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Primary Health Care Services in Bangladesh and the Prospects of Nutrition(FN-503).pptx

Primary Health Care Services in Bangladesh and the Prospects of Nutritional Care: This presentation outlines Bangladesh's PHC delivery system, from Community Clinics to tertiary hospitals, and its Essential Services Package (ESP), covering reproductive, child, and communicable disease services. It also highlights the growing integration of nutrition into PHC through the National Nutrition Services (NNS), addressing Bangladesh's double burden of malnutrition and outlining opportunities to strengthen nutritional care at the community level.

Education◦
PRIMARY HEALTH CARE SERVICES IN BANGLADESH AND THE PROSPECTS OF NUTRITIONAL CARE AKTARAFUN ZANNAT ASSISTANT PROFESSOR (FOOD AND NUTRITION) GOVERNMENT COLLEGE OF APPLIED HUMAN SCIENCE, AZIMPUR, DHAKA, BANGLADESH
CONTENTS  The current government delivery system of primary health care  Objectives, principles, strategies and essential components of primary health care  Level of health care services  Concepts of Essential Service Package (ESP)
DEFINITION OF PRIMARY HEALTH CARE The most widely accepted definition comes from the Alma-Ata Declaration (1978), jointly issued by WHO and UNICEF at the International Conference on Primary Health Care held in Alma-Ata, USSR:  Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination." This was reaffirmed and updated in the Astana Declaration (2018), which re-emphasized PHC as the most efficient and equitable way to achieve Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs).
OBJECTIVES OF PRIMARY HEALTH CARE 1. To provide equitable and universal access to essential health care for all, regardless of socioeconomic status. 2. To promote community participation in the planning, organization, and control of health care. 3. To emphasize disease prevention and health promotion rather than curative care alone. 4. To ensure intersectoral coordination (health, agriculture, education, water and sanitation, food, and nutrition). 5. To make appropriate use of available resources, including local health workers, traditional practitioners, and low-cost technology. 6. To reduce health inequities between urban and rural, and rich and poor populations. 7. To achieve "Health for All" as a fundamental human right.
PRINCIPLES OF PRIMARY HEALTH CARE Principle Explanation Equity Health services distributed based on need, not ability to pay Community participation Communities involved in identifying their own health problems and solutions Intersectoral coordination Collaboration between health and other sectors (agriculture, education, water/sanitation) Appropriate technology Use of scientifically sound, locally acceptable, and affordable technology Health promotion and prevention Emphasis on prevention over cure Decentralization Health planning and decision-making moved closer to the community level
STRATEGIES FOR IMPLEMENTING PRIMARY HEALTH CARE 1. Community-based approach – using community health workers, volunteers, and local leaders. 2. Decentralized health planning – district and upazila-level health management. 3. Integration of services – combining maternal and child health, immunization, family planning, and nutrition under one delivery platform. 4. Multisectoral collaboration – linking health with agriculture, water and sanitation (WASH), and education sectors. 5. Health system strengthening – improving referral linkages between community, primary, secondary, and tertiary care. 6. Use of mid-level and community health workers – e.g., Health Assistants (HA), FamilyWelfare Assistants (FWA), Community Health Care Providers (CHCP) in Bangladesh. 7. Information, Education, and Communication (IEC) – behavior change communication for health-seeking behavior.
ESSENTIAL COMPONENTS OF PRIMARY HEALTH CARE (ALMA-ATA, 1978) The Alma-Ata Declaration identified eight essential elements, often remembered using mnemonics in public health teaching: 1. Education concerning prevailing health problems and the methods of preventing and controlling them. 2. Promotion of food supply and proper nutrition. 3. An adequate supply of safe water and basic sanitation. 4. Maternal and child health care, including family planning. 5. Immunization against major infectious diseases. 6. Prevention and control of locally endemic diseases. 7. Appropriate treatment of common diseases and injuries. 8. Provision of essential drugs. (Later additions in some frameworks include: mental health, and provision of basic dental services.)
GOVERNMENT DELIVERY SYSTEM OF PRIMARY HEALTH CARE IN BANGLADESH  Bangladesh's PHC delivery system is organized hierarchically under the Ministry of Health and Family Welfare (MOHFW), primarily through two directorates:  Directorate General of Health Services (DGHS) – curative, preventive, and promotive health services  Directorate General of Family Planning (DGFP) – family planning and maternal/reproductive health services
STRUCTURE (RURAL HEALTH DELIVERY SYSTEM) Level Facility Catchment/Coverage Community level Community Clinic (CC) ~6,000 population Union level Union Sub-Center / Union Health and Family Welfare Centre (UH&FWC) ~25,000–30,000 population Upazila level Upazila Health Complex (UHC) ~200,000–400,000 population (sub- district) District level District Hospital District population Divisional/Tertiary level Medical College Hospitals, Specialized Hospitals Referral for divisions/whole country
 Community Clinics are the most peripheral and important innovation in Bangladesh's PHC system — they are the first point of contact, run jointly with community participation (land donated by local people, managed with Community Group/Community Support Group involvement), and deliver an Essential Services Package (ESP) at the doorstep level. Urban Primary Health Care  Urban PHC is delivered differently — largely through Urban Primary Health Care Centres (UPHCC) under city corporations/municipalities, often in partnership with NGOs, supported by the Urban Primary Health Care Services Delivery Project (UPHCSDP), since urban health does not fall under the rural DGHS/DGFP structure in the same way.
LEVELS OF HEALTH CARE SERVICES IN BANGLADESH Health care in Bangladesh, as in most health systems, is organized into three tiers: A. Primary Level  Community Clinics, Union Sub-centers, Upazila Health Complexes  First point of contact; promotive, preventive, and basic curative care  Includes maternal and child health, immunization, nutrition counseling, family planning, treatment of minor ailments B. Secondary Level  District Hospitals, General Hospitals  More specialized outpatient and inpatient care  Referral point from primary level facilities
C.Tertiary Level  Medical College Hospitals, Specialized Institutes (e.g., National Institute of Cardiovascular Diseases, National Institute of Diseases of the Chest and Hospital)  Highly specialized diagnostic, curative, and rehabilitative services  Referral and teaching hospitals  This is consistent with theWHO pyramidal model of health care delivery, where the broad base (primary care) serves the majority of the population's needs, narrowing toward highly specialized tertiary care.
CONCEPT OF ESSENTIAL SERVICES PACKAGE (ESP)  The Essential Services Package (ESP) is a defined set of basic health services that the Government of Bangladesh commits to providing at the primary health care level, particularly through Community Clinics and Union-level facilities, financed and delivered as part of the Health, Population and Nutrition Sector Programs (HPNSP). Components of ESP (as developed under successive Health, Nutrition and Population Sector Programs): 1. Reproductive Health – maternal health, safe delivery, family planning, antenatal and postnatal care 2. Child Health – immunization (EPI), management of childhood illnesses (ARI, diarrhea), growth monitoring 3. Communicable Disease Control – TB, malaria, leprosy, vector-borne diseases 4. Limited Curative Care – treatment of common illnesses and minor injuries at the community level
5. Behavioral Change Communication (BCC) – health education and promotion 6. Nutrition Services (increasingly integrated rather than fully separate) – growth monitoring, micronutrient supplementation (vitamin A, iron-folic acid), management of acute malnutrition, infant and young child feeding (IYCF) counseling 7. Non-communicable disease screening (added in later revisions) – hypertension, diabetes screening at the primary level The ESP was first conceptualized under the Health and Population Sector Programme (HPSP, 1998–2003) and has been revised under subsequent sector-wide programs (HNPSP, HPNSDP, and the current 4th Health, Population and Nutrition Sector Program), with nutrition increasingly mainstreamed into the package rather than run as a separate vertical program.
PROSPECTS OF NUTRITIONAL CAREWITHIN PHC IN BANGLADESH  Historical separation: Nutrition programs in Bangladesh (e.g., the National Nutrition Programme, Bangladesh Integrated Nutrition Project) have often run as vertical, donor-funded projects parallel to mainstream PHC, leading to fragmentation.  Current direction:The National Nutrition Services (NNS), operating under DGHS since 2011, represents a deliberate shift toward integrating nutrition into mainstream PHC service delivery — nutrition corners/counters are now established within Upazila Health Complexes, Union Sub-centers, and Community Clinics.  Double burden of malnutrition: Bangladesh faces simultaneous undernutrition (stunting, wasting) and rising overnutrition/obesity and diet-related NCDs, requiring PHC to address both ends of the nutrition spectrum — this strengthens the case for nutrition's permanent place within ESP rather than as a standalone vertical intervention.  Workforce gap:A recurring challenge is the shortage of trained nutrition personnel at the primary level (most PHC facilities rely on general health workers with limited nutrition training), which is frequently cited as a barrier to effective ESP nutrition service delivery.  Opportunities: Community Clinics' close community linkage, the Community Health Care Provider's regular contact with households, and the existing platform of EPI/antenatal care visits all present strong entry points for scaling up nutrition counseling, screening, and referral within PHC — without needing entirely new infrastructure.