LAMB Integrated Rural Health and Development is a Christian NGO that has been providing medical services to poor communities in rural northwest Bangladesh for over 30 years. LAMB provides health care at the household level as well as through local clinics and a 150-bed hospital. It prioritises support for women and children’s health.
The year 2008 brings the 30th anniversary of the Alma Ata Declaration on Primary Health Care, which aimed to achieve ‘Health for All’ by the year 2000. There is still a long way to go to realise this goal.
Access to care
Recent research by the NGO Action Aid into access to health care in Bangladesh revealed many barriers. Eighty-seven percent of people surveyed said they were discouraged from using government health facilities by the poor attitudes of staff, quality of services, and the need to pay ‘tips’ as well as fees. In private facilities, costs were 20 times higher than in government facilities. Most of this expense was for medicines, although many of these medicines were not essential. People also used informal health providers including pharmacists, village ‘doctors’, and herbalists.
The Alma Ata Declaration prioritised community participation, but in practice, more attention has been given to government programmes such as immunisation of children and family planning services. These ‘top-down’ programmes are important, but rather than empowering communities, they can often create an attitude of dependency. NGOs can help to prevent this by using a rightsbased approach, which encourages local communities to engage in advocacy to hold service providers accountable for proper allocation of care. LAMB’s community activities focus on the facilitation of grassroots groups, and working together with local leadership and government officials to ensure that communities have access to health care.
LAMB believes that the best progress in health care provision comes when communities, government officials and health experts work together. LAMB works with both local communities and officials, to provide expertise and build relationships across the sectors.
In many communities, the interlinking causes of ill health, such as poverty, lack of education and social injustice, are common. These need to be addressed to restore people’s physical, social, and emotional health. Poor communities often feel they have no way to improve things. NGOs that work in these communities can help promote awareness of rights, such as the right to health care. They often have a position of influence and so can help to build good relationships and bridge the gap between powerful local authorities and poor communities.
In Bangladesh, local area health committees are set up with government backing to provide a forum at which accessibility to health care can be addressed. NGOs can help to set up such advisory committees, and equip citizens to participate, so that local communities can influence service provision. Local representatives should be enabled to communicate community concerns directly to local and national leadership.
In countries where volunteering is not a common concept, it may require (non-financial) incentives to encourage people to take action. Communities must take responsibility for demanding what they need, such as health care or latrines. NGO staff must remember to step back. Government accountability is not to NGOs, but to the community.
LAMB emphasises the involvement of women in its work. To address the gender inequalities in communities, LAMB provides biblical values training (Genesis 1: male and female created in God’s image) and uses drama activities to raise awareness about early marriage, dowry demands, family violence, forced abortions and other issues.
LAMB focuses on training women as health promoters and paramedics, giving them a strong public role in household and clinic-based health care. Micro-credit work gives women increased influence because of the financial contribution they can then make to their family’s economic security. In areas where LAMB works, women’s groups support some of the running costs of the community clinics. Members of the groups then pay lower fees when they visit the clinic.
Working with government
LAMB has worked to develop the capacity of local government in providing health services. This co-operation is important, but can be difficult. Problems with communication between NGOs and local authorities can be easily caused when there are changes of personnel. Government funding limits and paperwork requirements can be problems. Government suspicion of NGOs, and desire to maintain control, can also create challenges. Patience on both sides is needed in negotiating contracts and demonstrating results. At the local level, community members themselves are often the best advocates to convince officials to support services, even if these services are provided by NGOs.
Building relationships at a local level is vital to targeting national influence. LAMB presents monthly reports of local programme activities at meetings with local officials. A careful balance is required to maintain the support of the government, but also present the truth where there are gaps in service provision. Partnership with both communities and government is necessary to promote a sustainable health system. The development of stronger communities will help move the world nearer to achieving the 30-year-old target of ‘Health for All’.
Dr Kris Prenger is the Community Health and Development Advisor for LAMB.
LAMB Integrated Rural Health and Development
Dinajpur Dt. 5250
Working together - an exercise
At a recent training session, the following activity was used to demonstrate the importance of relationships. Each participant took a few strips of coloured paper, some wide, some narrow. On the wider strips, they had to write positions of local power and influence, such as council chairman, landowner or government ministry official. On the narrow strips, they wrote down the people who had low status in the community such as farmer, beggar, widow, child. The strips were then tied together in loops to form a long paper chain, with narrow and wide strips mixed.
The participants were then asked:
- Where is this chain stronger?
- Where is it weaker?
Where the chain joined two narrow strips together, it was easier to tear. Where two wider strips were linked it was more difficult to break. Then the participants were asked how they could help the whole chain to be as strong as possible. The answer is for each link to be equally wide.
The chain is like a local community. The links represent relationships between people of varying status. If the strips were all wide, then the chain would be stronger. Therefore if people of low status were empowered and able to participate, it would make the whole community stronger.