracycline 200 mg Cap Indomethacin Cap Cephradin 500 mg Cap Flucloxin 500 mg Cap Amoxycillin 250 mg Cap Amoxycillin 500 mg Syp Metronidazole Inj Dexamethason Surgical gloves (Sterile) Disposable syringe Bleaching Powder (in kg) Inj Ceftriaxone 1 gm Syp Erythromycin Tab Zinc Sulphate Tab Levofluxacin Tab Paracetamol 500 mg Tab Ferrous Sulphate Chloramphenicol Eye Drop Managers added that medicine is purchased as ‘block' which is also not based on future projection. Though stock of drugs should be kept for three months, it never happens in reality. It was evident that there was shortage of supply of a number of drugs in
Debhata UHC, while there was excess supply of some drugs. Respondents gave the
example of ‘Cotrim'- the amount they generally receive is in excess of what is required,
which represents serious drawback of centralised planning and purchasing power.
The managers and health care providers reported that they had enough supplies of
logistics, such as, gauze, cotton and plaster. However, sometimes they face the problem
of irregular supply of logistics, which hampers the service provision.
Trend of patients in UHC
The number of patients who visited the UHC over the period of 2010-2011 is presented
in Table 3.1.8. It appears that patients were generally admitted in the in-patient
department of the UHC for delivery care, emergency obstetric care (EmOC), abortion,
diarrhoea, asthma and diabetes. In 2011, the admission rate per 100,000 population was
2391.54, while the ratio was 1307 in 2010.
The major disease/ conditions for which people visited the outpatient department of
UHC included Ante natal Care (ANC), Post Natal Care (PNC), Acute Respiratory
Infection (ARI), diarrhoea, asthma, scabies, eye infection, helminthiasis, family
planning and anaemia. Among the total patients who visited UHC in 2011, 5% were
admitted in inpatient department (Fig 1).
Table 3.1.8: Number of patients who visited the UHC by disease and year
Name of disease/ condition/service
In-patient
In-patient
a) Maternal health
- EmOC (Obstructed labor) b) Pelvic infections, STI/RTI /UTI
Bronchial asthma c) Skin, ENT and dental infection
Dental infection d) Helminthiasis
e) Family Planning
Family planning for male Family planning for female f) Non-Communicable Disease
Hypertension, CHD Road traffic accident (RTA) Viral fever, Pyrexia of unknown origin)

Figure 1: Proportion of inpatient and outpatient in Debhata UHC, 2010-2011
Among the total patients who visited UHC in 2011, 15% received care for maternal health and 33% patients received care for pelvic infection (Fig 2). Though the number of total persons seeking care from UHC increased by 13.85% from 2010 to 2011, the number of women seeking maternal care (ANC, delivery, EmOC, abortion and PNC) increased by 205.88% over the same period. Figure 2: Percentage distribution of total patients (inpatients and outpatients) by
type of disease/condition in 2011 in Debhata UHC

Pelvic infections, STI/RTI /UTI Skin, ENT and dental infection Non-Communicable Disease
It was evident that among the patients who were admitted in the UHC, 48% received
care for maternal health, while 27% of the inpatients received care for non-
communicable disease (Fig 3).
Figure 3: Percentage distribution of the inpatients by type of disease/condition in
2011 in Debhata UHC

Pelvic infections, STI/RTI /UTI Skin, ENT and dental infection Non-Communicable Disease Patients who received care from outpatient department, 14% received care for maternal health and 34% received care for pelvic infections (Fig 4).








Figure 4: Percentage distribution of the outpatients by type of disease/condition in
2011 in Debhata UHC

Pelvic infections, STI/RTI /UTI Skin, ENT and dental infection Non-Communicable Disease
The patient record suggests that the number of both inpatient and outpatient increases
in summer (July-September), and declines considerably in winter (November). The
seasonal variation in the number of patients in Debhata UHC is presented in Figure 5.
Figure 5: Number of outdoor and indoor patients by month for 2011 in Debhata
UHC

Management issues

Referrals
There remains weak referral mechanism at UHC, which is almost non-existent.
Respondents informed that they often send burn patients to specialised hospital,
however no follow-up is done, and neither any feed-back is received from the hospital.
There is no mechanism to know whether the patient has really visited the District
Hospital and what was the treatment outcome. The only exception is the case of TB
referral mechanism: there remains relatively strong referral mechanism for TB patients.
Budget management
The upazilla get their revenue budget directly from the national level and development
budget through civil surgeon of the district. However, there remains time gap between
sending budget request and disbursement of money. Though budget is sent in March,
upazila receives money for first quarter under Annual Development Programme (ADP)
in October-November. Revenue budget is also released in September. Respondents
argued that late disbursement of money adversely affects activities. There remains
inadequate budget for repair and maintenance. Upazilla can approve only 3,000 Taka
for maintenance. Contingency fund of 1,000 Taka is available per month. Resources
generated at upazilla level from user fees and bed admission fees (5 Taka) have to be
returned to central level at the end of year.

Supervision and monitoring
RMO supervises emergency services and in-door services at the UHC, while field
supervision is conducted by health inspector (HI) and Sanitary inspector (SI). Overall
supervision of UHC is done by UH&FPO through reporting to CS office, DG health
and MIS. It was apparent that lack of manpower and transport led to weak monitoring
and supervision system.
Respondents were asked whether they follow any mechanism to assess performance
and quality of care at the facility overtime. They stated that though they collect routine
data on several issues, there is no specific indicator to monitor overall performance and
quality of care at the UHC.
Information System
UHFWCs and CCs send monthly information to UHC on number of patient treated per
month. Upazila Health Complex compiles the information and sends this to District
Hospital.
It appeared that information system, record keeping and data base at public facilities
had some limitations. The record keeping mechanism in the UHCs in three pilot
upazilas varied considerably. For example, while Rangunia maintains consolidated
records for referred cases, no such record was readily available in Debhata and
Tungipara. Number of patients referred from UHC to district hospital was stored in
three different departments in Debhata UHC: indoor, outdoor and emergency. There
was no consolidated record for referred cases at UHC. Respondents stated that they
referred approximately 300 patients to District Hospital from Debhata UHC.
Though outpatient department maintains disease-wise patient record, it was difficult to
collect inpatient number by disease. There is inappropriate record keeping for drugs.
The amount of drugs received at UHC is recorded by the store keeper, while the
pharmacist maintains registers of drugs distributed per day. This record keeping system
makes it difficult to look at the pattern of drugs distribution in a holistic way. Managers
argued that if data is not available, it is difficult to set target, indicator and to assess
progress of work.
The UHC does not appropriately maintain patient record by name, address, age, gender,
disease condition, diagnosis or treatment protocol. Managers in the facility stated that
introduction of SSK will require substantial improvement in maintaining patient record
especially for referral and follow-up. The existing system of compiling and maintaining
records is weak.
The major limitation of the current recurrent record keeping mechanism is the manual
record keeping and data compilation system, which is time consuming. This paper-
based manual record keeping system increases the possibility of errors in calculating
lots of numerical values and transferring records from one paper to another. As records
are kept on paper, finding previous records for more than three years become difficult.
Respondents in UHC stated that though they use computer-based record keeping
system for compiling patient record, regular power failure in the UHC hampers the
process.
Another limitation of the current information system is its inability to produce updated
personnel status. Staff turn over is high in public facilities, and there are many aspects
of staff movements including recruitment, leave, transfer, joining, promotion,
suspension, termination, retirement, and death. However, all these are done through
paper-based manual system and in different levels (MOHFW, DGHS, Divisional
Directors' offices; Civil Surgeons' offices, Upazila Health Offices and each
institutional level). If data related to all these information are not fed into personnel
information system from the source in real time, a complete real time status of national
health personnel is not possible to produce.
Maintenance
One of the greatest challenges of the government health system of Bangladesh is the
poor maintenance of equipments and logistics at the health facility level. It is therefore
important to collect status reports of equipment periodically, such as, the numbers of
major equipment by type in each institution, their functional status, if non-functional
whether repairable or not. Though it remains a difficult task to get periodic data on the
equipment, locally hosted computer-based inventory management system is crucial in
public facilities for implementing the insurance scheme.
3.2. Capacity of the UHFWC
The survey collected data from four UHFWCs in Debhata on the existing human
resources, availability of equipments, supplies, logistics and drugs, availability of land
and space, and number of patients.
Human resources
A total of 22 personnel are employed in four UHFWCs in Debhata. However, among
the four UHFWCs, there is no Medical Officer in three UHFWCs. There also remains
vacant post of SACMO in one UHFWC and pharmacist in one UHFWC. All the
UHFWCs in Debhata need additional posts at present to cope up with existing patient
flow. A total of nine posts are required at present in the UHFWCs while the health care
providers predict that a total of 20 posts will be required for SSK in these four
UHFWCs.
Table 3.2.1: Existing and required human resources in UHFWCs of Debhata
Upazila by designation
Designation
of persons UHFWCs
Equipment
It was evident that some equipment in the UHFWCs had in enough quantity, while a
number of important equipments were not available in adequate number for providing
services efficiently. On an average, a UHFWC had 6 to 7 stethoscope, one delivery kit
while there was no D&C set or instrument cabinet in any of the four UHFWCs (Table
3.2.2).
Table 3.2.2: Important equipments at UHFWC of Debhata Upazila
Name of equipment
Average Number of working condition) required for SSK Bandage cutting scissors Cursor vaginal speculam Examination table Instrument cabinet M.R set with canula (manual) Managers in the UHFWCs were asked about the additional number of patients they expect after the introduction of the SSK, and they suggested that introduction of SSK would increase patient by 20% at the UHFWC. Managers stated that they would therefore require additional number of important equipment for smooth functioning of
the scheme.

Furniture
It was also found that there were a total of 7 IUD tables, 5 dispensary tables, 4 patient
beds and 11 steel almirah in the four UHFWCs. However, some UHFWCs did not have
OT table, normal waste basket and file cabinet (Table 3.2.3).
Table 3.2.3: Important furniture and fixture at UHFWC of Debhata Upazila

Average Number of of furniture and additional furniture and fixture (in order) fixture requiring fixture required for SSK IUD/Insertion table Dispensary table Normal waste basket
Land and space
It was apparent that UHFWCs had an average of 0.40 acre of land with a building of
2393 square feet (Table 3.2.4). Three UHFWCs had room for MO and FWV, and had
OT, store room and waiting room. In one UHFWC, SACMO was employed but there
was no room for SACMO. The managers in two UHFWCs reported that their buildings
were constructed in 1985/1986 and therefore need repairing of the buildings. During
rainy season, water leaks from the roof and makes it difficult to work in the premise.
Table 3.2.4: Existing and required infrastructural inputs in UHFWCs of Debhata Upazila
Infrastructure
Average costs of additional inputs required for SSK Pharmacist Store room
Among the four UHFWCs, manager in one UHFWC stated that though the number of
patient seeking care from the UHFWC is not that high at this moment, they would
require additional space at present and also for SSK to provide services more
efficiently. Manager in another UHFWC stated that they would require additional space
for SSK if patient increases by 20% after SSK. Manager in two other UHFWCs could
not suggest whether they would need any additional space for SSK, and suggested that
it would depend on the activities and functioning of the SSK.
Providers at UHFWCs informed that they receive a number of drugs in excess amount
which they do not need, while there remains shortage of supply of some essential
drugs. Respondents also informed that there remained limited supply of implant and
copper -T for last few years.
Table 3.2.5: Average amount of important drugs received in 2011, inventory, and
required amount in UHFWCs of Debhata upazila
Name of drugs
additional amount required for SSK Tablet metronidagol Tablet paracetamol Tablet Iebuprofen Capsule Tetracyclin Capsule Cefradin Capsule Amoxicillin 250 Tablet Renitidin Syrup Paracetamol It was evident that maternal health, child health and family planning were the major services provided at UHFWCs. The patient record suggests that the number of patients seeking care from UHFWC increased by 82% from 2009 to 2010, however, it reduced by 7% in 2011 from 2010. Among the total patients in 2011, 9% received maternal care, and 23% received care for child health (Fig 6). Table 3.2.6: Average number of patients in the UHFWCs of Debhata upazila in the last
three years by disease/condition

Maternal Health
- ANC 1
Pelvic infection
STI/RTI
Skin disease and eye infection
Eye infection
Family planning
Family planning for male
Family planning for female Child Care
Other
Helminthiasis,
Infertile couple
Figure 6: Percentage distribution of the patients by type of disease/condition in 2011 in
Debhata UHFWCs

It is evident from Table 3.2.7 that the number of patients in a UHFWC varied
considerably per month. For example, in Debhata Sadar, the lowest number of patient
was in November (733) and the highest number was in February (1166).
Table 3.2.7: Number of patients in 2011 by month and UHFWC
Month

Nawapara

There remained seasonal variation in the number of patients seeking care from
UHFWC. It was found that 29% of the total patients received care during January –
March, 2011 in four UHFWCs, while 22% of the total patients received care during
October-December (Fig 7). This seasonal variation in number of patients seeking care
from modern facilities is common in Bangladesh: the number of patients reduces in
winter and increases in summer.
Figure 7: Proportion of patients in UHFWCs by quarter (2011)
UHFWCs refer patients to UHC. A total of 132 patients from the four UHFWCs were referred to UHC in 2011. Among them, 12% (n=26) required EmOC and 32% (n=42) were referred to UHC with ARI. Figure 8: Percentage distribution of patients referred to UHC by disease/condition
3.3. Capacity of Community Clinics
There is a total of 14 CCs in Debhata, of which, 12 CCs were functioning during the
data collection period. This section presents the findings of 12 CCs.
It was found that one CC has three sanctioned posts: Community Health Care Provider
(CHCP), FWA and HA. All the 12 CCs in Debhata had CHCP, one FWA and one HA.
There was no vacant post in these 12 CCs. All the respondents in these 12 CCs stated
that they require one guard and one aya in each CC at present and also for SSK. The
CHCPs reported that they feel insecure to store the drugs in CC as there is no guard in
the CC. They also reported that as there is no cleaner in the CC, CHCP has to clean the
CC including the toilet.
Table 3.3.1: Existing and required human resources in CCs of Debhata upazila
Designation
Average number of sanctioned Number of CCs with employed During the survey period, training for CHCPs were going on. The CHCPs reported that they started their job without any training. They now look forward to complete their training and providing services efficiently at CC. It was found that a CC generally had a number of important equipments including hanging weight machine, thermometer clinical, measuring tape and diabetes strip. However, none of the CCs had BP machine aneroid, stethoscope, weight machine and steel measuring. All the 12 CCs suggested that they would require additional number of equipments for SSK (Table 3.3.2). Table 3.3.2: Important equipments at CCs of Debhata Upazila
Name of equipment
required for SSK Bandage cutting scissors BP machine Aneroid Hanging weight machine Thermometer clinical Surgical gauge (box)
All the CCs had almirah, table, chair, examination table and delivery table. The
respondents suggested that they would require all these furniture in additional quantity
for SSK. The average no of additional furniture and fixture required for SSK in the 12
CCs are presented in Table 3.3.3.
Table 3.3.3: Important furniture and fixture at CC of Debhata Upazila
Furniture and fixture
Average Number of Average Number of additional furniture and fixture furniture and fixture required (in order) in a CC Examination table
Among the 12 CCs, 11 had own land of 5 decimals. All these 11 CCs had a building
with two rooms and one veranda. Respondents in these 11 CCs suggested that they
would not require any additional space for SSK. Rather they need water and electricity
supply for smooth functioning of CC, which is currently not available in some of the
CCs.
Table 3.3.4: Existing and required infrastructural inputs in CCs of Debhata Upazila
Item
Number of CCs with the inputs It was evident that there was enough supply of drugs in the CCs. They receive 2 kits of drugs per quarter, each containing 29 medicines. They received drugs in regular intervals. However, a number of CHCP suggested that as they were not allowed to prescribe antibiotics, such as, Cotrim, there was no reason to provide these antibiotics in CCs. They added that a number of such medicines remain unused in CC. Some
CHCPs informed that cold, caught, weakness, diarrhoea, anaemia, stomach pain,
gastric and skin disease were the common illness for which people seek treatment from
CC. CHCP refers patients to UHC for major diseases including very high fever,
pneumonia and TB. They therefore suggested providing more basic medicines to treat
common illness at CCs.
Table 3.3.5: Average quantity of major drugs received in 2011 by CCs of Debhata upazila
Name of drugs
Average quantity received in 2011 (number) Amoxicillin Capsule Chlorpheniramine Ferrous Fumarate and folic acid tab Hyoscine butoylbromide Zinc disperesivle Amoxicillin dry syrup Amoxicillin pediatric drop Paracetamol suspension Salbutamol syrup Chloramphenicol eye ointment (1% ) gm Gentian violate 2% solution
A number of CHCP reported that people often demand some medicines from the CHCP
irrespective of the disease they are suffering from, such as, vitamin, calcium and iron
tablet. They added that some people come to CC only to collect these vitamins, and
insists CHCP to give them some of these medicines. The CHCPs stated that it is a
challenge for them to meet the expectation of the community. They suggested that
awareness should be created among people on issues related to what services are
available at CCs, UHFWCs and UHC, and the adverse effects of using unnecessary
drugs.
CHCP maintains register to keep patient record. They enter the name, age, gender,
symptoms/illness of the patient and the drugs distributed. CHCPs in Debhata also
recorded the number of persons they referred to UHFWC/UHC per month. The total
number of patients in the 12 CCs in 2011 and the number of persons referred from CC
are presented in Table 3.3.6. However, as there was no consolidated data available on
the number of patients by disease per month, it was not possible for the FIs to collate
disease-wise monthly patient record from CCs in Debhata within the short span of the
survey period.


Table 3.3.6: Total number of patients and the number of referrals in the 12 CCs of
Debhata upazila
Name of CC
Number of persons Ashkarpur, Noapara Pachpota, Shokhipur Najirer Gher, Parulia Idgah Model Clinic, Shokhipur Atshoto Bigha, Noapara Gelepara, Parulia Bhatshala, Debhata Town Sripur, Debhata Komorpur, Parulia Chaltetla, Parulia It appears from the above Table that the number of persons visited CC and the persons referred from CC varied considerably among the 12 CCs. The average number of persons visited CC per month in 2011 was 393 in Ashkarpur, Noapara and was 138 in Komorpur, Parulia. 3.4. Capacity of the private sector
In the private facility, there was six full time permanent staff: one doctor, two nurses,
one accountant and two cleaners. The building was operating in a rented house. It had
one room for doctor (225 sq feet), one office room (225 sq feet), five wards (5*225 sq
feet), one operation theatre (225 sq feet), waiting room (300 sq feet), veranda (675 sq
feet) and three toilets (3*100 sq feet). The clinic did not maintain any patient register.
Hence, it was not possible to collect disease-wise patient record from this clinic. The
representative of the clinic informed that they generally provide services to persons for
normal and C-Section delivery, appendicitis, and gallbladder operation. The
representative recalled that the total number of normal delivery was approximately 120,
C-Section delivery was 144, appendicitis was 240 and gallbladder operation was 60 in
2011. The private clinic did not procure any medicine as it did not provide medicine to
the patients. Patients had to buy medicine from nearby pharmacy.
Respondent in the private clinic stated that the existing number of personnel and the
available space would not be enough to provide services to an increased number of
patients under SSK. The clinic would require additional staff including two medical
assistants, one nurse, one accountant, one office assistant and four other support staff.
Moreover, they would need one additional floor of the building having five more
wards, ten beds, five toilets, one OT and waiting. It would cost the clinic of 50,00,000
(Fifty Lac) Taka- as was suggested by the respondent in the clinic.
Though a number of important equipments were functioning at present in the private
clinic, most of them had been procured long ago, and therefore need to be replaced
(Table 3.4.1).
Table 3.4.1: Important equipments at private clinic of Debhata Upazila
Name of equipment
condition) in the required for SSK BP machine aneroid Bandage cutting scissors Cursor vaginal speculam Examination table Instrument cabinet M.R set with canula (manual) Generator
The private clinic had some important furniture and fixtures, as outlined in Table 3.4.2.
The respondent in the private clinic informed that they would require additional
furniture if they need to provide services to increased number of patients for SSK.
Table 3.4.2: Important furniture and fixture at private clinic of Debhata Upazila
Name of the furniture Additional number equipments requiring of furniture required Patient Table (wooden) Table for machinery The FIs collected the fee charged for different services in the private clinic. It was found that the consultation fee charged for a patient is 50 Taka. Fee for urine test is 20 Taka and blood test is 30 Taka. Charge for normal delivery is 500 Taka and C-section delivery is 5,000 Taka.
4. FINDINGS IN TUNGIPARA UPAZILA
Tungipara is situated in Gopalganj district with an area of 125.25 sq km. The total population of the area is 100,136. Along with the Upazila Health Complex (UHC), five Union Health and Family Welfare Centres (UHFWCs) and 16 Community Clinics (CCs) provide health services in the area. This section analyses the capacity of public (UHC, UHFWCs and CCs) and private (one NGO and one private clinic) health care facilities in Tungipara upazila. 4.1. Capacity of the Tungipara UHC
The study assesses the capacity of the UHC in terms of availability of personnel and
their qualification, availability of physical infrastructure (land, equipment and
furniture), availability of medicines and logistics, data availability and whether there
remains appropriate input skill-mix in the facility. Some management issues including
financial management systems, and referral, monitoring and supervision mechanism are
also analysed. The study also explores requirement of additional resources to meet the
needs of the SSK.
Human resources
The UHC in Tungipara had a total of 137 sanctioned posts, of which 76 persons were
employed and 61 posts (44.5% of total) were vacant at the time of survey (Table 4.1.1).
Ten doctors and 11 nurses were employed in the UHC. There was no female doctor
working in the UHC. It was evident that there was inappropriate mix of skill in the
UHC in Tungipara. There was no sanctioned post for pathologist and emergency
attendant in the UHC during the survey period. Though there were sanctioned posts for
storekeeper and statistician, these posts were vacant in the UHC, which impeded the
process of drug distribution and record keeping in the UHC.
Table 4.1.1: Existing and required human resources at UHC of Tungipara Upazila
Clinical staff responsible for both inpatient and outpatient department
UHFPO
Jr Consultant (gynaecology) Nurse (senior and assistant) Medical technologists Clinical staff responsible for inpatient department
Jr Consultant (Surgery)
Jr Consultant (Anaesthetist) Clinical staff responsible for outpatient department
Jr. Consultant (Medicine)
Medical Assistant Health Assistant Administrative staff
Statistician
Head assistant cum Accountant Health Inspector/ Assistant HI Family Planning staff providing outpatient care
UFPO

In Tungipara, the number of doctors and nurses per 10,000 population is only 2.1. If the
total number of doctors, nurses and health workers (MA, HA, HI, AHI, UFPO, FWV)
are considered, the ratio of health workforce per 10,000 population becomes 4.7 (Table
4.1.2).
Table 4.1.2: Human resource management indicators in Tungipara
Indicators
Nurse to physician ratio (number of physicians employed) Ratio of physician per 10,000 population Ratio of nurse per 10,000 population Ratio of physician and nurse per 10,000 population Ratio of health assistant per 10,000 population Ratio of health workforce (physician, nurse and health workers) per 10,000 population Percentage of female physician among total physicians However, managers in the UHC informed that among the ten employed doctors, only five to six doctors provide services in the UHC. Field Investigators (FIs) also reported that despite being employed in the UHC, some of the health care providers do not regularly work in the facility: they found five doctors working during their data collection period in the UHC, and two doctors were attending training at district level. If the actual number of physicians working in the facility is considered, the ratio of physician per ten thousand population becomes even smaller (0.5). It was evident that a provider works for maximum of five hours per day in the Tungipara UHC, of which they spend three hours in outdoor department, one hour in inpatient department and one hour for other managerial activities. This is consistent with the findings of Debhata UHC. The managers stated that on an average 300 patients seek care from outpatient department. This suggests that on an average, each of the five doctors treat 60 patients in three hours per day, spending three minutes per patient, which was considered as inadequate by a number of respondents. Managers predicted that after the introduction of SSK, the patient in UHC would increase by 15% to 20%. The managers and health care providers were asked whether they need any additional posts at present to provide services efficiently and after the introduction of SSK to meet the increased demand for services. They suggested that
they do not need to create any additional posts of health care providers; rather if the
existing 15 sanctioned posts of Junior Consultants, specialists and Medical Officers are
being filled, they can provide services efficiently at present and even after the SSK.
Expertise and experience of the health care providers
Majority of health care providers in Tungipara UHC have more than five years of
experience. However, a number of junior consultants joined the service very recently,
and did not receive any training in addition to their basic MBBS degree. During
discussion, the managers suggested that refresher training should be arranged for health
care providers on issues related to midwifery, maternal and child health, and non-
communicable diseases, while basic training needs to be arranged on managerial
(recording, reporting, data management) and financial (book keeping, accounting and
auditing) issues to improve service delivery of the facility.
Table 4.1.3: Educational qualification and basic training of physicians in
Tungipara UHC

Issues of basic training (highest degree) Obstetric/gynaecology, breast feeding Jr Consultant (Paediatrics) IMCI, Sick new born Care Medical Officer* Medical Officer* *The person was attending training at district level during the data collection period
Equipments, furniture and fixture
It was found that the inpatient department of Tungipara UHC had a total of 143
important medical equipments, though it lacked a number of crucial equipments. There
was no ECG machine in the UHC. Among the 143 equipments, 70 equipments were
not functioning during the survey period. The ultrasound machine was out of order.
However, the managers suggested that minor repair of some of the non-functioning
equipments may make them functional. Though 73 equipments were functioning, 18 of
them have already exceeded their expected life years and need immediate replacement
(Table 4.1.4). In the outpatient department, large proportion of the equipments was out
of order, while some need replacement. For example, though the X-ray machine was
in-order, considering the average life expectancy of 10 years, it needs replacement as it
was procured 15 years ago in 1997. Respondents stated that the budgetary allocation
for repair and maintenance of equipments in the UHC is not enough, which reduces the
expected life years of expensive and life saving equipments.


Table 4.1.4: Important equipments at UHC of Tungipara Upazila
Number of equipment Name of the equipment need replacement Inpatient department
Anaesthesia Machine Diathermy machine Haemoglobin meter Nitrous oxide cylinder O.T. Light, Ceiling 9 bulb Obstetric Delivery Table Oxygen cylinder trolley Oxygen flow meter Sucker machine 250 w/400 watt B.P. machine Aneroid Instrument tray 10"-12" Mouth gag rubber Sponge holding forceps Sterilizer small Boiling water sterilizer Cusco's vaginal speculum Suction unit portable (manual) Outpatient department
Haemoglobin meter Nitrous oxide cylinder Obstetric Delivery Table Oxygen cylinder trolley Oxygen flow meter Refrigerator 10cft Sucker machine 250 w/400 watt B.P. machine Aneroid Hanging weight machine Instrument tray 10"-12" Mouth gag rubber Thermometer clinical Examination table Patient stretcher In Tungipara UHC, a total of 113 important equipments were functioning in inpatient
and outpatient departments. This implies that there exist 12 important equipments per
10,000 population. Tungipara UHC has 50 inpatient beds. The ratio of inpatient bed per
1,000 population in Tungipara is 0.5, which is relatively low as compared to a number
of countries in Asia.
The inpatient department in Tungipara UHC had all the important furniture, and
majority of these were procured over the period of 2011-2012. Hence, all the furniture
is functioning well and do not need any repair or replacement at present. However, in
the outdoor department, a considerable proportion of furniture was procured in 1997
and therefore need replacement (Table 4.1.5).
Table 4.1.5: Important furniture and fixture at UHC of Tungipara Upazila
Name of the furniture Number of furniture need replacement Inpatient department
Bed
Cabinet (Almirah) steel Patient examination Table Bed Guide Locker Temperature Chart Holder Medicine Trolley Out patient department
Plastic Chair
Patient examination Table Dispensing Table Medicine Cub board Medicine Cabinet Cabinet (Almirah) -Steel Emergency Duty Roster
Respondents suggested that they do not need additional number of furniture/fixture at
present, except bed. They suggested that Tungipara UHC would require 100 additional
beds for smooth functioning of SSK. However, they also informed that there is no spare
space available in the UHC to place additional beds.
Land and space
The managers of the UHC stated that there remains inadequate space in the inpatient
department in Tungipara UHC. In the outpatient department, a total of 16 rooms are
available, including rooms for doctors and other staff, with an average size of 221
square feet. The respondents suggested that the UHC would require 10% additional
space, especially in inpatient department, to provide services after SSK.
Table 4.1.6: Amount of land and space of UHC of Tungipara upazila
Land and space
Inpatient department Total space (in square feet) Out patient department Total space (in square feet) Leprosy & Tuberculosis
Drugs, supplies and logistics
Providers at UHC informed that the process of procurement and distribution of drugs is
centralised. They added that central level requires more than a year to procure drugs.
Due to this time lag in the procurement process, additional drugs cannot be supplied
during emergency. It was also evident that a number of drugs were supplied
inadequately, while there was excess supply of some other drugs. Some important
drugs including tablet Riboflavin and tablet Ibuprofen were not supplied in 2011, while
capsule Cephradine 500 mg, IV Canula and tablet Ciprofloxacin remained unused.
However, the stock of some life saving drugs, such as Dexamethason became nil at the
end of the year 2011 (Table 4.1.7).
Table 4.1.7: Drugs received in 2011 by UHC of Tungipara upazila
Name
Quantity received in 2011 The amount of inventory at the end of year 2011 Tab Metronidazole 400 mg Tab Ranitidine 150 mg Tab Cotrim 400 mg Cap Cephradine 500 mg Cap Flucloxin 500 mg Cap Amoxicillin 250 mg Cap Amoxicillin 500 mg Whitfield Ointment Surgical gloves (Sterile) Disposable syringe Inj Ceftriaxone 1 gm Solbutamol solution Syp Erithromycincor tab zinc sulphate Tab Ferrus Fumaret Tab Vitamin B Com Tab Ciprofloxacin
Supplies and logistics
It was reported that a number of supplies and logistics were not provided to the UHC
for a long time, and some of the items are required at present to ensure quality of care.
Stocks were finished for some of the items at the end of year 2011 and needs to be
supplied. For example, they require 400 Foley's catheter of different size at present. It
was also reported that supplies and logistics needs to be increased by 10% for SSK.
Table 4.1.8: Amount of supplies and logistics received in 2011 in Tungipara UHC
Item of supplies and logistics
Quantity received in 2011 The amount of inventory at the end of year 2011 Plaster of Paris Foley's catheter different size Implantation set Trend of patients in UHC
The number of patients who visited the UHC over the period of 2010-2011 is presented
in Table 4.1.9. It appears that people were generally admitted in the UHC for delivery
care, emergency obstetric care, ARI, diarrhoea, poisoning and injury.
Table 4.1.9: Number of patients by disease and year in Tungipara UHC
Disease/condition a) Maternal health ANC b) Pelvic infection, STI/RTI ARI Bronchial asthma c) Skin, ENT and dental infection Eye infection d) Family planning FP f) Non-Communicable Disease: Diabetes It appears that the number of total persons seeking care from UHC increased by 30.12% from 2010 to 2011, while the number of inpatients increased by 33% over the same period. However, the proportion of inpatient in total patient remained almost same over this period: 7.6% and 7.8% in 2010 and 2011 respectively (Fig 9). Figure 9: Proportion of inpatient and outpatient to total patient

Among the total patients (both inpatient and outpatient) who visited the facility in
2011, majority (58%) sought maternal care and 38% received family planning services
(Fig 10).
Figure 10: Percentage distribution of total patient (both inpatient and outpatient)
by type of disease/condition in 2011

Pelvic infection, STI/RTI It was evident that 43% of the total inpatients were admitted in the UHC for maternal care, while 16% received care for pelvic infection/STI (Fig 11). Figure 11: Percentage distribution of inpatient by type of disease/condition in 2011
Pelvic infection, STI/RTI
It was found that people visited the outpatient department of Tungipara UHC for
receiving ANC, PNC and family planning services. 58% of the outdoor patients visited
the UHC for ANC care while only 2% of the patients received PNC from the outpatient
department (Fig 12).
Figure 12: Percentage distribution of outpatient by type of disease/condition in
2011


Figure 13 suggests that the number of inpatients per month did not vary in Tungipara
UHC in 2011. However, the outpatient was relatively higher over the period of July-
October, and declined markedly in November and December.


Figure 13: Number of outdoor and indoor patients by month in Tungipara UHC
in 2011


Management issues
During field trips of the core research team, respondents stated that doctors are not fully
accountable to the UH&FPO. Physicians often take leave for long period or even get
transferred without informing the UH&FPO, which adversely affects service provision
of the facility.
Managers informed that UHC receives drugs from different sources. They receive some
drugs from Civil Surgeon and some directly from the central level. Different records
are maintained for drugs received from these two sources. Drugs are supplied to ward
and outpatient department through indent.
Respondents stated that referral is maintained by referral slip, which is issued by the
doctor. However, they considered the referral mechanism ‘weak' as there is no formal
procedure to follow up the patient, to ensure whether the patient is ultimately seeking
care, and to identify them in case of discontinuation of treatment. The UHC do not
maintain record for referred patients. They suggested that on an average 35 patients are
referred to district hospital per month, of which 75% are referred from emergency unit
and 25% from inpatient department.
Managers and health care providers in the UHC also raised the issue of coordination of
SSK project with other programmes of the government. They stated that due to the
implementation of ‘Demand Side Financing' (DSF) in Tungipara, utilisation of
maternal health care is high. Respondents suggested that a mechanism needs to be
developed to co-ordinate the activities of DSF and SSK projects to avoid duplication of
efforts.
4.2. Capacity of the UHFWC
A total of 10 personnel are employed in four UHFWCs in Tungipara. However, there is
no Medical Officer in any of the four UHFWCs. Total 11 posts are vacant in the four
UHFWCs. Only one FWV serves three facilities. Two SACMOs were appointed in
February, 2012. None of the UHFWCs has cleaner/sweeper, which is essential to
maintain the cleanliness of the facilities. All UHFWCs in Tungipara suggested that they
need to fill in the vacant posts at present to cope with existing patient flow.
Table 4.2.1: Existing and required human resources in UHFWCs of Tungipara
Upazila by designation

Number of UHFWCs Number of vacant posts with employed persons persons employed  One UHFWC has no information on MO, no persons employed in one UHFWC
It was evident that some equipment in the UHFWCs were enough in quantity, while a
number of important equipments were not available in adequate number. One UHFWC
has no equipment and a bed is broken. On an average, a UHFWC had one delivery kit
while there was no stethoscope, D&C set or instrument cabinet in any of the four
UHFWCs (Table 4.2.2). All UHFWCs require additional number of equipments for
SSK.
Table 4.2.2: Important equipments at UHFWC of Tungipara Upazila
Name of equipment
Average Number of Average Number of working condition) equipment required Bandage cutting scissors Cuscors vaginal speculam Examination table Instrument cabinet M.R set with canula (manual) Managers in the UHFWCs were asked about the additional number of patients they expect after the introduction of the SSK, and they suggested that introduction of SSK would increase patient by 20% at the UHFWC. Managers stated that they would therefore require additional number of important equipment for smooth functioning of the scheme. The UHFWCs in Tungipara lacks some important furniture and fixture. There was no
waiting bench and file cabinet.
Table 4.2.3. Important furniture and fixture at UHFWC of Tungipara Upazila
Furniture
Average Number of Number of furniture Average Number of furniture and fixture and fixture requiring additional furniture and fixture required for SSK Intern/IUD table Dispensary table
One of the UHFWC was used as a police camp till last year. The condition of the
facility is therefore not so well. It was apparent that UHFWCs had an average of 0.56
acre of land with a building of 1927 square feet (Table 4.2.4). All UHFWCs needs
additional land, space for drug store and waiting room after SSK.
Table 4.2.4: Existing and required infrastructural inputs in UHFWCs of Tungipara
Upazila

Number of Average at required at inputs SACMO Drug Store
UHFWCs informed that some of the drugs are in excess supply, while there remains
shortage of supply of some essential drugs.


Table 4.2.5: Average amount of important drugs received in 2011, inventory, and
required amount in UHFWCs of Tungipara upazila
Name of drugs
Tablet metronidagol Tablet Ranitidine-150 Tablet paracetamol Tablet Iebuprofen Capsule Tetracyclin Capsule Cefradin Capsule Amoxicillin Syrup Metronidajol Syrup Flu-Cloxacillin Syrup Mebendajol Syrup paracetamol Tablet B Complex
It was evident that the child health, maternal health and family planning for female,
ARI were the major services provided at UHFWCs. On an average UHFWC provide
service to 50 patients daily.
Table 4.2.6: Average number of patients in the UHFWCs of Tungipara upazila in the last
three years by disease/condition

Disease/condition In 2011, average number of patients per month in a UHFWC was 627. Patients in a UHFWC varied considerably per month. The lowest number of patient was in November (2085) and the highest number was in January (3206). Table 4.2.7: Number of patients in 2011 by month and UHFWCs
Month

It was found that Kusholi UHFWC had highest number of patients (18057) in 2011,
whereas Gopalpur has the lowest number of patients (1861). In rural Bangladesh, the
number of patients not only depends on onset of disease, but also on the availability of
drugs.
Figure 14: Average number of patients per month in Tungipara UHFWCs in 2011

Seasonal variation is an important factor determining the number of patients seeking
care from UHFWC. It was found that almost 30% of the total patients received care
during January –March, 2011 in four UHFWCs (Fig 15).


Figure 15: Proportion of patients in UHFWCs by quarter in 2011
4.3. Capacity of CC
There is a total of 16 CCs in Tungipara, of which, 14 CCs were functioning during the
data collection period. This section presents the findings of these14 CCs.
It was found that one CC has three sanctioned posts: Community Health Care Provider
(CHCP), FWA and HA. Out of 14 CCs, 12 CCs in Tungipara had CHCP, while two
CCs had no CHCP. All the respondents in these 14 CCs stated that they require one
guard and one aya in each CC at present and also for SSK.
Table 4.3.1: Existing and required human resources in CCs of Tungiparat upazila
Designation
Average number of Number of CCs with
Among the 14 CCs, two CCs did not report on furniture and fixture. Some of the CCs
lack furniture, for example – four CCs did not have any almirah, eight CCs did not
have examination table and delivery table. The respondents suggested that they would
require all these furniture for SSK. The average number of additional furniture and
fixture required for SSK in the CCs are presented in Table 4.3.2.


Table 4.3.2: Important furniture and fixture at CC of Tungipara Upazila

Average Number (in Average Number of CC order) in a UHFWC furniture furniture and fixture required for SSK Examination table and delivery table *Data was not reported for 2 CCs Among the 14 CCs, 10 had own land of 5 decimals. Three of the CCs do not have any land of their own and they are using the office of the union council. Respondents in 4 of these CCs suggested that they would not require any additional space for SSK. Rather they need water and electricity supply for smooth functioning of CC, which is currently not available in some of the CCs. Table 4.3.3: Existing and required infrastructural inputs in CCs of Tungipara Upazila
Item

CCs received drugs in regular intervals. However, a number of CHCP suggested that as
they were not allowed to prescribe antibiotics, such as, Cotrim, there was no reason to
provide these antibiotics in CCs. They added that a number of such medicines remain
unused in CC.
Table 4.3.4: Amount of major drugs received in 2011
Average quantity received in 2011(12CC) Amoxicillin Capsule Chlorpheniramine Ferrous Fumarate and folic acid tab Hyoscine butoylbromide Zinc disperesivle Amoxicillin dry syrup Amoxicillin pediatric drop Paracetamol suspension Chloramphenicol eye ointment (1% ) gm Gentian violate 2% solution CHCP maintains register to keep patient record. The total number of patients in the 14
CCs in 2011 is presented in Table 4.3.5. CHCPs in Tungipara also maintained record of
number of persons they referred to UHFWC/UHC per month. However, as no
consolidated data on the number of patients by disease per month was available, it was
not possible for the FIs to collate disease-wise monthly patient record from CCs in
Tungipara.
Table 4.3.5: Average number of patients in the CCs of Tungipara upazila during 2011
Name of CC
Sriram kandi ghosh er ghat Purbo patgati mobari Geemadanga munshichar Moliker math geema 4.4. Capacity of the private sector
In the private facility, there was no full time doctor, doctors come on call. The owner
himself is the provider of the facility. There are 8 patient beds in the clinic. Average
patient per month is 15. No diagnostic test is available. No patient record was kept in
last two years. They use a rented space to provide service. The respondent said that
equipments need to be increased by 50% if SSK is implemented.

5. FINDINGS IN RANGUNIA UPAZILA
Rangunia is one of the upazilas in Chittagong district with an area of 351.95 sq km. The total population of the area is more than 263,217. Along with the UHC, 10 UHFWCs, 7 Rural Dispensaries (RD) and 38 CCs provide health services in the area. This section analyses the capacity of UHC, UHFWCs and CCs and the capacity of one private clinic providing health care in Rangunia. 5.1. Capacity of the UHC
Capacity of the UHC in terms of availability of personnel and their qualification,
availability of physical infrastructure (land, equipment and furniture), availability of
medicines and logistics, data availability and whether there remains appropriate input
skill-mix in the facility were studied.
Human resources
The UHC in Rangunia had a total of 284 sanctioned posts, of which 230 persons were
employed and 54 posts were vacant (Table 5.1.1). The posts of RMO, Junior
Consultant- Surgery, store keeper, head assistant cum accountant, and UFPO were
vacant in the UHC during the survey period. However, though there were six
sanctioned posts for Medical Officer in the UHC, four additional MOs from UHFWCs
were working temporarily in the UHC through local order.
Table 5.1.1: Existing and required human resources at UHC of Rangunia Upazila
Clinical staff responsible for both inpatient and outpatient department
UHFPO
Jr Consultant (Gynaecology) Nurse (senior and assistant) Medical technologists Clinical staff responsible for inpatient department
Jr Consultant (Surgery)
Jr Consultant (Anaesthetist) Clinical staff responsible for outpatient department
Jr. Consultant
Medical Officer, IMO, EMO Medical Assistant Health Assistant Administrative staff
Statistician
Head assistant cum Accountant Health Inspector/ Assistant HI Family Planning staff providing outpatient care
UFPO

In Rangunia, the number of doctors and nurses per 10,000 population is only 1.14.
Ratio of physician per 10,000 population is 0.65 (Table .5.1.2).
Table 5.1.2: Indicators of human resource management
Indicators
Nurse to physician ratio (number of physicians employed) Ratio of physician per 10,000 population Ratio of nurse per 10,000 population Ratio of physician and nurse per 10,000 population Ratio of health assistant per 10,000 population Ratio of health workforce (physician, nurse and health workers) per 10,000 population Percentage of female physician among total physicians Ratio of inpatient beds per 1000 population
During survey it was observed that only 45% of the employed providers generally
provide services in the facility. The general physicians, who work in both inpatient and
outpatient departments, visit the inpatient department for an hour per day. During the
remaining hours, they treat patients in the outdoor department and also accomplish
some managerial tasks. This indicates that only 45% of the capacity of the UHC is
currently being utilised in the facility. If all the employed persons work in the UHC and
work for full time, they can provide services to twice the number of current patients.
Managers suggested that they do not need to create any additional posts of health care
providers; rather if the employed persons work in the UHC, they can provide services
efficiently at present and even after the SSK.

Expertise and experience of the health care providers
Most of the health care providers in Rangunia UHC have adequate experience,
however, a number of them, especially the junior consultants, require training on
reproductive health, child health and non-communicable disease. Respondents
suggested that training should be provided based on the training need of local level
health professions, and relevant participants should be selected for the training sessions.
They reported that central level often does not consider the expertise of the personnel to
attend a training session, rather select a person based on his availability. Respondents
added that due to high staff turnover, refresher training needs to be arranged regularly.
Table 5.1.3: Educational qualification of the physicians
Educational qualification Issues of basic training (highest degree) Communicable disease Jr. Consultant (Medicine) Reproductive health (Gynaecology) Jr. Consultant (Anesthesia) (Orthopedics) Jr. Consultant (Paediatrics) Jr. Consultant (Cardiology) (Ophthalmology) Jr. Consultant (ENT) Jr. Consultant (Skin & VD) MBBS, FCPS (P-1) Reproductive health Assistant Surgeon Emergency Medical Officer Nursing Supervisor Reproductive health, Communicable disease
Equipments, furniture and fixture
It was found that the UHC had a total of 183 important medical equipments for
inpatient department and 21 equipments for outpatient department. However, in
inpatient department, 90% of the equipments were out of order.
Table 5.1.4: Important equipments at UHC of Rangunia Upazila
Name of the equipment Inpatient department
Anaesthesia Machine Diathermy machine Haemoglobin meter Nitrous oxide cylinder O.T. Light, Ceiling 9 bulb Obstetric Delivery Table Oxygen flow meter Sucker machine 250 w/400 watt B.P. machine Aneroid Instrument tray 10"-12" Sponge holding and sinus forceps Cusco's vaginal speculum Cuscors vaginal speculum Outpatient department
Refrigerator 10cft B.P. machine Aneroid Instrument tray 10"-12" Thermometer clinical
The Rangunia UHC has 50 beds, and a total of 174 furniture of which 131 are for
inpatient department and 43 for outpatient department. The ratio of inpatient bed per
1,000 population is 0.19 in Rangunia.
Table 5.1.5: Important furniture and fixture at UHC of Rangunia Upazila
Name of the furniture Inpatient department Cabinet (Almirah) steel and wood Chair armed Wood and steel rack Out patient department board/cabinet File Cabinet Land and space
The UHC has 5 acre of land and the building is 15000 sq. ft. There are 18 rooms in the
facility with an average size of 300 Sq ft. The UHC requires 10% more rooms to
provide services after SBP. Number of toilet facility has to be increased to support the
patient flow after SSK. The facility has an ambulance and a motorcycle. The
connecting road to the facility is under construction and currently in a bad condition.
Table 5.1.6: Amount of land and space of UHC of Rangunia upazila
Land and space
Inpatient department Total space (in square feet) Out patient department Total space (in square feet) OPD registration room Consultation room
Drugs, supplies and logistics
Providers at UHC informed that medicine is procured by and distributed from the
central level based on the number of bed in the facility. They reported that the drugs are
supplied as per availability, not as per need, which creates a problem for the managers.
Calculations of drug consumption rate (DCR) are not being practiced. Therefore, there
remains shortage of some drugs and some drugs are supplied in excess quantity.
Sometimes the excess drugs get expired and cannot be used, which causes inefficient
utilisation of scarce government resources. Respondents also suggested that excess
supply of drugs often opens the avenue for over-prescribing drugs, such as vitamin,
iron tables and pain killers, thereby enhancing misuse of drugs in the UHC. At the end
of 2011, stock of several drugs, such as, amoxicillin, Syp Metronidazole, Salbutamol
Solution dexamethason became nil.
Table 5.1.7: Drugs received in 2011 by UHC of Rangunia upazila
Name
Quantity received in 2011 The amount of inventory at the end of year 2011 Tab Metronidazole 400 mg Tab Hyoscine N Butyl Bromide Tab Ranitidin 150 mg Tab Cotrim 400 mg Cap Tetracycline 200 mg Cap Cephradin 500 mg Cap Flucloxin 500 mg Cap Amoxycillin 250 mg Syp Metronidazole Whitfield Ointment Inj Dexamethacin Surgical gloves (Sterile) Disposable syringe Inj Cephtriaxone 1 gm Salbutamol Solution Syp Erythromycin Tab Zinc Sulphate
The managers reported that supplies and logistics, including blood slide glass, cotton,
and needle were adequate in supply. They suggested that 10% more supplies and
logistics would be required for implementing SSK.
Trend of patients in UHC
The number of patients who visited the UHC over the period of 2010-2011 is presented
in Table 5.1.8. It appears that the number of total persons seeking care from UHC
increased by 65.71% from 2010 to 2011. Among the total patients who visited UHC in
2011, highest number of patients suffered from asthma. In 2011 highest number of
patients sought both outpatient and inpatient care for diarrhoea.
Table 5.1.8: Number of patients by disease, 2010-2011
Disease/condition a) Maternal health
b) Pelvic infection, STI/RTI
Bronchial asthma c) Skin, ENT and dental infection
Fungal infections
d) Family planning
e) Non-Communicable Disease
Diabetes

The proportion of inpatient in total patient in Rangunia UHC reduced from 8% in 2010
to 6% in 2011.
Figure 16: Proportion of inpatient and outpatient in total patient, 2010-2011
It was found that 70% of the inpatients in Rangunia UHC were admitted for treating pelvic infection and STI. Figure 17: Percentage distribution of inpatient by type of disease,
2011

Maternal health Pelvic infection, ARI NCD Other
Figure 18 suggests that there was little variation in number of inpatients per month in
Rangunia UHC in 2011, however, the number of outpatient varied considerably per
month. The number of patients was relatively high in June-October, while was low in
November-January.
Figure 18: Number of outdoor and indoor patients by month in 2011 in Rangunia
UHC

Management issues
It was reported that referral depends on severity of the disease. RMO supervises
emergency services and in-door services at the UHC, while field supervision is
conducted by health inspector (HI) and Sanitary inspector (SI). It was apparent that
lack of manpower and transport led to weak monitoring system. The budget
management is the same as the other districts.
Though outpatient department maintains disease-wise patient record, it was difficult to
collect inpatient number by disease. Rangunia UHC maintained record for referred
patient. They referred 1200 patients to District Hospital in 2011.
5.2. Capacity of the UHFWC/RD
There were 10 UHFWCs and 7 RDs in Rangunia. However, seven unions had both
UHFWCs and RDs, three unions had UHFWC and five unions had no UHFWC or RD.
This section presents the findings of these 17 UHFWCs/RDs.
Among the 17 UHFWCs/RDs, there is no Medical Officer in seven UHFWCs/RDs.
Eight UHFWCs/RDs reported vacant post of SACMO and 15 of the UHFWCs/RDs
had no pharmacist. All the UHFWCs/RDs in Rangunia need to fill the vacant posts at
present for smooth functioning of the facility.
Table 5.2.1: Existing and required human resources in UHFWCs/RDs of Rangunia
Upazila by designation
Designation
Number of UHFWCs with Number of UHFWCs with employed persons
It was evident that equipments in the UHFWCs/RDs were not enough in quantity. Not
all the UHFWCs had stethoscopes. On an average, a UHFWC had 1 BP machine, 1
IUD kit while there was no D&C set in most of the UHFWCs/RDs.
Table 5.2.2: Important equipments at UHFWC/RD of Rangunia Upazila
Name of equipment
of equipments (in scissors D & C set Examination table M.R set with canula Suction unit portable (manual) Weight machine
Managers in the UHFWC/RDs were asked about the additional number of patients they
expect after the introduction of the SSK, and they suggested that introduction of SSK
would increase patient by 15% to 20% at the UHFWC/RD. Managers stated that they
would therefore require additional number of important equipment for smooth
functioning of the scheme (Table 5.2.2).
The UHFWC/RDs lack adequate number of furniture and fixture. It was also found that
there were a total of 4 IUD tables, 3 dispensary tables and 53 almirahs in 17
UHFWC/RDs. However, some UHFWC/RDs did not have OT table, normal waste
basket or file cabinet (Table 5.2.3). All of the UHFWC/RDs require furniture to support
SSK.
Table 5.2.3: Important furniture and fixture at UHFWC/RD of Rangunia Upazila

Total number of furniture and total number of additional furniture fixture in and fixture required for SSK Dispensary table examination table Chair
It was apparent that UHFWCs had an average of 27 decimal of land with a building of
1430 square feet (Table 5.2.4). Six UHFWCs had room for MO and OT, and waiting
room.
Table 5.2.4: Existing and required infrastructural inputs in UHFWC/RDs of Rangunia
Upazila

Number of UHFWCs Number of UHFWCs requiring additional requiring additional inputs at resent SACMO Room for FWV Pharmacist Waiting room Providers at UHFWC/RDSs informed that they receive a number of drugs in excess
amount which they do not need, while there remains shortage of supply of some
essential drugs.
Table 5.2.5: Average amount of important drugs received in 2011, inventory, and
required amount in UHFWC/RDs of Rangunia upazila
Name of drugs
Tablet metronidagol Tablet Iebuprofen Capsule Tetracyclin Capsule Cefradin Cloxacillin Capsule Amoxicillin Syrup Metronidajol Syrup Flu-Cloxacillin Syrup Mebendajol Syrup paracetamol Tablet Peniciline Tablet Vitamin B 1
It was evident that the child health, maternal health and family planning were the major
services provided at UHFWC/RD.
Table 5.2.6: Average number of patients in the UHFWCs of Rangunia upazila in the last
three years by disease/condition
Disease/condition
- Prevention and management of STI/RTI - Prevention of HIV/AIDS Family planning for male Family planning for female It is evident from Table 5.2.7 that the number of patients in a UHFWC varied
considerably per month.
Table 5.2.7: Number of patients in 2011 by month and UHFWC/RDs
Month

In Rangunia number of patients seeking care from UHFWC/RDS is lowest (24.70%) in
the first quarter of the year (Fig 19).
Figure 19: Proportion of patients in UHFWC/RDs by quarter (2011)
5.3. Capacity of CC
There are a total of 45 CCs in Rangunia of which, 38 CCs were functioning during the
data collection period. This section presents the findings of these 38 CCs.
It was found that one CC has three sanctioned posts: Community Health Care Provider
(CHCP), FWA and HA. Out of 38 CCs there are 40 CHCP posts. Two of the CCs had
each 2 CHCPs. All the respondents in these CCs stated that they require guard, aya,
MA, MLSS, sweeper, cleaner, night guard in each CC at present and also for SSK.
Table 5.3.1: Existing and required human resources in CCs of Rangunia upazila
Average number of It was evident from the data that some of the CCs had adequate number of equipment but some of them do not have any of important items. For example, there were 12 stethoscopes in 11 CCs, while other CCs do not have the equipment. Table 5.3.2: Important equipments at CCs of Rangunia Upazila (in order) in a equipment depressor Weight scissor Artery forceps curved -5" Artery forceps straight -5" Bandage cutting scissors Curved cutting needle Hanging weight Two of the CCs did not report on furniture and fixture. Some of the CCs lack furniture, for example – 35 CCs did not have any delivery table. The respondents suggested that they would require all these furniture in additional quantity for SSK. The average number of additional furniture and fixture required for SSK in the CCs are presented in Table 5.3.3. Table 5.3.3: Important furniture and fixture at CCs of Rangunia Upazila
furniture/fixture furniture/fixture Examination table Patient Bed/Table CCs have on average 5 decimal land and almost all of them reported additional requirement of space for SSK. It was evident that there was enough supply of drugs in the CCs. They receive 2 kits of drugs per quarter, each containing 29 medicines. They received drugs in regular intervals. However, a number of such medicines remains unused in CCs. Table 5.3.4: Major drugs received in 2011
Tablet metronidagol Cotrimoxazole Tablet 120 Cotrimoxazole Tablet 960 Albendazole Tablet 400mg Amoxicillin Capsule 250mg Amoxicillin Dry Syrup(125 mg/5ml) 100ml Amoxicillin Paediatric drop(125 mg/1.25ml)10ml Benzyl Benzoate Application(25% W/V) 100ml Calcium Lactate Tablet 300mg Chloramphenicol Eye Oinment 1%, 5gm Chlorhexidine & Cetrimide Solution 1itr(Hos. Con.) Chlorpheniramine Syrup (2mg/5ml) 100ml Chlorpheniramine Tablet 4 mg Compound Benzoic Acid Oinment 1kg Doxycycline Capsule 100mg Erythromycin Dry Syrup(125 mg/5ml) 100ml Erythromycin Stearate Tablet 250 mg Ferrous Fumarate & Folic Acid Tablet 200.20 mg Genatian Violet Topical Solution 2%, 10ml Hyoscine Butylbromide Tablet 10 mg Neomycin & Bacitracin Oinment 10g Paracetamol Suspension(120mg/5ml)60ml Paracetamol Tablet 500 mg Penicillin V Tablet 250 mg Sabutamol Syrup(2mg/5ml)100ml Vitamin B-Complex tablet Zinc Dispersible Tablet 20 mg 5. 4. Capacity of the private sector
Two of the private facilities were surveyed in the Rangunia Upazila. In the private
facility, there were on average six experienced doctors in the facility. Average number
of persons employed in each facility was 36. The facilities had adequate equipments
and furniture and fixture in order. On an average, they provide services to 13 patients
daily.
6. FINDINGS FROM THREE PILOT UPAZILAS: A COMPARATIVE
ANALYSIS

The researchers and FIs visited the district hospitals in the three pilot upazilas. They
discussed with the Civil Surgeon (CS) and Residential Medical Officer (RMO) about
the existing capacity of the district hospitals and whether they will need any additional
inputs for SSK. They all informed that there remains excess capacity in the district
hospitals, especially in the inpatient department. They reported that the bed occupancy
rate in the district hospital is around 70 to 75%, and other inputs are also underutilised.
They therefore suggested that they can provide services to 20 to 25% additional
patients without increasing the available fixed inputs. Only the variable inputs, such as,
drugs and logistics will need to supply more depending on the coverage of SSK.
This study assessed the capacity of the public facilities in three pilot upazilas-Debhata,
Tungipara and Rangunia. Capacity was defined in terms of availability of personnel
with experience, training and appropriate skill-mix, availability of enough space,
important equipment and furniture, regular supply of essential drugs based on local
needs with no shortage and/or surplus, appropriate input mix and data availability.
Underutilisation of human resources is a common phenomenon in all the three UHCs in
three upazilas. It was evident that 24% of the total sanctioned posts remained vacant in
the three UHCs (Fig 20). However, among them, the proportion of vacant posts in total
posts was highest in Tungipara (45%). Inappropriate skill-mix was also common
among the three UHCs. None of the UHCs had anaesthetists.
Figure 20: Proportion of filled-in and vacant posts in total posts in UHC by area
% of filled-in posts % of vacant posts It was evident that among the three pilot upazilas, the proportion of vacant posts to sanctioned posts was higher in Tungipara for all types of personnel. The vacant posts were higher for clinical staff working at the inpatient department in all the UHC. Figure 21: Proportion of vacant posts to sanctioned posts by staff category and by
area in UHC

Inpatient clinical Outpatient clinical
It was also evident that a large proportion of the personnel, who were employed in the
public facilities, do not regularly work in the facility. Moreover, they work for only five
hours per day in the facility, of which three hours is spent for treating patients. The
situations was more or less similar in all the three areas, and around 40-50% of staff
capacity remain unutilised in public facilities at upazila and lower administrative levels.
It was evident that though human resources were available for provision of health
services in the facilities, non availability of some complementary inputs such as
equipments, drugs, or logistics, or even some components of human resources (viz,
nurse, technician, and anaesthetist) constrained the capacity of the public health
facilities.
There remains inappropriate skill mix in UHCs as was indicated by the less number of
nurses than doctors in UHC, and also inadequate female doctors available in UHC. The
ratio of nurse to doctor was lowest in Rangunia UHC- 0.76. There was no female
doctor in Tungipara (Table 6.1.1). The current nurse-doctor ratio in all the three UHC is
considerably less than the international standard of around three nurses per doctor.
Table 6.1.1: Indicators of inappropriate skill mix
The average number of patients treated by a doctor per day in UHC was highest in Tungipara (33). There was one doctor available for 15,483 population in Rangunia (Table 6.1.1). It was found that In Debhata, among the most important equipment in the inpatient department, 44% equipment was properly functioning, while in Rangunia, only 7% equipment was properly functioning and do not need any repair or replacement at
present (Fig 22 ).
Figure 22: Percentage distribution of important equipment in IPD in UHC by
condition and by area

There was a number of equipment in the facilities, which remain un-used due to unavailability of personnel to operate those (e.g. dental equipment in Debhata, ultra-sonogram in Tungipara). The managers in UHC also faced the problem of inadequate fund available for repair and maintenance of equipment. Non use of equipment combined with inadequate fund resulted in damage of equipment and thereby wastage of scarce resources. It was found that local needs are not considered for supplying drugs at UHC. This is partially reflected in the figures below (Fig 23 and 24). At the end of 2011, 15% of the drugs received were unused, which included tablet Ranitidine, inj Ceftriaxone 1 gram, tablet Levofluxacin and Fetorolac. However, providers reported that a number of life saving antibiotics including tetracycline, indomethacine, cephradine, amoxicillin and doxycycline were supplied in inadequate amount. Assessment of pattern to be done by the provider, drug should comply with that need. Even then, the problem of imbalance between supply and need can sometimes arise due to sudden increase or decrease of occurrence of some diseases-abrupt change in the disease profile. There should be proper arrangement of correcting the suddenly arising imbalance at the central level. It appears that the amount of unused capacity, if judged in terms of the fixed inputs, exists at all of the UHC under study, and it is a bit high in Debhata and low in Tungipara. Figure 23: Percentage distribution of drugs by use at UHCs in 2011
% of total drugs used in 2011 % of total drugs as inventory at the end of year 2011
Among the three UHCs, drug usage as a proportion of total drugs received was
relatively higher in Rangunia and lowest in Debhata (Fig 24).
Figure 24: Percentage distribution of drugs by use and by area in UHC
% of total drugs % of total drugs as used in 2011 inventory at the end Bed occupanct rate was calculated for the three UHCs, the rate was highest in Tungipara (70%) and lowest in Rangunia (40%) (Fig 25). This needs further investigation. The varying health care seeking behaviour among different areas, or supply side barriers might cause difference in bed occupancy rate among areas. Figure 25: Bed occupancy rate in three UHCs

Per capita cost and cost incurred per patient by public sector was calculated for three
surveyed upazilas. Per patient cost was found lowest (258 Tk.) in Tungipara and cost
per capita was lowest in Rangunia (90 Tk.).
Table 6.1.2: Cost per patient and population*
* The figures of total cost were taken from the costing study. It can be said that in terms of availability of fixed inputs (land, personnel and equipment) and variable inputs (drugs and logistics), Debhata had more capacity as compared to other two upazilas. It appeared that among the three UHCs, performance of the Debhata UHC was high, the other two UHCs - Rangunia and Tungipara - were medium performing. The performance was assessed on the basis of manpower employed, usage of equipment, drug, logistics and proportion of population utilizing the services provided at the facility. In terms of availability of fixed inputs (land, personnel and equipment), variable inputs (drugs and logistics) and number of patient treated, among the 4 UHFWCs functioning in Debhata, one UHFWC is high performing, two are medium performing and one is performing low (Table 6.1.3). All 12 CCs in Debhata are medium performing. Among the 4 UHFWCs functioning in Tungipara, one UHFWC is high performing, one is medium performing and two are performing low. One CC in Tungipara is high performing and the rest are medium performing. Table 6.1.3: Performance of UHC, UHFWC/RD and CCs in three upazilas
Among the 17 UHFWC/RDs functioning in Rangunia, five is high performing, 7 is medium performing and 5 are performing low. Out of 38 CCs in Rangunia 7 are high performing, 7 are low and the rest are medium performing (Table 6.1.3). 7. CONCLUSION AND RECOMMENDATIONS
The aim of the study was to assess overall existing competence of health facilities at three upazilas from three pilot districts, taking one upazila from each of the three pilot districts, to meet the needs of the SSK. The specific objectives were to assess the existing capacity of public facilities, additional capacity required at present to meet the current health care need, and increased capacity required in future to meet the additional health care need that might arise as a result of introducing the proposed benefit package. The findings of the study suggest that an artificial constraint has emerged in the service provision in the public facilities due to the lack of regular and sufficient availability of drugs and logistics, as well as, of lack of appropriate combination of human resource and equipments. The main inputs exist in public facilities; however, they cannot work to their full potential due to inadequate amount of auxiliary inputs, such as, drugs, and logistics. Moreover, the main inputs- human resources and equipments- are not working for full time, and are being utilised for maximum of five hours a day. There also remains inadequate land and space in a number of facilities. For example, the infrastructure in a number of UHFWCs in Tungipara is extremely limited. Due to absenteeism of personnel, there remains high work load for employed personnel in the UHCs. The average number of patients seen per day was 27 in Debhata and 33 in Tungipara. Managers in the UHCs reported that as the actual number of doctors working in the facility is much lower than that of employed persons, the average number of patients seen by a doctor per day becomes 45. This implies that on an average a doctor allocates only four to five minutes per patient. The managers and the providers predicted that implementing the insurance will increase the patient load by 20% in public facilities. As there remains under utilisation of human resources, land, space and equipments in the public facilities at present, the increased number of patients resulting from implementing the insurance scheme can still be treated without increasing the fixed inputs, if all the persons employed in the facility work. For smooth functioning of the scheme, the study comes up with the following recommendations:  Issues related to human resource management must be addressed adequately before implementing the insurance scheme. Measures need to be taken to ensure that all the employed staff works in the facility for full time. Special arrangements must be adopted to retain the required number of medical personnel in the facilities in the pilot areas for smooth functioning of the scheme. There needs to be adequate number of personnel available for emergency care for 24 hours. An arrangement should be made for giving some financial incentive out of the collected premium so as to induce them to increase enrolment in the scheme and provide services of improved quality. Appropriate combination of human resource and equipments should also be maintained.  Training of administrative and support staff is crucial. The relevant providers and staff should be adequately and regularly imparted basic training on the emerging clinical issues. They should also be trained on procurement, record keeping and financial management. A simple guideline needs to be issued for them to help them maintain proper accounts and meet Government's audit requirements. Training needs to be provided at all the tiers up to district level on Management Information System (MIS) for maintaining patient record and networking. Store keeper also needs training on store management. Training on local level planning is also needed to relevant personnel. Refresher training also needs to be arranged periodically.  Supply of drugs and logistics should be based on local level needs. The amount of drugs and logistics received and utilised and additional requirement for next three months need to be assessed periodically. Use of BIN card can be useful to maintain the drug register. Regular and sufficient availability of drugs and logistics should be ensured.  Involvement of community representatives in the management and evaluation process should be ensured. This can be initiated through proper implementation of local level planning process.  Implementation of the SSK scheme will require a strong health information system in order to keep the record of the number of health cards issued and to which families, their demographic and socio-economic status, medical record of client, amount of money spent for client per visit, referral made and record of follow up. The data base needs to help in processing and accounting claims and monitoring the overall activities performed under the scheme.  Monitoring and supervision of the service provision at all tiers needs to be strengthened. Similar indicators can be developed and used for all the three pilot upazilas to monitor the activities of the insurance scheme. Besides regular monitoring, mid-term and end-line evaluation of the pilot project should be undertaken to assess the impact and derive the lessons.  Some amount of operational autonomy is needed for the facilities at the UHC so that they can take some decisions locally to meet requirement of the changing circumstances can improve management using the local level planning done by themselves, and also improve their performance through entering into competition with the non public facility at the local level.  The UHFWCs and CCs should be established in all the unions and wards. Besides, the UHFWCs and CCs that have already been established should properly function. This is needed for providing basic outpatient care, for creating demand for health care from the formal sources, and for enforcing referral mechanism. A strong referral mechanism needs to be maintained among different tiers. REFERENCES
Abel-Smith, B.(1992) Health insurance in developing countries: Lessons from experience Health Policy and Planning 7(3):215-226. Ahmed S M, Hossain M A, Chowdhury A M R, Bhuiya A U (2011) The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution Human Resources for Health 2011, 9:3: 2-7. Kondo A and Shigeoka H (2011) Effects of Universal Health Insurance on Health Care Utilization, Supply-Side Responses and Mortality Rates: Evidence from Japan, available online at http://www.columbia.edu/ hs2166/Kondo_Shigeoka_Dec27_2011.pdf BHW (2008) Bangladesh Health Watch 2008 Bhattacharjya Ashoke S. and Sapra Puneet K.(2008) Health Insurance In China And India: Segmented Roles For Public And Private Financing, Health Affairs, 27 (4):1005-1015. Normand, C.(1999) Using Social insurance to meet policy goals Social Science & Medicine 48: 865-869. WHO (2007) Not enough here, too many there: Health workforce in India, World Health Organisation, Country Office, India. ANNEXURE
Table A1: Educational qualifications of physicians in Debhata UHC Year of joining present (highest degree) Jr. Consultant (Medicine) Jr. Consultant (Surgery) Jr Consultant (Gynae) Table A2: Number of persons by Length (years) of experience of personnel at UHC of Debhata Upazila Table A.3. Issues of basic training received by the personnel of UHC of Debhata Upazila Issues surgery Basic service management Diabetics Leprosy Vactic Mg management Midwifery Table A. 4: Drugs prescribed by providers by disease/ condition Disease/Condition Vitamin B Complex L. Treatment Failure Chronic Pneumonia Hydrocortison oinment New-born Diseases Vitamin B Complex Moxycyline Diclofenac Aetrophincephradin Metformin Insulin Table A.5. Information from the UHFPO about some activities and managerial issues of the UHC of Debhata Item of information Number of patients visiting UHC everyday Main diseases and conditions of the patients Diarrhea, RTI/SSTI, PUD, Skin disease, LMP Number of patients referred from UHC Drug management system DRS(local purchase) and CMSD to store to indoor, outdoor and emergency Financial management system Monitoring system Supervision system, delivered by RMO( emergency services, in-door services), field supervision by health inspector(HI) and Sanitary inspector(SI). Overall supervision by UH&FPO through reporting to CS office, DG health and MIS Referral mechanism followed Record keeping system through In-door and emergency. Problems faced at present Slow internet connection, No broad band internet system. Additional inputs required at present Inputs to increase internet speed Awareness about SSK Possible effects of SSK Health service receiver and provider get benefit through their inner communication by SSK. That is why both will be benefitted. Easy to get facility. Additional inputs required for SSK Ensure provider's benefit and promotion. % of increase of patients after SSK 2013-15%, 2014-20% and 2015-30%. Additional support system required Purposeful training for planner, benefit package for provider, part of pathological fees should be given to provider. Modification of management system for SSK Local level planning needed. Table A.6: Training requirement for human resources in UHFWCs of Debhata Upazila by issues of training Issues Table A.7 : Number of persons by Length (years) of experience of personnel at UHC of Tungipara Upazila Jn Consultant/specialist Table A.8. Information from the UHFPO about some activities and managerial issues of the UHC of Tungipara Item of information Number of patients visiting UHC everyday Main diseases and conditions of the patients Fever, knee pain, injury, poisoning, delivery care Number of patients referred from UHC 32(24 emergency and 8 indoor) Drug management system CMSD , AID and maintain ledger. Supplied to ward and outdoor patient department through indent. Financial management system Budgeting through MSR form, To receive procurement by demand letter. Keeping records of expenditure by stock ledger and send expenditure sheet to CS. Bill is sent to AG office if approved then money is received through bank. Monitoring system Referral mechanism followed Reffered by referral slip. The slip is used by the doctor. Central data base system, web site Problems faced at present Staff not available according to sanction. Additional inputs required at present Fill all sanctioned post immediately Awareness about SSK Possible effects of SSK Health service delivery will be improved and general people will be benefitted. Additional inputs required for SSK % of increase of patients after SSK 10 to 20% increased gradually Additional support system required Trained manpower and budget Modification of management system for SSK Local level planning and proper monitoring b y higher health professional. Table A.9 : Length (years) of experience of personnel at UHC of Rangunia Upazila Table A.10. Issues of basic training received by the personnel of UHC of Rangunia Upazila Issues Did not Received surgery Basic service management Diabetics Leprosy Vactic Mg management Midwifery health(IMCI) Reproductive 1 Table A.11. Information from the UHFPO about some activities and managerial issues of the UHC of Rangunia Item of information Number of patients visiting UHC everyday Main diseases and conditions of the patients Road accident and injuries, COPD,Pneumonia, poisoning, scabies, diarrhea, melmintheiasin, fever, common cold. Number of patients referred from UHC Drug management system CMSD to store, RMO supervision Financial management system DG health, allotted on installment, if ss shortage dd note placed Monitoring system Visit indoor, outdoor, manpower, field visit, meeting Referral mechanism followed EMO decides, depends on severity and existing facility Manpower mgt, overall mgt. report, patient record, send to CS office, also send through e-mail. Problems faced at present Doctor shortage, other manpower crisis, shortage of bed OT., doctor's residential facility. Additional inputs required at present Doctor, manpower, modern machinery, drug and other infrastructure Awareness about SSK Possible effects of SSK Positive effects on Health system, better health facility Additional inputs required for SSK % of increase of patients after SSK 2013-20%, 2014-30% and 2015-30%. Additional support system required Bed, doctor, support staff, equipment and additional fund Modification of management system for SSK Table A. 12: Training requirement for human resources in FWCs of Debhatta Upazila by issues of training Issues of basic Table A. 13 Supplies and logistics in Debhata (in 2011) Item of supplies and logistics Quantity received in 2011 The amount of inventory at the end of year 2011 Plaster of Paris Foley's catheter different size Implantation set Table A.14 Supplies and logistics in Tungipara (in 2011) Item of supplies and logistics Quantity received in 2011 The amount of inventory at the end of year 2011 Plaster of Paris Foley's catheter different size Implantation set Table A.15: Number of persons employed in a private clinic in Debhata Designation
Name of the
Educational
Issues of
persons qualification
(highest
training
salary and
received*
allowances
Medical Officer 1 Md. Rafikul Islam Table A.16: Medical equipments in a private clinic in Debhata expected
Name of the equipment procureme
life years
required
after SBP
Air way (different sizes) Artery forceps (different size) B.P. machine Aneroid Bandage cutting scissors Boiling water sterilizer Buckect, plastic (large, medium, small) Dressing forceps Dressing tray (shallow) SS Drum sterilizer (shallow) SS Examination table Gauge cutting scissors Haemostat forceps Sims Vaginal Speculum Tongue depressor Table A.17: Furniture and fixture in a private clinic in Debhata Name of the furniture
(Vintage)
required
Patient Table Wood Table for Machinery Table A.18: Land and space in a private clinic in Debhata Table A.19: Equipments in a private clinic in Tungipara Name of the equipment
procurement
Electric Sacker Machine Oxygen cylinder Machine Auto clab machine baby weight machine Electric Needle Crush x Syringe pump machine Operational tools Furniture and Machinery Table A.20: Furniture in a private clinic in Tungipara Name of the furniture
(Vintage)
Examination Table Table A.21: Number of persons employed in a private clinic in Rangunia Designation
Name of the
Educational
Issues of
(highest degree)
training
salary and
present received*
allowances
MBBS, FCPS, FMD, Medical Officer 2 Medical Officer 3 Medical Officer 4 Medical Officer 5 Medical Officer 6 Medical Officer 7 MBBS, DGO, MCPS, Medical Officer 9 Table A.22: Number of persons employed in a private clinic in Rangunia Designation Category
Number of posts
Number of
Number of vacant posts
No. of posts
sanctioned
employed
required
after SBP
Medical Assistant Office Assistant Table A.24: Medical Equipments in a private clinic in Rangunia Equipment
Name of the
procurement expected
required
equipment
procurement
after SBP
(different sizes) Artery forceps (different size) B.P. machine Aneroid Bandage cutting scissors Boiling water sterilizer Buckect, plastic (large, medium, small) Cuscors vaginal speculam Dissecting forcep (plain/toothed) (shallow) SS Drum sterilizer (shallow) SS Examination table Forcep sponge holding plan Forcep tissue 2x3 teeth 191 mm Gauge cutting scissors Patient stretcher Sims Vaginal Speculum Stomach wash tube portable (manual) Tongue depressor Table A.25: Furniture and fixture in a private clinic in Rangunia Name of the
Furniture
furniture
procurement
expected
required
(Vintage)
(per unit)
life years
Wooden Table (Big) Wooden Table (Small)

Source: http://www.sskcell.gov.bd/PDF/inventory_study.pdf

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