Activities through the 3-tier Health care Model
Friendship’s activities include various health care services but are not limited to antenatal care (ANC), postnatal care (PNC), family planning, respiratory tract infections, skin diseases, diarrhea, fever, cough, typhoid, and specialized services like cataract surgery, cleft lip and palate surgery, club foot surgery, etc. through the 3-tier health care model. It also involves monthly nutrition demonstration sessions, regular health and family care follow-ups (data tracking), assessment, treatment, and referral of malnutrition cases for under-5 children and pregnant and lactating mothers. Their hospital ships (Tier 1) provide primary, secondary, and specialized health care in distant climate-vulnerable areas where the government and other non-governmental organizations have little or no intervention, depending on the people’s needs and feasibility of moving, considering the navigability of the rivers. The paramedic-led Satellite and Static Clinics (Tier 2) run biweekly or monthly to provide basic medical services for communicable and non-communicable disease prevention, behavioral change communication, and general health care issues. Moreover, Friendship trains female community members as medic aides (FCMs) (Tier 3) to act as the first point of contact for Friendship health care initiative (Figure 1). FCMs with specialized training to be Community Skilled Birth Attendants (CSBAs) facilitate access to safe delivery, advanced family planning services, ANC, PNC, and basic infant/neonatal care for Char communities. Furthermore, some FCMs are equipped with mobile phones to enable m-health services for remote diagnosis and connecting patients with Friendship assigned doctors when needed, following the app's step-by-step instructions, ensuring comprehensive accessibility at any time.
Sociodemographic and Economic Conditions
A significant proportion (43.0%) of the quantitative survey participants had no formal education. Among others, 26.8% attended primary school, 20.4% attended high school, and only 4.5% pursued college education. The majority of service recipients were female (88.9%) and aged 18-35 years (57.5%). Most households have 5—10 members (45.8%), approximately two-thirds (66.6%) earning less than 1620 USD, and 14.4% reported unawareness about their income. Regarding water and sanitation, the majority of households had individual tube wells (66.7%) and used covered pit latrines (29.0%) (Table 1).
Table 1: Sociodemographic and economic characteristics of survey respondents
Characteristics
|
n=760
N (%)
|
Sex
|
Male
|
84 (11.1%)
|
Female
|
676 (88.9%)
|
Age category
|
18-25
|
210 (27.6%)
|
26-35
|
227 (29.9%)
|
36- 45
|
111 (14.6%)
|
46- 60
|
139 (18.3%)
|
61- 90
|
34 (4.4%)
|
Don't know
|
39 (5.1%)
|
Religion
|
Islam
|
731(96.2%)
|
Hindu
|
29 (3.8%)
|
Household size category
|
1 to 4
|
406 (53.4%)
|
5 to 10
|
348 (45.8%)
|
>10
|
6 (0.8%)
|
Years of schooling
|
None
|
328 (43.1%)
|
1 – 5
|
204 (26.8%)
|
6 – 10
|
155 (20.4%)
|
10+
|
33 (4.5%)
|
Don't know
|
40 (5.2%)
|
Occupation
|
Housewife
|
585 (76.9%)
|
Auto/ Van/Rickshaw Driver
|
10 (1.3%)
|
Day Labour
|
12 (1.6%)
|
Fisherman
|
3 (0.4%)
|
Farmer
|
113 (14.9%)
|
Service Holder
|
8 (1.1%)
|
Small Business
|
18 (2.4%)
|
Others
|
11 (1.4%)
|
Source of Water
|
Pipe(internal)
|
1 (0.1%)
|
Pipe(yard)
|
2 (0.3%)
|
Tube-well (Joint)
|
241 (31.7%)
|
Tube-well (Individual)
|
507 (66.7%)
|
Well (With coverage)
|
2 (0.3%)
|
Well (Without coverage)
|
2 (0.3%)
|
Geosphere (Pond/River/canal/fen)
|
1 (0.1%)
|
Others
|
4 (0.5%)
|
Latrine type
|
With septic tank
|
59 (7.7%)
|
With water seal
|
82 (10.8%)
|
Without water seal
|
325 (42.8%)
|
Covered pit
|
220 (29.0%)
|
Open pit
|
16 (2.1%)
|
Hanging latrine
|
2 (0.3%)
|
No Latrine
|
33 (4.3%)
|
Others
|
23 (3.0%)
|
Yearly expenditure (USD)*
|
<=108
|
8 (1.1%)
|
108.01- 540
|
172 (22.6%)
|
540.01- 1080
|
256 (33.7%)
|
1080.01- 1620
|
132 (17.4%)
|
1620.01- 2160
|
46 (6.0%)
|
2160.01- 2700
|
8 (1.1%)
|
>2700.01
|
4 (0.5%)
|
Don't know
|
134 (17.6%)
|
Yearly income (USD)*
|
<=108
|
4 (0.5%)
|
108.01- 540
|
96 (12.7%)
|
540.01- 1080
|
217 (28.5%)
|
1080.01- 1620
|
189 (24.9%)
|
1620.01- 2160
|
80 (10.5%)
|
2160.01- 2700
|
26 (3.4%)
|
>2700
|
39 (5.1%)
|
Don't know
|
109 (14.4%)
|
*Converted using 01 BDT = 0.009 USD; OANDA currency converter as of 25 January 2023
According to the hospital ship register (2008 to 2022), for EFH and LFH, nearly 37-40% of beneficiaries were male, while around 59-62% were female, with over 70% of the beneficiaries aged between 26-60 years.
General Health Service-Seeking Practices
The Char people have been facing challenges in accessing government health services due to various factors such as geographical distance, transportation time, and cost associated with traveling to health care facilities. The 3-tier health care program provides convenient access to health care services in their neighborhood and enables them to get high-quality over-the-counter medicines at the most affordable price from the FCMs. The common health issues experienced by the residents of these areas included fever, common cold, diarrhea, dysentery, skin diseases, acidity, gastric pain, and worm infestation, among others. Over the last six months, 90.8% of the community people took health care services from the FCMs and Satellite Clinics, while 12.8% sought medical care from the hospital ships for common diseases. The hospital ships registers showed that approximately 551,289 and 647,090 individuals received services from the LFH and EFH, respectively, from 2008 to 2022. The geographical distribution of these beneficiaries (Figure 2) indicates patients coming from distant locations beyond the ships’ primary catchment area. This can be attributed to high praise and positive word-of-mouth recommendations from patients and their relatives, as well as the availability of free and advanced specialized care provided by national and international doctors during these special camps.
Alongside Friendship services, they also received health care services from district hospitals (5.7%), Upazila Health Complexes (UHCs) (7.1%), Upazila Health and Family Welfare Centres (UH&FWCs) (0.7%), community clinics (1.6%), and community health workers (1.1%). Apart from these, 27.2% of people visited a village doctor/quack, while 19.8% purchased medicine based on recommendations from a drug seller/pharmacist. Furthermore, 6.2% sought treatment from a traditional healer. A 32y old female respondent (FGD) from the study area commented on FCMs services:
"We can access the FCM at any time. It might be day or night, but we can call her for medical help. If she could not give us any suggestions, she contacted the MBBS doctor from Dhaka (capital of Bangladesh) over the phone."
The community people are familiar with and used to receiving services from the Friendship hospital ships, satellite clinics, and FCMs. The satellite clinic team typically sets up in the courtyard of FCM's house to distribute medication and other services. The hospital ships provide routine basic and secondary health care services, including ANC, PNC, gynecology, pediatrics, family planning, obstetrics, etc. Friendship also organizes specialized health camps where volunteer doctors, both local and international, perform surgeries and medical consultations. These health camps offer consultations for a range of health conditions, as well as provide specialized treatments like cataract surgery, cleft lip repair, and club foot correction. One of the respondents (IDI, male, 36y) stated:
“When the ship is accessible in this region, almost everyone prefers to visit the ship to reduce service expenses. We also receive quality services and medicines. Sometimes, they run camps for eye surgeries.”
Experience and Perception of the Service Recipients and Stakeholders
Community people are receiving specialized health care services from the Friendship hospital ships. In the past, people did not care much about their disabilities. Sometimes, they considered such disabilities as curses or "divine retribution." Following the implementation of the 3-tier health care system, the population has become well aware of cataract surgery, club foot treatment, cleft lip correction, etc. A participant (IDI, Male, 45y) from the study area stated:
"We receive treatment for general health problems from satellite clinics. However, for more complex health issues, we are advised to visit the hospital ship. Once, I had a problem with my leg, and I was asked to visit the ship. There, I received treatment with check-ups, and it was very helpful for me. Also, I observed some people receiving spectacles after eye surgery there."
A service provider (KII, Male, 46y) stated that,
“The health services of hospital ship play an important role in reducing many complex diseases such as eye, uterine, dental, club foot, general, etc. Now char-living people feel relieved about their health problems”.
The community people consider the Friendship hospital ships to be a blessing. A female respondent (IDI, 58y) expressed her opinion:
"Perhaps I couldn't afford to go to a government or private hospital for my uterus problem; however, I received the operation at this ship with excellent care. The staff here carefully monitored me after the surgery."
At the satellite clinics, the "paramedic(s)" provide individualized care to the patients, ensuring appropriate privacy. They also prescribe the permitted over-the-counter medicines, which are distributed by the "organizer(s)". If any medicines were not in stock on a given day, they advised the patients to buy them from nearby medicine stores. One of the service recipients (IDI, female, 43y) said,
"The medicines we get from Friendship are better than what we buy from the local medicine shops. It worked, and we got better faster by taking the medicines from Friendship. But the types of medicines should be increased."
The majority of the community people expressed satisfaction with the services provided by the FCMs and Satellite clinics, mostly due to convenient access and proximity to their residences. Now, they don't have to go on lengthy journeys to get medical advice and medicines. Overall, 83% of the community people were satisfied with the service, as well as, 82.4% were happy with the service environment of the satellite clinics. One of the recipients (IDI, female, 24y) shared the opinion:
"We can avail health care in the courtyard of our house. We clean and arrange the courtyard where the clinic will take place ourselves. We don't need to go to Sadar (urban centers) for minor illnesses anymore".
Apart from addressing the health care needs for different diseases, the nutrition sessions and the courtyard sessions create awareness and reinforce a nutrition drive. FCMs lead the nutrition sessions, where they discuss the nutritional facts of locally produced vegetables and demonstrate how to cut and clean the vegetables while preserving their nutritional value. They also prepare nutritious and delicious "Khichuri," a balanced diet, from locally sourced produce for the community children, as well as pregnant and lactating mothers. One of the community members (FGD, female, 35y) showed her satisfaction with the health care model and stated:
"Friendship helps us to know the nutritional facts of vegetables. We had no idea that khichuri could be cooked using our locally available vegetables and be nutritious and delicious at the same time. Previously, we used to cook khichuri only with one type of lentil and no other vegetables or eggs. Now, we learned the whole procedure from the FCM Apa (sister)".
Courtyard sessions are usually conducted in a similar setting where FCMs discuss various topics such as diarrhea, respiratory tract infection, skin disease, hygiene, safe water and sanitation, food and nutrition, primary health care, gender and reproductive health, family planning, Extended Programme of Immunization (EPI) activities, pregnant mother care, labor planning, safe labor and PNC, care of newborn and benefits of breastfeeding, STIs and STDs, child marriage and adolescent reproductive health care, etc. using flip charts. One of the participants (FGD, female, 35y) shared,
"We attend the session regularly and learned a lot from those sessions. For example, why we should wash our hands and when we must wash our hands. Our babies also adopted this behavior and washed their hands before eating. FCM apa also discussed birth control and family planning methods in the sessions".
A total of four courtyard sessions are conducted monthly in different locations throughout the community. Each session focuses on health awareness issues and offers opportunities for social interaction and education on health and wellbeing. A participant (FGD, Male, 46y) mentioned:
"Community people are now more aware about maintaining their health issues and healthy lifestyles. For example, pregnant women were not aware of their health during pregnancy before Friendship arrived here. But now they have learned many things, such as the five danger signs, and are aware of the four check-ups."
Friendship is the only Social Purpose Organization providing essential health care services in these hard-to-reach northern riverine Char communities. Though there were very few GoB Family Welfare Assistants (FWAs) in some districts (e.g., Jamalpur) to provide health care to the Char dwellers, the service was limited and insufficient considering the needs. One of the Upazila Health & Family Planning Officers (UH&FPO) (KII, Male, 42y) of the intervention area expressed his positive view and said,
"By providing transportation support, Friendship made our work much easier. We have a very limited budget for transportation. Our EPI and Family Planning staffs use the boats of Friendship to go to the Char areas to implement and achieve the target set by the government. It's possible because they maintain a strong liaison with us, with the government. Their staffs are very supportive. I would like to add that they work based on community people's needs."
Friendship’s efforts to prioritize public-private collaboration for sustainable intervention are also reflected in another government health manager’s (KII, Male, 44y) quote,
"We expect continuous support from Friendship to meet the government goals collaboratively. Even if there are any possibilities of discontinuation for any funding or other issues, please inform us beforehand. Otherwise, a lot of programme will be largely affected."
Cost Benefits
Satellite clinics charge flat fees of 0.05 USD for females and children aged under 18 years, and 0.09 USD for males. In the absence of these clinics, community people would need to seek alternative outdoor services at a private clinic with an average registration fee of 2.79 USD. The net benefit for a beneficiary using a specific service is 2.75 USD. According to a quantitative survey, 43.4% of the community people expressed complete satisfaction with the service charge of a satellite clinic, while 40.8% expressed overall satisfaction. Moreover, they had to endure lengthy and expensive journeys to reach the sub-district or district city. One of the participants mentioned (IDI, Male, 27y),
“Friendship team's efforts in our community are commendable. We no longer have to waste 2-3 hours travelling to reach the government Upazilla Health Complex for general illness. The best part is, they provide the services and medicine at a very minimal cost.”
The transport cost by reserved boat to the nearby port ranged from 13.98 USD to 18.63 USD and could take 2:00 to 2:30 hours to reach the port. From there, it took a minimum of 30 minutes to 1 hour to reach the health care facilities. There were also local or shared boats but with limited operating hours and routes from the Chars to lands. The costs of these boats ranged from 0.46-1.40 USD depending on the distance and geographical area.
Friendship's five key services, antenatal care (ANC), postnatal care (PNC), diarrhea, respiratory tract infections, and skin diseases, were considered for cost-effective analysis. The relative cost per beneficiary for each service was -0.96, -0.95, -1.02, - 0.74, and -0.79 USD, respectively. The negative values indicate that the relative cost of providing the service by Friendship was lower than that of alternative private facilities.
Challenges
Despite Friendship's 3-tier health care model being well regarded for its cost-effective provision of essential health care services and higher satisfaction levels, there are still areas where improvements are crucial. The providers experienced a heavy workload and expressed the necessity for additional training in communication, counseling, management, and networking skills, as well as increasing the number of trained FCMS as CSBAs. Moreover, there was an immediate requirement to increase the number of providers, which was reflected in the quote from one of the project officers (KII, Male, 38y):
“We are always overwhelmed with lots of work compared to our salary. Also, we only receive the necessary training to perform our jobs. But it is crucial to get additional training to enhance our job performance and develop our skills. However, we do get verbal appreciation and motivation from our supervisors often.”
For the recipients, the primary barriers were long waiting periods to receive services at satellite clinics and limited mobility of the hospital ships due to poor navigability in dry seasons. Finally, despite providing support to the referred patients to government facilities or hospital ships for critical illness and specialized care, the absence of a formal and structured referral mechanism poses a significant challenge. Generally, patients are referred to Hospital Ships and government facilities (if hospital ships are not stationed nearby) for specialized care. However, there is a lack of systematic tracking of referred patients. This includes insufficient follow-up and record keeping by FCMS or satellite clinics, as well as the lack of systematic tracking of referral status in hospital ships, even though the ship is considered the higher level of service point in this 3-tier model.