Collaboration In The Health Sector: The Case Of Bangladesh And Tuberculosis

Collaboration takes many different forms. In the case of Bangladesh, there has been a long history of government collaborating with non-governmental organizations (NGOs), particularly on issues related to poverty and health. In 1972, the Bangladesh Rural Advancement Committee (BRAC) was founded and has since developed different programmes including micro-credit. BRAC has also expanded to other countries including Pakistan, Afghanistan and Sri Lanka. One of the main areas for which it has received recognition is its tuberculosis
programme. This article will look at how BRAC has collaborated with the Bangladeshi government with regard to tubercu-losis. The first section will look at the problem of tuberculosis in Bangladesh, the second will examine BRAC’s approach to tuberculosis and the third will analyze how government and BRAC worked successfully together.

The Problem of Tuberculosis in Bangladesh

The World Health Organization compiled a list of 22 countries where tuberculosis affects a high proportion of the population. On this list, Bangladesh ranks sixth, which means that the incidence of tuberculosis is quite high, according to the BRAC Annual Report ‘Breaking New Grounds in Public Health’. In 2006, there were 101,988 new cases of tuberculosis (TB), according to the World Health Organization (WHO); however, this does not show the full scope of the problem because many people go to the private sector for medical care and the records from these visits are not included in the national count. Most estimates show that there are 300,000 new cases every year and 70,000 deaths, states the Ministry of Health and Family Welfare, Dhaka, Bangladesh.

One of the reasons why TB spreads easily throughout Bangladesh is that the country is very small and crowded. TB is very contagious, thus if someone starts coughing and does not seek treatment right away, there is a high likelihood that others will catch it. In addition, the medication for tuberculosis must be taken over a period of six months; however, many people start to feel better after two months and decide to end the treatment, states Snegupta in NY Times. Lastly, there is a large stigma attached to TB. People do not wish to develop it and often hide it if they do develop it because the community may view them in a bad light. For these reasons, BRAC decided to utilize the power of women in the community in order to halt the spread of TB. It was hoped that women would be able to break the stigma of TB and also persuade people to continue the course of their medication.

BRAC’s Approach to Tuberculosis

The BRAC TB programme began as a pilot project in the district of Manikgonj in 1984 to complement the government’s and the WHO’s strategy known as DOTS, which stands for Direct Observed Treatment Short course. In 1992, the programme was extended to ten other areas and in 1994, the government signed a memorandum of understanding (MOU) with many different NGOs including BRAC in order to collaborate on TB, according to the BRAC Annual Report. By 1998, all districts of Bangladesh were covered by the DOTS programme. There are two very important innovative components of the BRAC programme, which are user fees and the use of community health volunteers known as shasthya shebikas (SS).

User Fees

It is much easier for NGOs such as BRAC to impose user fees because the government is not widely trusted in Bangladesh. This is one of the main reasons why the government collaborated with BRAC; NGOs are seen as closer to the people and are very active in Bangladesh. In Bangladesh, there are over 6000 registered NGOs and they cover at least one quarter of the popu-lation. With regards to BRAC and TB, user fees were seen as a way for people to comply with their treatment. Each patient has to pay 200 Taka ($3.50) and signs a bond in front of two witnesses, who ensure that the patient continues with their medication. If the patient is unable to pay, the community attempts to raise money; however, if they are not successful, the patient is exempt from the payment. After the patient finishes six months of treatment, the money is refunded. This has led to a 93 percent treatment success rate, which is very high, according to BRAC. In 1991, WHO set a goal of detecting 70 percent of new cases and curing 85 percent of those, reveals Kumaresan in a Review of National Tuberculosis Programmes. In 2005, only 68 percent of cases were detected; however, this rose to 80 percent in 2006 after an infusion of money from the Global Fund to Fight AIDS, TB and Malaria, according to BRAC.

Shasthya Shebikas (SS)

The SS programme began in the 1970s when BRAC was still focused primarily on micro-finance issues. BRAC had many different village organizations that were charged with decrea-sing poverty and one idea that came from this was to nominate women to become community health volunteers. The criteria for becoming an SS is being a woman who is socially acceptable in the community; 25 to 35 years of age and having no children under the age of five, according to Faruque Ahmed speaking at the Regional Conference on “Revitalizing Primary Health Care” held in Indonesia in 2008. Each SS is given training in health problems such as diarrhea, the common cold, stomach problems and many other health issues. A special subset of SS’s is also given training in TB. One of the main reasons why the treatment success rate in Bangladesh is so high is because each SS works in her own neighbourhood and people in the neighbourhood come to respect and trust her.

Although SS’s are volunteers, they are able to earn money through two means: selling medical supplies and successful treatment of TB patients. BRAC gives the SS’s supplies such as birth control pills and cough medication and the SS’s can sell it at a small markup. In addition, for each TB patient that the SS successfully treats, they are given $2.25. Although this is a small amount of money, it gives the SS a bit of economic power since they are usually housewives. There are now over 70,000 SS’s in Bangladesh and the programme has also been replicated in many other countries including Afghanistan, Tanzania and Sudan. The SS programme is one of the main reasons why the
government decided to colla-borate with BRAC, as the SS’s give the government a link to the community.

Collaboration between BRAC and the Government of Bangladesh

History and Benefits to Government

There is a long history with regard to the Bangladeshi government collaborating with NGOs. In 1961, the government passed the voluntary social welfare agencies ordinance, which required all NGOs to register with the government, according to Zafar Ullah in a report published in Oxford Journals. In 1996, the government created an NGO consultative council to have direct communication with NGOs. Lastly, in the 1997-2002 Five Year Plan, the government explicitly stated that “collaboration of private organizations/institutes and NGOs will be fostered,” states Zafar Ullah. The government derives many benefits from working with NGOs because many people in Bangladesh do not trust the government due to years of corruption. In addition, because NGOs such as BRAC cover such a wide area of Bangladesh, many people have contact with them in their everyday lives. BRAC can reach at least 110 million people in Asia and Africa, thus the government can benefit a lot from this, states Jahfery in the Pakistan Observer.

Benefits to BRAC

NGOs such as BRAC benefit a lot from collaborating with the government, despite the fact that they may be viewed badly for working with government. NGOs are able to use government facilities such as laboratories and they can also use the purchasing power of the government for TB medication. In addition, BRAC has the ability to cover many local areas while the government can see the larger picture and can draw up policy for the entire country. BRAC also has the ability to influence the government and, because they use government resources for TB, the organization can use the extra funds for other issues that require attention.

The Future of Collaboration for TB in Bangladesh

As mentioned above, the number of TB cases in Bangladesh is not known for certain due to many people using the private sector. In Bangladesh, 54 percent of people use the private sector for health care, according to WHO. This is quite high considering that approximately 63 million people live in “severe deprivation,” according to the World Bank. Thus, in the future, the government must collaborate with the private sector in order to accomplish two things: better monitoring of TB and a higher treatment rate.

In conclusion, TB is still a serious problem in Bangladesh and in many other countries around the world; however, Bangladesh has shown that collaboration can increase treatment rates. BRAC’s innovative SS programme is a model for the world, but they could not have achieved everything they have without the government and the government benefits a lot from collaborating with NGOs. In the future, the government must work with the private sector in order to increase treatment rates even further. Thus, collaboration is often the key to success.

References
BRAC “Breaking New Grounds in Public Health: Annual Report 2006”

World Health Organization “National Tuberculosis Control Programme Bangladesh: Report of the Fourth Joint Review”

AN Zafar Ullah et al “Government?NGO Collaboration: The Case of Tuberculosis Control in Bangladesh”

Faruque Ahmed “Community empowerment through micro?credit scheme to improve community health”

SHR Jahfery “PPAF Extends Facility of Rs 220 million to BRAC”

“Confidence grows as
slowly as a coconut tree,
and falls as fast as a coconut”.
Montek Singh Ahluwalia,
Indian Economist
World Economic Forum, Davos

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