Field Trip Report 2009
6 Aug. Openig session at BRAC Center 10 Aug. BRAC’s Human Rights Education with local children
10 Aug. Human Rights Education Class of BRAC 12 Aug. Community Health Research Worker in Matlab
12 Aug. Mother and child in Matlab 11 Aug. Lecture by Dr. Midori Sato at UNICEF
11 Aug. Lecture at MCHTI 11 Aug. Mother and baby 13 Aug. After the midterm presentation by MPH students at BRAC Uni. 12 Aug. Household Survey in Matlab
12 Aug. Visit to hospital and HbSS in Matlab 16 Aug. District Hospital in Narsinghdi
18 Aug. Birth Delivery Center of BRAC in an urban slum 18 Aug. View in urban slum
18 Aug. With local children in urban slum 18 Aug. Father and daughter in urban slam 19 Aug. BRAC staff (SK and SS) in Bogra 19 Aug. Recap meeting in Bogra
20 Aug. WASH Program of BRAC in Bogra 20 Aug. Pre-primary School of BRAC in Bogra
20 Aug. Primary School of BRAC in Bogra 20 Aug. WASH Program of BRAC
22 Aug. With children at Ekmattra 22 Aug. With children at Ekmattra Map（Field Trip Sites）
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Photos & Map
Foreword…………………………………………………………………………… 2
Introduction to the Field Trip……………………………………………………… 3
Schedule…………………………………………………………………………… 4
Acronyms… ……………………………………………………………………… 6
◆Day by Day Student Notes……………………………………………………… 7
◆Student Reports… …………………………………………………………… 23
111 Mr. Yoshito Kawakatsu … …………………………………………… 25
222 Ms. Kanako Kikuchi… ……………………………………………… 28
333 Ms. Kanako Koyama… ……………………………………………… 32
444 Ms. Naomi Takagi… ………………………………………………… 35
555 Mr. Junichi Tanaka… ………………………………………………… 38
666 Ms. Miyuki Tsuruoka… ……………………………………………… 41
777 Ms. Sayaka Toyoshima… …………………………………………… 45
888 Ms. Akiko Nagata… ………………………………………………… 48
999 Ms. Mami Hitachi… ………………………………………………… 52
1111 Ms. Shiho Hirano……………………………………………………… 55
1111 Ms. Tomoko Masunaga… …………………………………………… 58
◆Student Group Presentation… ……………………………………………… 63
◆Organizations Visited………………………………………………………… 69
◆Afterword… ………………………………………………………………… 71 Foreword
The Graduate School of International Health Development opened at Nagasaki University in April 2008 to develop professional human resources with advanced practical knowledge and skills that will enable them to contribute to resolving global health problems, particularly healthcare problems that confront developing countries. Individuals who have successfully completed the master’s program at this graduate school receive a Master of Public Health (MPH) degree.
International healthcare professionals who play important roles in developing countries must possess a broad spectrum of knowledge, skill and ability, including: basic knowledge of maternal and child health and tropical diseases; understanding of various factors complicating current healthcare problems; and the ability to take an interdisciplinary approach, as well as establishing trustful relationships with relevant parties in resolving such problems.
With the aim of developing such professionals, who can work effectively in the field of international cooperation, the Graduate School of International Health Development provides a balanced curriculum comprising classroom lectures and practical training in real-life situations, so as to facilitate students’ understanding and acquisition of adequate knowledge and skills. The important pillars of the curriculum are a short-term (three-week) field trip during the summer of the first year, and a long-term (eight-month) internship program during the second year.
The field trip is designed to enable students who have acquired knowledge of basic subjects during the first semester of the first year to learn first-hand the realities of developing countries and to observe the activities of organizations that have played significant roles in development assistance. The field trip also aims at promoting interaction between participating students and such organizations through discussions and presentations of the field trip results, thereby enhancing learning outcomes and preparing the students for the second semester coursework.
This report summarizes the students’ activities during the field trip that the Graduate School of International Health Development organized this year. The destination was Bangladesh, the same as last year. During the field trip, participating students visited the Bangladesh Rural Advancement Committee (BRAC)- -a leading world-wide NGO engaged in promoting social development in such areas as healthcare--and other developmental assistance organizations in Bangladesh, and inspected the regions covered by the organizations’ ongoing projects. Under the guidance of Assistant Professor Kaori Miyachi, participating students prepared observation summaries and minutes of the presentations and discussions at organizations they visited during the field trip and produced reports after the trip. These materials were compiled into this Bangladesh Field Trip report. At first, I was concerned about the language barrier, but upon reading the report I was greatly pleased to learn that participating students were able to overcome the language barrier and understand well the content of lectures and presentations given to them in Bangladesh, and that the field trip enhanced their motivation to continue studying. I hope that those who are playing important roles in international healthcare and those who are interested in such matters will read this report and make suggestions to improve our education.
Finally, I would like to express my deep and sincere gratitude to all the staff at BRAC, and BRAC university, especially Prof. Anwar Islam, Dr. Farah M. Ahmed and Mr. Nakib Rajib Anmed, who provided a great opportunity for our students to receive training, and to JICA, UNICEF and the many other organizations our students visited.
Prof. Yoshiki AOKI Dean, Graduate School of International Health Development Nagasaki University
2 Introduction to the Field Trip
【Object】
The purpose of this field trip is to develop understanding and insight through field observation in developing countries about health promotion and other related projects, such as infectious diseases, maternal and child health, and local health and medical care systems. In addition, students are expected to view the actual field site after learning at school in the first semester, to learn how case studies are done in the field, to know about security management, and to develop understanding of the culture and environment and other things during the field trip to utilize these experiences for a long term internship in the second year of MPH.
【Method】
In 2008 and 2009, the field trip was in Bangladesh supported by BRAC*1, the largest NGO in Bangladesh and in the world. Students visited not only BRAC, but also other international organizations, such as ICDDR,B*2, JICA, UNICEF, and others, to observe and to have discussions with related personnel and students in Bangladesh. Furthermore, students had the opportunity to chair meetings and to gain experience of the logistics involved in developing their skills for international health activities.
【Main Field】
BRAC ICDDR, B (Dhaka and Matlab) JICA Bangladesh Office and JICA Project Site UNICEF Bangladesh Office Ministry of Health and Family Welfare
*1: BRAC is the largest development NGO in Bangladesh and it develops projects for health, education, rural development, etc. in all parts of Bangladesh. In some cases, the Bangladesh government applies BRAC’s model of activities in its projects. BRAC has a graduate school for public health (MPH) (professors are invited from Harvard and other universities) where international students from Bangladesh, Africa, and other Asian nations are enrolled.
*2: ICDDR,B (the International Centre for Diarrhoeal Disease Research, Bangladesh) is world-renowned center as well as a research area studying 200,000 local people. For more than 40 years, it has been studying health conditions of poverty-stricken people in tropical areas, taking measures and conducting activities for improving health case surveys and other studies.
3 Schedule
Date Schedule Leader Reporter
Departure Fukuoka (TG649) 11:45 Arrival Bangkok 15:05 4th Aug Tue − −
Departure Bangkok (TG321) 10:35 Arrival Dhaka 12:00 5th Aug Wed − −
11:30 Orientation at BRAC Center 12:30 Lunch at BRAC Center (Restaurant Shuruchi) 14:00 Visit to ICDDR,B 6th Aug Thu Kawakatsu Toyoshima Lecture, discussion, tour within ICDDR,B 15:30 Participation in “Knowledge Fair” 16:30 Tea party with students and staff of BRAC University
7th Aug Fri AM Recap meeting; PM Free Time
8th Aug Sat Free Day
10:30 Visit to the Program Support Office of the Ministry of Health and Family Welfare 9th Aug Sun Lecture and Q&A session Hitachi Tanaka 15:30 Visit to JICA Bangladesh Office Lecture and Q&A session
9:30 Visit to BRAC Project Site in Sreepur Micro-finance Programme, Income Generating Project by Women, 10th Aug Mon Masunaga Takagi Discussion and Q&A Session 13:00 Human Rights and Legal Education Class
9:30 Mother and Child Health Training Institute Lecture and Q&A session 11th Aug Tue 14:00 Visit to UNICEF; Lecture and Q&A session Koyama Masunaga 16:30 Departure for Matlab 21:00 Briefing at Matlab Health Center
9:00 Field Observation of HDSS by ICDDR,B in Matlab 12th Aug Wed Visit to communities, community clinics, sub-center clinic, Matlab Kikuchi Koyama Hospital, data collection room
11:30 Midterm presentation by MPH students of Nagasaki at JPGSPH in 13th Aug Thu BRAC University − − 13:00 Lunch with professors at BRAC University
14th Aug Fri Free Day
15th Aug Sat Free Day; dinner with JICA staff
9:00 Visit to JICA Safe Motherhood Promotion Project in Narsinghdi District; Field observation at Community Support System (CmSS); Family Welfare Center, Mother and Child Welfare Center, District 16th Aug Sun Tsuruoka Hitachi Hospital; Q&A Session 16:00 Lecture about JICA Projects Q&A Session
4 Date Schedule Leader Reporter 10:00 Visit to BRAC Project Site in Kishoreganj Field visit to STUP (Specially Targeted Ultra Poor) members, 17th Aug Mon observation of income generating activities, Village Poverty Koyama Kawakatsu Alleviation Committee members 19:00 Dinner with members of Toyo University and JOCVs
9:00 Visit to BRAC Project Site in Kamnangichair Lecture on Monashi Project (Urban Maternal, Neonatal and Child Health Programme) , observation of birth delivery center, and visit to 18th Aug Tue Kawakatsu Hirano mothers’ houses 15:00 Visit to the Center for the Rehabilitation of the Paralyzed Lecture, Facility tour, Q&A session
11:00 Visit to BRAC Project Site in Bogra 19th Aug Wed Visit to Health Programme projects, Adolescent Development Center Tanaka Nagata
8:30 BRAC Project Site in Bogra 20th Aug Thu Wash Programme, Sanitation Programme Education Programme Takagi Kikuchi 16:00 Excursion to Mohastangorh (archeological site)
21st Aug Fri Preparation day for presentation
22nd Aug Sat 13:30 Visit to Ekmattra (Bangladesh NGO for street children)
11:00 Presentation by MPH students of Nagasaki University at BRAC 23rd Aug Sun Toyosima Hirano University
24th Aug Mon Departure Dhaka 13:10 （TG322) Arrival Bangkok 16:35 − −
25th Aug Tue Departure Bangkok 00:50 （TG 648) Arrival Fukuoka 08:00 − −
5 ACRONYMS
BRAC Bangladesh Rural Advancement Committee CmSS Community Support System CRHW Community Research Health Worker CRP Center for the Rehabilitation of the Paralyzed EmOC Emergency Obstetric Care EPI Expanded Programme on Immunization FP Family Planning HDSS Health Demographic Surveillance System HNPSP Health, Nutrition and Population Sector Program HPSS Health and Population Sector Strategy ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh IMR Infant Mortality Rate JICA Japan International Cooperation Agency JOCV Japan Overseas Cooperation Volunteers JPGSPH James P. Grant School of Public Health LLDC Least Less-Developed Countries MCHTI Mother and Child Health Training Institute MDGs Millennium Development Goals MIS Medical Information System MMR Maternal Mortality Rate MOHFW Ministry of Health and Family Welfare ORS Oral Rehydration Salt PHC Primary Health Care PRSP Poverty Reduction Strategy Paper SK Shasthya Kormi SS Shasthya Shebika SMPP Safe Motherhood Promotion Project TBA Traditional Birth Attendant UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund U5MR Under 5 Mortality Rate WASH Water and Sanitation Hygine
6 Day by Day Student Notes
August 6, 2009 (Toyoshima) Orientation on International Center for Diarrhoeal BRAC Center Disease Research, Bangladesh (ICDDR,B) 12:00 – 13:00 14:30 – 15:30 Ms. Tania Zaman (Director, Chairperson's Office), Mr. Md. Dr. Jena D. Hamadani (Head, Child Development Unit ; Rezaul Haque (Senior Specialist, BRAC Health Program), Scientist, Clinical Science Division) Dr. Sabina F. Rashid (Associate Professor & MPH Mr. Nazim Uddin (Senior Manager, Library & Information Coordinator, BRAC University), Dr. Farah Mahjabeen Service Unit) Ahmed (Coordinator, Continuing Education Programme, BRAC University), Mr. Nakib Rajib Ahmed (Project Coordinator, BRAC University)
[Outline] ·· Self-introduction of the BRAC staff and MPH students of Nagasaki University. ·· Outline of the BRAC (presented via DVD: “A New Horizon”) ·· Questions about BRAC’s educational program for ethnic minorities. According to the staff of BRAC, it is difficult [Outline] in rural areas (remote areas) to spread education among ·· ICDDR,B was originally started in 1960 as a preventive ethnic groups. Another question considered was from the measure against cholera. In 1978, seven years after annual report 2008, asking why expenditures had been the independence of Bangladesh in 1971, activities by increased in 2008 despite the constant drop during 2007. ICDDR,B were initiated under the leadership of the The answer was that support from foreign countries (the Government Assembly. Netherlands, Australia, UK) had increased temporarily ·· It seems that the ICDDR,B deals with not only diarrheal due to the recent cyclone. but also other chronic diseases. In the presentation, this was illustrated by a Life Cycle Approach figure. A specific approach is taken at each growth stage, which includes HIV/AIDS. ·· About workers in reproductive health ·· At first, triage is practiced at the reception desk. Triage is performed in accord with the center's protocol by trained non-medical professionals. Treatment is free of charge. ·· There is also a rehabilitation facility for patients who are experiencing physical difficulties in caloric intake due to long-term malnutrition (treatment through diet).
[Impression] [Impression] BRAC looked familiar because of images we had seen Lectures and hospital tours were conducted in a packed many times in Japan during our prior study. The size of the schedule. The facility was nicer and larger than we had committee was larger and its human resources more varied previously imagined. It was unfortunate that the explanation than we had imagined. It was really a pity that we did not during the hospital tour was hard to hear sometimes, have enough time for Q & A, due to a considerable delay in and no question time was available afterward, as we had the starting time for being caught in a traffic jam caused by many questions. Dr. Jena, who gave a lecture, was such rain and flooding. It was nice of Dr. Sabina to compile our an interesting and enthusiastic staff member that I wanted questions into a concise form for us before we passed them to listen to her more. With their library opened for our on to Dr. Farah, for we had many questions after putting all convenience, we were grateful for the opportunity to learn our energy into reading annual reports. I was impressed by new things through reading Dr. Sabina’s quick wit. Lunch served in the cafeteria was also in Bangladesh. I very delicious. Even the short lunch time seemed to make w a s a m a z e d t h a t t h e a good learning opportunity for those students who could library contained so many glean information through communicating with BRAC’s journals! One thing we staff. We hoped by learning as much as possible, to work students regret was the toward a better report after three weeks went by. insufficient preliminary research done by us.
9 Knowledge fair 2009 Although our preliminary research was certainly insufficient 15:30 – 18:00 and the schedule was tight, I don’t believe this can be an excuse for us not having asked more questions. Our time is ICDDR,B (Sasakawa Auditorium) valuable and so are the opportunities. We should be more Prof. Anwar Islam (Associate Dean & Director, James P. outgoing. Grant School of Public Health, BRAC University) August 9 (Tanaka) MOHFW PROGRAMME SUPPORT OFFICE 10:00 – 12:00 Dr. Muhammod Abdus Sabur (Team Leader, PSO)
[Outline] ·· Explanation of the organization of MOHFW (Ministry of Health and Family Welfare) and role of each department [Outline] and division. ·· Explanation of the James P. Grant School of Public ·· Dr. Sabur has been working for health issues in internal Health (JPGSPH)’s curriculum was conducted first. We and international organization for a long time. The role of found several differences between our school and theirs. PSO is to support MOHFW by acting as a consultant and For example, school fees are different according to their expert in health policy. nationalities. There are three levels: for Bangladeshi ·· There were a number of questions on the relationship students, for students from eveloping countries, and for between NGOs and Government; on stationing and students from developed countries. Another difference is securing of nurses and doctors; on what, if any, problems in class formation. Among 30 students, 15 students were arise in the case of Government and BRAC implementing Bangladeshi and the rest were non-medical professionals, similar types of activities, such as those by HAs (Health half of whom were women, and others. Assistants), FWAs (Family Welfare Assistants) and ·· There were brief explanations of their subjects by SSs (Shasthya Shebika); and also questions on arsenic professors and teachers, among a seemingly wide range contamination. of JPGSPH’s teachers. ·· Interaction with JPGSPH students during a tea party after [Learning] the fair was interesting. 111 Our understanding of the MOHFW and health policy of ·· We could realize the close collaboration and mutual Bangladesh was deepened. support system between BRAC, BRAC University and 222 We understood that a health policy can be easily ICDDR,B. changed due to a change in Government, which causes a change in the Administration. (I was informed at this [Impression] fair that in fact a change in administration in January, We sincerely regret arriving late to the Knowledge Fair. 2009 had just resulted in a change in the national health During the fair, there was an explanation on JPGSPH policy.) courses, master’s thesis and research schedule. We also 333 Many students were interested in how the government had a glimpse into a tough aspect of the one-year course. I controls (or competes with) NGOs which have greatly developed a strong desire to learn here because this was an increased in number. In today’s explanation, they ideal environment for me with an interesting curriculum that seemed to think that even if the FAs (FWAs) and provided training in rural areas and with a class formation SSs conduct similar activities in the same village for slightly different from ours. I was happy to know that instance, it would be good for communities because it JPGSPH students were also interested in Japanese MPH offers more options. However, they seemed to think that students and that they were people we could relate to as the fact that the DGHS and DGFP were both divided like-minded peers. This fair actually gave us a chance to vertically was a problem that should be addressed. make connections with some of the students. I would also like to have visited NGOs where students whom I became [Impression] friends with were working, but unfortunately this was ·· Dr. Sabur answered students’ questions carefully and in difficult to do in our tight schedule. We thought it would be detail, even after the scheduled Q & A time ended. Many good if the personal connections with students which could students could not follow the doctor because they had a be made in this fair could be considered in the scheduling problem understanding English. This reaffirmed for us of the Knowledge Fair 2010. It was a fulfilling day that that self-improvement is required for each one. The fact made us really feel happy to have joined the MPH course. that the supplementary lectures and group work were
10 conducted as prior learning, and that we looked over all (SMPP) implemented by JICA. reports by JICA and BRAC, seems to have been very effective. [Impression] Today, it was truly significant for us to deepen our JICA Bangladesh Office understanding about the general situation and administrative 16:30 – 19:00 system of Bangladesh by visiting MOHFW and JICA. Ms. Saeda Makimoto (JICA Officer), Mr. Katsumi Ishii We would like to learn more about the details in future (JICA Coordinator) field training. One thing we should reflect on today is that we may have caused trouble for doctors and teachers by [Outline] extending the Q& A session without thinking about keeping ·· Explanation of Bangladesh in general (the country’s to the allotted time. We will have to improve our procedural general situation, guidelines, PRSP, budget, administrative skills in cooperation with other students in order to reach system, decentralization of power) the highest level of efficiency. ·· Explanation of the outline of JICA’s projects (prioritized fields for aid, local ODA tasks) August 10 (Takagi) ·· Explanation of the status of public health and cooperation BRAC AREA OFFICE in SREEPUR in the field of public health (especially in SMPP: Safe 10:00 – 15:30 Motherhood Promotion Project) 1. Microfinance Program Leaving the hotel at 8:00 a.m., 14 of us rode separately in two cars: Mr. Rajib from BRAC University, Mr. Rana who is responsible for public relations of BRAC programs, Ms. Miyachi and 11 students. We took a break on our way there, and arrived at a BRAC branch office in SREEPUR area at 10:00 a.m. Immediately after that, we were treated with tandoori and dal (bean curry) for breakfast. Subsequently, joined by Mr. Aron (Branch Office Manager), we were transported by car to a village where the Microfinance Program had been implemented, in order to take a tour of the program. The Microfinance Program was started with 28 women as [Learning] well as BRAC’s male staff members as coordinators. This 111 We learned about the details of the general situation, program is one of the three microfinance programs called administrative system, decentralization of power, and “Dabi”, and is designed for poor women (but not for the cooperation in the field of public health in Bangladesh. ultra poor). The 28 women form a group and participate in 222 We learned that Bangladesh experiences the third this program once a week. highest level of corruption in the world, which seems to In SREEPUR area, there are nine offices besides the one be culturally ingrained from upper to lower classes. we visited recently. Each of them is an upazila-level office 333 Since the central government is rarely involved in which has jurisdiction over four unions. In the office we practical business, its intervention is said to be difficult visited recently, 31 staffers cover 5,000 people from 68 to obtain. We understood that frequent transfers of villages. In addition, the SREEPUR area has 18 similar personnel between government ministries and offices groups and 800 borrowers. has become a problem. 444 We understood the weakness in local autonomy and its complex system. 555 We l e a r n e d t h a t people do not trust t h e B a n g l a d e s h i g o v e r n m e n t a n d frequently use private medical facilities. 666 We learned the details of the Safe Motherhood Promotion Project
11 Among 28 women in a group, a committee that is 3. BRAC Health Center (Shushasthya) comprised of five members, including president, general After lunch at the BCDM (BRAC Center of Development affairs manager, secretary and cashiers, is established. Management), we took a tour to the BRAC Health Center Persons responsible for these roles are changed once (Shushasthya). There are two types of health centers: every two years. Candidates take out an unsecured loan upgraded and ordinary. In upgraded facilities where two from BRAC, and develop various small-scale businesses or three doctors are stationed, surgery such as Caesarean to become independent, using the loan as capital. Among section can be performed. This time, we visited an upgraded several women’s businesses we were introduced to, there type health center which specializes in maternal and child were vegetable farmers and vendors, furniture makers and health (MCH). Dr. Ferah took us to the center, which was vendors, persons who bought from 40 to 50 rickshaws and equipped with a hospitalization facility with about 15 beds. operate rickshaw businesses, house repair persons, service A clinic was on the first floor of the center, delivery rooms providers and seamstresses. Technical assistance for these on the second floor and operating rooms on the third floor. businesses is also provided by the BRAC. In this center, which is visited by 200 patients a day, a Through the implementation of this program, villagers total of 100 deliveries were conducted a month, including could escape from extreme poverty. The improvement of 40 natural deliveries and 50 Caesarean sections. This health their living conditions has resulted in providing children center covers 600,000 residents. with educational opportunities. Women themselves have It was a valuable experience for us to be able to see also understood the importance of this program, and many BRAC clinics on this visit, which was not originally have been motivated to participate in this program because scheduled. Despite the bare hospital setting, the facility was of its good reputation. filled with the joy of new lives, with new-born babies and The re-payment rate of borrowers through microfinance is mothers and young mothers expecting babies. as high as 99.3%. The interest for paying off the loan is 15%. August 11 (Masunaga) 2. Human Rights Program Maternal & Child Health Training Institute (MCHTI) We moved to another location to observe the Human 9:00 – 12:30 Rights Program. The target of this program is also women. Dr. Md. Serajul Islam, Dr. Rokfhanaivy, Dr. Rowshan Hosne Approximately 30 women assemble at the site and receive Jahan and Mr. Chinmoy K. Das(Assistant Coordinator of guidance on legal rights and human rights from BRAC staff. Training & Research) Half of the remuneration for program implementers is paid by BRAC, and the rest by the participants. The borrowers [Outline] of microfinance loans participate in this program, which is In 1953, MCHTI was started by UNICEF and WHO as held for 2 hours a day for 22 days. a hospital with 20 beds that provided services focusing on The participants we observed were married women whose maternal and child health care. In July 2000, the hospital, average age was 25 to 27. Shortly after the session of the now equipped with 173 beds, was reconstructed into its program began, the husbands of these women surrounded present form with the aid of the Bangladeshi Prime Minister their group as observers. These husbands said that they and the Japanese Government. welcomed their wives’ participation in the program. The MCHTI has two objectives. One is to function as One of the changes effected by the program was that a Maternal and Child Health Training Institute under the some of the women who had taken the course before, did motto of “Woman and Baby Friendly.” The other is to not pay dowry. When Mr. Rajib of BRAC University, asked function as a training facility to enable expansion of MCH the women whether or not they pay dowry, approximately service in Bangladesh. 30% of the women participating answered that they didn’t In addition, we learned about MCHTI’s broad and pay a dowry. Mr. Rajib said that this old custom could not comprehensive approach and its importance, which includes be given up easily, but could be gradually eliminated. the implementation of projects such as antenatal care and postnatal care, as well as the opening of a “Fathers’ Class.” They said the details of the “Fathers’ Class” were based on suggestions by JICA. The Fathers’ Class consists of a 30-minute class and open to one or two groups. When taking a tour of the facility, we could actually see fathers learning firsthand what a pregnant woman actually undergoes.
12 such as family planning, and the mothers’ and children’s health. However, we got the impression that while many women use the facility, the number of staffers who deal with these women is insufficient. We felt that forming staffers is an important issue as well as expanding facilities and programs, and the education of workers. In addition, we questioned the system of contraception promoted through a monetary incentive. We wonder how a cash incentive can be continuously paid in the future. In the first place, it is desirable that family planning should spread without such incentive. Our future issues of concern include whether or not MCH aims can be met without relying on incentives, and how it should be done.
The MCHTI is committed to contraception as a part of family planning. Ten to fifteen percent of those who took contraception counseling after childbirth were fitted with an IUD. If a woman undergoes tube litigation, 500Tk and a dress (a sari and bracelet) is provided as an incentive. Many of these women are said to be around 30 years old. If a woman introduces contraception to other people, 200Tk is paid to her as an incentive. Aside from that in this institute, various health activities and approaches were conducted, including nutrition guidance for mothers, vaccination of women and infants, two-month practical training course for district-level UNICEF Bangladesh Office maternity and child health workers (MCHW). 14:00 – 16:00 Dr. Midori Sato (Health Manager of Child Survival, Health &Nutrition Section), Ms. Chie Takahashi (Education Officer, Education Section) Ms. Yuko Osawa (Child Protection Specialist, Children at Risk Project, Child Protection Section), Mr. Syeed Milky
[Outline] UNICEF has six offices divided into four divisions for organizing the programmes. From 2006 to 2010, there have been five projects; Health & Nutrition, Education, Water & Environment Sanitation, Child Protection, Policy Advocacy & Partnerships. Under the Educational Programme are the following: “Primary Education with the Government” targeting 6-10 year- olds, and “Early Learning” for 0-5 year-olds, and “Basic education for hard-to-reach urban [Impression] working children” (HTR) targeting children age 10-14 who First of all, we were surprised by the MCHTI’s better- were not able to go to school or who became dropouts. It equipped facility, which is partly due to aid from Japan, and is so important, not only to provide education for health by the wide range of activities targeting not only pregnant promotion and basic general education, but also to protect women and mothers but also their families and MCHWs. children from violence, that legitimatization and promotion When taking a tour of the facility, we saw many men of social workers be fostered and systems established for a (fathers) even outside the fathers’ classroom. We believe this comprehensive approach to child protection. is a promising situation in which we have gradually come Health projects are carried out in the section called Health to gain men’s understanding of and cooperation with issues & Nutrition, which include Child Survival Treatment, EPI,
13 IMCI & NBH, and Maternal Health, EmOC, and protection of the site. against HIV/AIDS, plus Mother & Child Nutrition targeting Each community researcher goes to an assigned area IYC/ anemia, as well as Vitamin A, and Community and asks questions based on a questionnaire. These visits Nutrition. occur once every two months and are always scheduled In EPI, we have an approach called Reach Every District in advance. Each community researcher is responsible for (RED) which shows a high level of full immunization 1,500 families. Details of the questions vary, ranging from coverage among the countries in the world. In Bangladesh, income, whether or not any family members have moved there is no strong leadership by the Government for and so on, to childbirths and deaths. With regard to women, promoting CHW, so the role of NGOs and UNICEF are there are also details such as the number of days of breast- especially important. We are still assigned with the work of feeding, menstruation and the use of contraceptive devices. how we can step up to the next level of EPI. Prerequisites for a community researcher include the In terms of U5MR, we could see the big differences completion of at least 10 years of education, being a woman, among social classes, with such as 43 cases in the upper 25 and being a member of that community. When the position % and 86 cases in the lower 25 % because of the economic was first opened to all who wanted to apply, many people gap which leads to promote health seeking behavior. In are said to have responded. That may be partly because addition, there are many cases of drowning; reportedly 30% of the relatively high salary of 180 dollars per month. All of child deaths were caused by drowning or other accidents. the residents of the Matlab area are given a pair of IDs, a To prevent drowning, UNICEF organizes a swimming class permanent registration number and a present status number. session for secondary school children, collaborating with a While the permanent registration number is unchanging, the lifesaving association from Australia. present status number differs according to changes, such as Another danger is a tendency for people not to wash their marriage or moving house. Community researchers bring hands; clasping hands is frowned on culturally. It would pregnancy test kits with them. If the test result is positive, help to develop some way to tackle these problems. the women are referred to a clinic.
[Comments] It was a very valuable presentation through which we could understand the comprehensive approach by UNICEF to deal with the problems of children and health in Bangladesh. Again, it was also impressive that UNICEF oversees the system and the organizations dealing with health, including the relations with NGOs. For us, Japanese speakers, the presentation in the Japanese language made it easy to understand, especially complicated health systems of Bangladesh. Also talking with Japanese UN officers was useful for us in terms of career development. We appreciate so much this opportunity and support from the UNICEF staff. 222 Community Clinics August 12 (Koyama) Using a clinic staff member’s own house, community ICDDR,B Matlab researchers provide clinical services. Since they specialize 9:00 – 16:00 in maternal and child health and are specially trained Dr. Md. Anisur Rahman, Dr. Md. Al Fazal Khan, even though they are not health professionals, they also Dr. Md. Taslim Ali (Senior Manager, Matlab Health and implement EPI. Mothers are supposed to visit a clinic 10 Demographic Surveillance System) times: 4 times during pregnancy, 4 times after delivery for post-partum care, and twice for infant care. During these ten [Outline] visits, mothers receive medical checkups and education by 111 Surveys on health status and population community researchers. According to staff, regarding the Matlab Health Center, which was established in 1963, effectiveness of these clinics, hospital delivery cases have is located approximately 57 km south of Dhaka. Matlab is increased to about 80%. In cases that are too difficult to be an area selected for cohort study and covers approximately dealt with in these community clinics, patients are referred 225,000 people. Three main roles of this area are surveys on to a different hospital. health status and population, research on communities, and medical research (Matlab Hospital). Thinking about how we should go about gleaning information, we first took a tour
14 333 Sub-center Clinics these methods) to 10-14%. Also, the hospital is equipped Four sub-center clinics in the Matlab area receive patients with a computer room, in which collected data is entered, from 41 community clinics, while managing and supervising managed, and stored. Computerized management of data was community researchers. Their activities include maternal initiated in 1982. When a person’s permanent registration and child health services (health examination for expectant number is entered on the computer, all the person’s data are or nursing mothers, neonatal care, normal delivery, automatically preserved. ultrasonic tests, and blood tests) and services related to diarrhea. The staff consists of three members in total; two [Impression] paramedical staff members (MCHWs or medical assistants) On our way to Matlab, a route which actually takes as and one field coordinator who controls field work. Also, long as five hours by car, we enjoyed the magnificence of one male staff member provides technical support for nature that was quite different from the urban scene. Most community researchers in two sub-centers. Each sub-center surprising was that all the data processing from collection has rickshaws and boats as patient transport methods by to management was systematized. The information content which patients are able to lie down. is immeasurable. Data can be inputted on the spot via a These sub-centers cover an average population of 27,000. kind of terminal device that community researchers carry Although the data cross-check is conducted twice a month with them. They told us that they aim to create a paperless among community researchers, there is not enough time environment. The sight of such a tremendous number of to discuss details, and information exchange is frequently operations being carried out is overwhelming. It was truly conducted. In addition, two upgrade meetings are conducted significant for those of us who will continue our own annually. Many users of community clinics and their research to have been able to observe the actual method of families show positive reactions to sub-center clinics. We collecting data at the site. Each operation was thoroughly took a tour of the health examination clinic for expectant explained even while we asked many questions. We truly or nursing mothers, classrooms for health education, and thank the doctors of ICDDR,B. natural delivery rooms. When cases cannot be dealt with in sub-center clinics, patients are transported to a different hospital. August 16 (Hitachi) JICA Safe Motherhood Promotion Project (SMPP) in 444 Matlab Hospital Narsinghdi This hospital provides services for diarrhea cases as well 10:00 – 11:30 as maternal and child health, and offers free health care to Ms. Akiko Endo (JICA Expert), Mr. Kenji Yokoi (JICA some of the residents in Matlab. The hospital is equipped Coordinator) with 120 beds in total (70 beds for diarrhea patients and [Outline] 50 beds for children and women) in the pediatric ward, The regional support system was a system created on a neonatal ward, delivery rooms, ladies’ ward, and diarrhea community level mainly by residents. The objectives of this ward. Not only are doctor fees free, but also the food for system are to provide referral support on urgent obstetric patients and mothers who take care of them. Especially care, and to effectively deal with three types of delay surprising was the Kangaroo Care ward, a ward in which causing maternal deaths. low-birth-weight babies are taken care of 24 hours a day During our drive to the project site from Dhaka, a briefing at their mothers’ bosom. Primary patients are infants of on the program was given to us by Ms. Endo and Mr. Yokoi. 1,000g or under. According to the hospital, the survival With the Community Support System (CmSS), women rate has improved from 6.5% (the number before initiating who live in the area can receive necessary services during pregnancy, childbirth and post-natal period. This is a system to establish an environment mainly by the residents themselves where adequate medical care is provided, especially in an emergency. Various activities are conducted, such as keeping tabs on local pregnant women, support for necessary expenses related to pregnancy and childbirth by establishing funds, securing transport methods in an emergency, and providing information to pregnant women. Also in this project, nine unions, which were selected as model unions out of 71 unions based on a certain prerequisite, are developing their activities. Danga Union, where we recently visited, is one of the nine unions. If the effectiveness of an approach with CmSS’s activities
15 is demonstrated with the model union, the activity will be [Impression] expanded to the other unions. The attitude of the chief of the village, who serves as the president of CmSS, in trying to be actively committed to problems related to the maternal and child health, could be very much felt. A positive attitude in the chief of the village, who is a key person in Bangladesh where villagers are strongly linked to each other, was truly reassuring. However, since not all areas are necessarily in such a situation, we had the impression that one important issue is how the FWC could be enlivened by the local residents.
Mothers’ and Children’s Welfare Center 14:00 – 15:30
[Outline] This is a district-level hospital under the jurisdiction of [Impression] the Family Planning Bureau, which initiated services from We were impressed to discover that community members May 2001. This is a facility specializing in family planning themselves individually participated in activities on a level and maternal and child health. available to residents: mapping of local pregnant women Details of its services include maternal and child health, and the monthly report of information on pregnant women. Sexually Transmitted Diseases (STD), family planning, In addition, it was impressive that traditional midwives, childbirth, Emergency Obstetrics Care, sterilization, and who participated in meetings as members of CmSS, a 6-month training course for health assistants selected evaluated the results of a project. Since today’s meeting, to foster MCHWs. The staff consists of obstetricians, with participation of district level officers, seemed to be gynecologists and anesthesiologists, Family Welfare Visitors slightly different from an ordinary one, we would like to (FWVs), pharmacists, Family Welfare Assistants, assistant have observed a more typical meeting. nurses, and ambulance drivers. Furthermore, all the medical expenses are free of charge and are covered by the national Family Welfare Center in Danga Union government. In an effort to foster and augment MCHWs, 11:30 – 13:00 the national government gives 1,000Tk and saris to families Dr. Md. Serajul Islam, Dr. Alamgin Hossain of MCHWs who have been trained in the Mothers’ and Children’s Welfare Center and selected by health assistants [Outline] and/or Family Welfare Assistants. The precondition for this The Family Welfare Center plays a role as a Primary selection is to be a woman aged 45 or under. The ages of Health Center. This facility is under the jurisdiction of students whom we saw in training during our tour of the the Family Planning Bureau, and is operated by Sakumos facility varied. (assistant doctors) and Family Welfare Visitors. [Impression] [Learning] Since the reputation of the assistance of deliveries by Serving as a Primary Health Center, the Family Welfare MCHWs seems to have caused a decrease in the Maternal Center deals with childbirth, sterilization and general health Mortality Rates (MMR), we realized that district-level practices. In addition, patients are divided into two types: training of MCHWs by the government at this hospital, patients who directly visit the facility and patients who specializing in maternal and child health, is very effective. receive treatment via satellite clinics by Family Welfare Although this hospital is available to many people for Visitors. The number of patients is 300 a day, 50 of whom free, we wondered whether this system could be continued are less than 5 years in age. The type of treatment differs indefinitely. according to the day. The Family Welfare Center (FWC) that we recently visited had rickshaw vans donated by the chief of the village of Narsinghdi, which were used for transportation in emergencies. Furthermore, special activities were conducted: recommendation of savings in preparation for childbirth as well as notifying women of the dosing time for pills by ringing a siren twice a day, which can be heard up to 10 km away.
16 JICA Narsinghdi Project Office where projects have once been conducted. 16:00 – 17:00 In the poorest area being attended by the BRAC, Ms. Akiko Endo, Mr. Kenji Yokoi three members survey each household in that area and classify them into five to eight categories. After that, to be officially classified as “ultra poor”, three or more out of five conditions --having a job unique to women or relying on begging; having land of 10 decimals (=0.1 Acres) or smaller; having no men who can be active; having a child (children) who must work and cannot go to school; having no productive property-- must be fulfilled. When recognized as ultra poor, households can receive four services; Enterprise Development Training, Special Investment, Tailor-made Social Development Support and Tailor-made Health Support. Beneficiaries get 3- to 6-days training and receive around 150 dollars (on average) worth of cattle or goats. (Monija, a person we actually saw on the [Outline] field, received one cow and two goats). The beneficiaries JICA SMPP was initiated in July 2006, and will end live on a monthly support of 175Tk until their enterprise in June 2010. The higher-order objective is to apply the yields productivity. With the CFPR-TUP, which is basically standardized methodology of reproductive health services, a two-year course, students will automatically take part in which was taken from the project, to other prefectures. The the micro credit system if they have completed the course goal of the project is to improve the health status of new- smoothly. Bruguri, whom we met in the field, was initiated born babies and pregnant and parturient women. The results into the CFPR-TUP in 2006, and is currently the recipient of the roughly 3-year-old project include the facts that of a micro-credit loan. This is said to be a very successful SMPP is effective in improving urgent obstetrical services, example with increased cattle and goats from those that that the process of getting such care has been improved, and were provided by the CFPR-TUP. that the rate of Caesarean section in the facility is higher. The GTBC, comprised of 11 members, plays the role of Further tasks to be achieved are urgent obstetrical services solving the community’s issues and actively follows their to be provided on a 24-hour basis; offering opportunities three policies. for blood transfusions at facilities for sub-prefectural- level urgent obstetrical services; improving the quality [Impression] of equipment maintenance, urgent obstetrical services, It was a very interesting project benefitting the ultra poor existing services, and staff. On the basis of these tasks, the who cannot ordinarily receive a micro credit loan. We were Mothers’ Health Promotion Project will proceed as it is until surprised to know that there had been only four dropouts its scheduled completion, after which the project will be among approximately 9400 people who have been targeted continued on a larger scale. since 2004. We were happy to know that under the cordial assistance by the BRAC, impoverished families also receive [Impression] financial aid. We spent a very fruitful time touring a series of projects, albeit only a part. Also, we were fortunate in being richly enough informed to deepen our understanding of the complexities of public health care administration. We would like to express our appreciation to all the people who cooperated in making our tour a success, especially the staff of JICA, who explained the projects to us.
August 17 (Wed) (Kawakatsu) BRAC District office in Kishoreganj 11:00 – 15:30 Mr.Akram, Mr.Saidur
[Outline] Explanation of the CFPR-TUP, which was initiated in 2004, and field work where projects are conducted and areas
17 August 18 (Thu) (Hirano) distributed savings boxes to pregnant women so that they Koylangnat Delivery Center, Kamnangirchair can save money for emergencies. AM Mr. Asrakul Alam Cholodhory (Regional Manager) Mr. Abdus Samad Talukder (Branch Manager)
[Outline] ·· Explanation concerning the number of the center’s staff and service content ·· Explanation concerning incentives for Shasthya Shebikas After that, we visited a mother who had just delivered (SSs – community health volunteers), monthly salaries of a baby two days before. In her room, posters distributed Shasthya Kormis (SKs - community health workers) and by the BRAC were displayed: one showing warning signs Urban Birth Attendants (UBAs) during pregnancy, and the other about newborn baby care. ·· Two home visits (before and after childbirth) Community Rehabilitation Paradise, Dhakka [Learning] Mr. Md. Emdad Moslem (Executive Director), This center covers a population of 15,328 with 3,830 Mr. Refayet Hossain (Publications Officer) households. The number of staff is as follows: -- Branch Managers: 1 [Outline] -- Program Officers: 3 In January 1979, the CRP was started by Ms. Valerie -- SKs: 2 Ann Taylor from the UK as a hospital by examining four -- SSs: 19 patients. This independent international organization is -- Urban Birth Attendants (UBAs): 2 currently financed by Canada, the US, Germany and the One of the SSs performed 220 to 250 home visits per UK, and has four sub-centers and one academic organization month. They receive an incentive per service, such as the in Bangladesh. It has become a facility with six doctors, 10 detection of pregnancy, assistance at childbirth and care physical therapists and eight occupational therapists, mainly for newborn babies. Also, in this area, more women prefer for the treatment of patients who suffer from spinal injuries. childbirth at home to childbirth in a hospital where male The main causes of spinal injuries in Bangladesh are as doctors are unwelcome on religious grounds. SSs sell follows: delivery kits (16 Taka per kit) and also assist at childbirth. ·· Traffic accidents According to interviews with SSs, the fact that their work is ·· Carrying heavy loads to help people serves as their motivation. ·· Fall from high places such as trees There are two beds which were designed for pregnant ·· Diving into shallow water women to give birth, so that they can be free to lie in any ·· Being gored from behind by domestic animals such as position at the delivery center in which UBAs stand by on cattle a 24-hour basis. Urgent transport destinations for pregnant The facility is equipped with 100 beds, divided into women are Dakka Medical Collage and private hospitals three sectors (physical therapy, occupational therapy and in neighboring areas. Last month, in nine childbirth cases language therapy). Being equipped with an Outpatient among 38, pregnant women were transported to other Ward and Hospitalization Ward, the facility is designed facilities. for patients from remote places to be hospitalized first. The delivery center has two committees, and plays a role The CRP provides follow-up care through home visits for in detecting pregnancy complications and assisting SSs’ discharged patients in remote places. Doctor’s fees are activities by mobilizing local people. decided according to the patient’s economic category. After interviews with the staff of the delivery center, we The CRP fosters technical experts who give patients with visited some pregnant women’s homes. The BRAC has speech disorders rehabilitation training. According to the
18 staff, since there are no speech therapists in Bangladesh, the August 19 (Nagata) CRP has invited instructors from overseas and is currently BRAC Bogra Training Center/Regional Office training them to be speech therapists for Bangladeshi needs. This kind of human resource development is the first such In the morning of August 19, 2009, we left Dhaka for the attempted in the country. The staff told us that the students BRAC Bogra Training Center. currently in training will play an important role in speech After arriving at the center a little past 12:00 p.m. therapies that will use sign language and gestures in the (approx. 4.5h), we spent two days taking a tour of the future. Health & Education Program (on the first day) and the Water, Sanitation and Hygiene Program (on the second day), both of which were being implemented by BRAC in Bogra Province. The following items are reports on the sites we visited on the first day.
1. Health Program: Health Forum activity Destination: Bogra District, Shaharanbal Upazila, Madira Union, Bojora Village
Visiting hours: 13:20p.m. - 14:00 p.m. Accompanying person: Mr. Jahurul Haque Siddique District Manager, BRAC Health Program
[Impression] We took a tour of the Health Forum (a health meeting BRAC’s activities in urban slums and the CRP were both for community residents) held in one of the communities very interesting. A slum that we visited in the morning (approximately 5 or 6 households) of Bojora Village. looked more like an ordinary town, with many solid The style of the Health Forum involves a Shasthya Kormi buildings, rather than a slum. According to the branch (hereinafter SK), in this case, Ms. Tanjura, who visits a manager, this is an old slum with a long history, and the community and conveys messages related to public health main sources of income for people are jobs such as rickshaw to ten or more female participants through a 30-minute driver, tailor and retailer. While thinking that residents can picture-story show. Topics of this Health Forum mainly be reassured with a delivery center which is available 24 consist of four themes: vaccination, hygiene, hand-washing, hours, we wonder whether there is any confrontation or and family planning. Accordingly, when we visited Bojora confusion with the diversity of agencies and workers related Village, she explained family planning, vaccination, clean to childbirth, services. toilets, how to cook, hand-washing, tuberculosis, and the Hearing that the delivery center calls an ambulance in health of pregnant women. an emergency such as a pregnancy complication, students We were told that SKs explain these topics once a month asked how long it takes for an ambulance to arrive upon for seven months, usually in the same community, to receiving a call. Although the answer was from 20 to residents holding a meeting with a Q & A session. At the 30 minutes, many lives that could be saved with earlier meeting which we observed, the community’s Shasthya treatment may be lost in areas like Dhaka where people are Shebika (hereinafter SS), Ms. Komira, was also assisting not willing to give way to an ambulance during daily traffic the SK (in arranging meeting places and calling for jams. participation). In the afternoon, we visited the CRP. The facility and its services looked better than we previously imagined, with [Learning] significant amounts of financial support flowing in from Several issues at the recap meeting at night: overseas. Seeing that reports were written on whiteboards ·· The fact that the health education was implemented by in an orderly manner in each bureau’s office, and that SKs rather than by SSs. activity introduction forms with photos were displayed in ·· Some residents could respond to many questions. This the corridor, we got an impression that donors’ tours of appeared to be a result of SKs and SSs’ constant activity this facility are frequently conducted. We were surprised to to convey information about health. see bedridden patients being turned over every two hours. ·· People become SKs by taking an examination after Hospital staff and patients’ families were so adept at this applying for it, rather than by being promoted from SSs. procedure that the patients’ very clean backs left a strong impression on us.
19 [Impression] •• The leader of the Kishori Kendo can make 25 taka per We are sorry that our delay in arriving due to heavy rain program. caused trouble for the staff and related people. [Impression] 2. Education Program: Adolescent Development Program ·· Having a third place to go, other than school and home, Kishori Kendo seemed to be a good thing. Destination: Bogra District, Bogra Sadar Upazila, Erlia Union, Polyvalley Village August 20 (Kikuchi) BRAC Project Observation in Bogra District Visiting hours: 16:35 – 18:20 p.m. 9:00 – 14:00 Accompanying person: Mr. Habibur Rahman District Manager, BRAC Education Program Mr. Masud Parvej (Regional Manager), Mr. Zakia Khatur (Upazila Manager). We took a tour of Kishori Kendo (club & extracurricular activities) in Polyvalley Village. Kishori Kendo is an activity [Outline] for adolescent girls conducted by the BRAC to promote ·· In the Water and Sanitation Program, a Program Assistant, knowledge and socialization through extracurricular using a flip chart, organized the session around five hand- activities. wash messages and nine sanitation messages. Specifically, using a room in a kindergarten twice a week ·· We observed a meeting of the Village Wash Committee for two hours from 4:00 p.m. to 6:00 p.m., 35 members (VWC). aged 11 to 18, who were selected by a villager in charge of ·· Learning about building of latrines at the Rural Sanitation implementing this program, gather together to play music, Center (RSC) in Birgram Village. dance, play games, have discussions, and borrow magazines ·· Taking a tour of women’s toilets in a senior school and books. This program has established a partnership with ·· In the Education Program, we had a session of cultural UNICEF and the Donor Consortium. Inside the facility, exchange with local students singing Japanese songs. game tables, musical instruments and books were prepared. ·· Taking a tour of the Gonokendra Library 80% of the members were girls and 20% were boys. This ·· The program guidance includes a wide range of items is because, while the target of the BRAC is adolescent girls, such as activities prior to the preparation of meals, its partner UNICEF hopes to provide opportunities for boys. washing hands with soap after using toilets, cutting nails, The selected boy members are younger than girl members. wearing shoes, disposing of garbage, and putting an anti- Of 29 participants that day, 26 go to junior high school insect cover on tableware, hygiene measures that were and three are young persons who do not go to school. taught by PAs (Program Assistants) once every three Participating members were energetic and had ambitions months. to be future teachers, police officers, doctors, dancers, ·· The VWC is composed of six women and 5 men. In a singers and lawyers. They listed dancing, singing and monthly meeting, based on a regularly updated map, discussions with friends as fun club activities. reports are given on which households have had toilets Then, the members showed us the dances and songs they installed. Roof colors of the households on the map practice daily. We saw various types of dance, including distinguished their financial level: red (Ultra Poor), blue energetic dancing and graceful dancing. Our students (Poor-support provided by the BRAC), purple (moderate sang “Do re mi”. After that, we danced together with the poor), and yellow (members of BRAC’s volunteer members, sweating through several numbers, and were organization). able to mingle with children who smiled beautifully. In the ·· A plastic toilet can be installed at a cost of 700Tk, review meeting that day, many students said that they had including mounting. A two-pit system (two holes in the fun through this precious opportunity. ground equipped with containers that can be alterated when full at a cost of 1,800Tk. This is free of charge [Learning] for ultra poor households. Other residents can receive a Details of discussions at the review meeting at night: free loan, which is provided by BRAC. Tube-wells are •• Several persons selected from the members of Kishori also shown on the map. Most families in this area have Kendo can take courses on ways to earn their living wells. (The cost of digging a well is covered by each expenses. (P.42 BRAC Annual report 2008.) In one household. Digging wells seems to be inexpensive in this case, a woman who received barber training in this area area because water rises plentifully from even a shallow opened a barbershop by herself. hole.) Since all the VMC members are volunteer workers, •• We think it is good that the BRAC develops programs they do not receive any incentives, even for the work of for various generations. introducing clean toilets to all the households. They are
20 currently striving to bring the installation rate of toilets to ·· T h e l i b r a r y h a s households to 100% by the end of October. Toilet seats a b o u t 1 , 1 1 1 and water tanks are built by the RSC under a private b o o k s , p r o v i d e d program rather than under the management of BRAC. by contributions BRAC implements training and quality control for local t h r o u g h B R A C , entrepreneurs. Toilet seats and water tanks are purchased and includes an IC by BRAC, and provided to all villages. Section, Children’s ·· In front of women’s toilets, the five Hand-Wash Messages S p a c e a n d a C D were displayed. Originally, there was no toilet available S e c t i o n . I n t h i s for women during their menstrual periods. For that reason, library, newspapers some students did not go to school. Today, two toilets that are also available can be used even during the menstrual period have been a n d t h e b o o k s , built for 250 female students. The students themselves which are mainly form committees in charge of cleaning the toilets. When in Bengali, can be we inspected them, the inside of the toilets had been kept borrowed. clean. ·· [Impression] ·· Wash & Sanitation is the most important program, considering sanitary conditions. Although toilets are installed in many homes, the depth of a toilet must never reach the depth of a well. We were impressed by the village’s stance maintaining that the village at large could solve its own regional problems. That day our stress was relieved by the children’s glowing smiles and people’s kindness.
·· The Pre-Primary School for children aged 5 or 6 has 29 students, including 17 girls and 12 boys. The curriculum consists of Bengali, science, arithmetic and drawing. Students’ favorite subject was Bengali. One of the conditions for becoming a teacher of this Pre-Primary School is to be a female who has graduated from at least a senior school. According to the data for 2008, out of approximately 550,000 students who graduated from the Pre-Primary School, a majority of them were enrolled in a Government’s Primary School. The Primary School is for students aged 8 to 10 on average, with the additional August 22 (Tsuruoka) subjects of English and Social Studies. The students’ Ekmattra (NGO) favorite subject was English. This is a program provided 13:00 – 17:30 by BRAC, which waives school fees and teaching Mr. Yoshiki Watanabe (Adviser) material costs. The number of students per class was set to be lower than those of the public schools. [Outline] This is an NGO revolving around two policies: Education and Empowerment of the socially vulnerable, and Enlightenment Activities for the wealthy in the society. The name: Ek (one) Mattra (lines shared by everybody).
21 [Learning] August 23 (Hirano) ·· People (Bangladeshi and Japanese) who were concerned BRAC University about the economic and physiological gap in Bangladesh 11:00 – 12:00 met at Dhaka University and initiated activities in 2003. Dr. Fara, Mr. Rajibu, eight members of BRAC University, ·· Main activities and Prof. Akiko Matsuyama and two 2nd-year students of
22 Student Reports
My Experiences through the Field Trip
Yoshito Kawakatsu
We went to Bangladesh from Aug 4 to Aug 25 to is a rare case. But it is very useful for me to learn both see the reality of Bangladesh which we only learned the advantages and disadvantages of Microfinance. about in Japan. In my case, this field trip was my first At present, Microfinance projects are practiced in time. So I was very much looking forward to going. In various countries. I am interested in the rate of repayment this field study, we visited some organizations (e.g., in each country, the different ethnic groups and the care BRAC, JICA, ICDDR,B ) and knew the details of each for ultra poor people. For that reason, I would like to do project and organizations. research about the development of Microfinance. In BRAC, we visited some programs like BRAC executes another project for the ultra Microfinance, human rights and legal education class poor, called CFPR-TUP because Microfinance isn’t for challenging the frontiers of poverty reduction, an effective method for these people. A person who is targeting the ultra poor (CFPR-TUP) and others. As identified as ultra poor by BRAC can get some cows and Microfinance showed effective methods, it helped the goats free of charge. Using these productive assets, they community people to stand on their own feet. Also the become candidates for Microfinance during two years. role of microfinance is not only to help the ultra poor, I think that only BRAC, as a big NGO, could conduct but also to help the moderately poor as a method to this system by themselves. But I want to focus on the promote their development. I guessed from the criterion definition of ultra poor. Regarding the annual report of of the Microfinance program and through conversations BRAC, the definition is as follows: that BRAC also selects persons who have possibility of 1. Ownership of Less Than 10 Decimals of Land; repaying as a VO (Village Organization member) and 2. Low-Status of Domestic Employment or Begging; makes loans to them for Microfinancing. In other words, 3. No Active Adult Male Member in the household; BRAC doesn’t conduct charities like an NGO, but acts 4. Having Children of School Age; as social entrepreneur, with a focus on profitable and 5. No Productive Assets; sustainable activities. As a result, they have achieved a 6. Dependence on Female Domestic Work or Begging. high rate of repayment. Of course, in the background, If someone meets 3 criteria out of these 5 items, the there is the sincere effort of Bangladeshi. But, it is also person is certified as ultra poor. I think that these criteria a fact that it sometimes leads to hounding community also pertain to a person who has the possibility to join members down and has generated cases of escape or Microfinance after CFPR-TUP. suicide. Although the philosophy of BRAC is greatly Through CFPR-TUP, Social Welfare service by opposed to becoming a leech on the poor, it is a big MCHTI (Maternal and Child Health Training Institute), problem when it causes the same result. I think that this the voucher system, and others, I wondered who are the
25 ultra poor people in this country. From reading journals, accurate data, no effective methods for PWDs, and other I had understood that the people in rural areas and slums such factors. However, it is not clear. are very poor, but I heard it is a condition even for Fortunately, in this field study, I visited the two staying in slums to pay a land fee, so I was thinking the facilities which focus on disabilities, CRP (Center of ultra poor are not really slum people, but street people. Rehabilitation Paradise) and BRAC Limb and Brace Later, we fortunately could go to the NGO Ekmattra Fitting Center (BLBC). CRP gets international funding, as the final organization we visited. Mr. Watanabe, so the facility is very big and magnificent. CRP has a who is adviser of Ekmattra told us that street children center facility and four sub-centers nationwide. But there can make as much money as ordinary people, live as are some problems like lack of human resources and a they like, and are vulnerable to being utilized by adults. follow-up system. And the target disease is limited to Furthermore, although I knew that the street children spinal cord and cerebral palsy. Furthermore, few people in Dhaka gather from rural areas to live in the cities, I can get specific therapy by a specialist. Although there learned the importance of support of street people. From are these problems, this facility is very important and the this information, I guess rural areas are ultra poor. And only facility which focuses on disability. a BRAC staff member told me where ultra poor live. He BLBC focuses on orthopedic patients, especially in mentioned three areas: the lower extremity. The causes of disability are mostly 111 the area straddling a river, called “choll ” in Bengali; road accidents. This facility provides the opportunity for 222 the area around Rangpur in northwest of Bangladesh, rehabilitation, braces and prosthetic limbs. The number called Monga; of patients is increasing from the year 2000 when this 333 The hilly terrain in Chittagong. facility was established. At the moment, there are only Comparing ultra poor areas with other areas, there is two facilities like this. But in the future, the number will a difference in the number of the BRAC branches. increase. At the same time, the next problem will be Especially, in the southern area and the hilly terrain near regional integration. Then I’d like to assist as one of the Chittagong they are very few in number. Of course, specialists. although there is the difference in extent of forest, and so Aside from this, the road accidents which cause on, I think that the ultra poor couldn’t get enough help, disabilities also cause delay of the referral system, and because it is very hard for a small NGO to start a project traffic jams. It was said in 1st semester classes that the in an area where BRAC cannot launch each project, and I problem of health is related to other area problems like felt that from now on, the approach to help should focus traffic, the economy, and culture. I actually felt this on equity for the people who live in ultra poor areas. problem. I’d like to learn not only about health problems, Moreover, I recognized again that equity for each but also related problems. individual is important as well as the equity of each Finally, I will summarize maternal and child health area. Almost all organizations focus on programs for as the main theme of this study. Almost all the facilities mother and child. I think that is correct. But persons which we visited, like the fixed site clinic, Sub-center with disabilities (PWDs) have vulnerability too, like and Matlab Hospital in Matlab, Up-grade BRAC Health mothers and children, and PWDs are susceptible to center, MCHTI, and Safe Motherhood Promotion Project discrimination. Through the journal review, I felt the (SMPP) by JICA, provide services in maternal and low interest in PWDs by government, international child health. It was impressive to see the continuum organizations and NGOs. The reasons may be lack of care provided from pregnancy through childbirth and
26 after. Especially in Matlab, the continuum care was me to consider not only health problems, but also other great. However, there are some cases which cannot problems. Moreover, it is very important for me to get continuum care because of lack of understanding know the reality of disabled children in Bangladesh by father and mother-in-law. Thus, in the next stage, as I consider my research topic in the next year. I I consider that it is necessary to help the father and have found the significance of focusing on disabled mother-in-law as a family because they have influence on children. Furthermore, talking with many specialists the decisions by women. MCHTI started assistance for gave me very good opportunities to consider my ideal the fathers to understand pregnant women and mothers. standards. The answer is unclear. But there is no doubt Through this study tour, I understood more that the experience of this field study is very valid for explicitly the information which I learned in first considering my future. semester. Accordingly, I could understand each problem in its entirety. I mean it became possible for
27 Primary Health Care in Bangladesh
Kanako Kikuchi
1. Summary changes have taken place since the NGOs began their One factor causing unfair health services to support. One of my goals for this internship is to learn residents of Bangladesh is the wastefulness of the clear answers to these questions. health-welfare system. Through my observation during I learned that volunteers from the community play a this internship, I learned about the NGO approach to role in improving the problems related to health, and the covering the fragile government of Bangladesh (GOB) power of mutual assistance by the citizens themselves. and encouraging communities in PHC matters and I’m really impressed by this. increasing awareness of the need for good PHC. This Thinking of what I learned from the people and internship also enabled me to develop practical skills NGOs, it occurs to me that when I go to Kenya for my that I can use when I go to developing countries as an long-term internship, there are great possibilities that intern and specialist. the power of helping one another can enhance people-s lives not only in Bangladesh, but also in other countries. 2. Introduction The Health and Welfare System is handled by the Ministry of Health and Family Welfare and is divided into two separate parts: the department of Health DGHS DGFP Service and the Department of Family Planning. That is the reason health care is out of reach for many people who are allotted unfair services. Government reform of health care is needed, but things just stand still. There are a lot of NGOs to cover the GOB in Bangladesh,
especially BRAC, which plays a wide role in providing Figure1 Pyramid of Health Administration in Bangladesh services to improve life conditions for people in the country and change for the better their healthcare 3. Body of the report problems. First, see Figure 1 to explain the structure of the Compared to other countries, Japan seems to be health and medical system of Bangladesh. The MOHFW blessed with good health care and anyone can receive (Ministry of Health and Family Welfare) has made itself fair services. I wonder how NGOs and other related a dual-partitioning. One part is the DGHS (Director organizations take the part of the people under the General of Health Services), and the other is the DGFP fragile GOB; then, what effect they have had, and what (Director General of Family Planning). DGHS takes
28 on basic health and medical services; DGFP takes on Districts have taken up the program. We visited a family planning services and other related matters. village where there is a committee composed of five We could not observe Dhaka Medical College males and six females, a total of 11 members. They because of the schedule. It belongs to DGHS, and talked about which villagers didn’t have a sanitary MCHTI (the Maternal and Child Health Training latrine or a tube well, which villagers were ultra poor, Institute) belongs to DGFP. On August 16th we visited and which were moderately poor. We could see the the district hospital of Narsinghdi which has 10 beds house information and mapping by color display. The for special mothers and children and belongs to DGHS. aim is to install sanitary latrines in all village houses Surprisingly, there is another hospital, which belongs to by the end of October. The ultra poor as defined by DGHS on the same property. In addition, in both DGHS BRAC are provided with sanitary latrine systems from and DGFP hospitals mothers can deliver, including BRAC and the poor (moderately poor) as defined by by Caesarean section. I wondered why there are two BRAC can borrow the cost of installation for a sanitary hospitals on the same property. There are not many system. Establishment of operation systems by local medical facilities in Bangladesh, and a lot of people residents, not only by the BRAC organization, is the want to have a doctor in rural or other areas far from most important thing. Community members themselves the capital city of Dhaka. In this situation, two hospitals decide how they can assist the people of their own on the same land seems needless. In such cases, it is village. I think that makes the bond among the residents hard for me to understand the health and medical care even tighter and builds a spirit of helping one another. systems of Bangladesh. I thought these should be the Surprisingly, the committee members don’t get any first priorities for development in the GOB system. salary from BRAC; they work hard free of charge. However, I know the NGO’s role in helping Among these people were student representatives of vulnerable government systems: they have the know- a students’ committee and representatives of the ultra how for cultivation of human resources, distribution of poor. To have representative students participate on the medication, and alleviation of the shortage of facilities. village committee makes it easier to have widespread NGOs are giving support and promoting cooperative realization, from school to village, of the importance systems for Bangladesh to provide better health of a sanitary system and to have a strong sense of services to the people. Especially BRAC has the widest solidarity and cooperation when problems happen in the approach, functioning like a company in order to help village. people also in matters other than health. I think the accumulation of such relationships will I was really interested in two programs. One is eventually become a strong link among community WASH (Water and Sanitation Hygiene) program; the residents and others sustained through the mutual other is the Safe Motherhood Promotion Project by assistance system and progress. JICA and the NGO Care, to make support teams from the community to help women from the beginning of 5. About Safe Motherhood Program Project pregnancy to delivery and postpartum care. Most of the problems concern maternal and child health care in Bangladesh. One reason is that the 4. About WASH program maternal mortality ratio and infant mortality rate is According to a BRAC report in 2008, WASH was higher than in other countries of the world. undertaken from 2006, and now 150 Upazila and 40 The purpose of this project is to make clear the
29 problems related to the three delays and then to make management skill. Management of health care is a top- a plan to fix them. The Community Support System to-bottom system in Japan. However, a health system (CmSS), made up of village members, plays a major from bottom-to-top can be created, too. I am not sure role in the village and community. This is a system that Japan’s system is better than one from bottom- to enable women living in the community to get the to-top. Moreover, not all countries agree with the service and support they need, throughout pregnancy, system. I think the best way is for both government and delivery, and after childbirth, especially in emergency citizens to exchange health plans that meet each need. cases when they can get appropriate services as far as is Government and community should try to achieve the possible. The committee has a meeting once a month to same aim hand in hand. inform about how many pregnant women there are and It is difficult to solve the health problem only by how many deliveries can be expected, the accounting focusing on one thing. The problems are complicated, report, and other related things. The members include a and health is only one dimension. Supporters should Traditional Birth Attendant, a Family Welfare Assistant, play behind-the-scenes role to promote healthcare a Chairman, and others. activities driven by local residents. This project plan consists of education for It has affected me to observe and know the emergency cases, preparation for delivery, management supporter’s cordial back-up help. I can relate this of “rikisha-ban”, antenatal care, and other connected to the first semester lectures where I learned about things. empowerment, strengthening relationships, a lot I am really interested in the idea of community of things for helping the community to help itself, members saving money for emergency cases of pregnant a concerted approach to problems, and more. It is women or for any other needy cases. In Bangladesh, important not to depend entirely on government, but to medical care is basically free. However, sometimes make more flexible arrangements to support developing patients have to pay themselves for medicines, delivery peoples. kits, and backhanders. There are also plenty of private Structure is made by a culture and the life of hospitals which do not offer free care. its inhabitants, so it is difficult to change behaviors This program also used community empowerment and feelings. However, I think that people hope for successfully. their own country’s betterment and for a better life. To do this, people need to feel motivated to achieve 6. Conclusion continuing effects in their country. The community empowerment idea impressed me The way to support this may be an application with the many ways to develop its full potential. I wrote of a culture’s potential even in other countries still mainly about health and medical services. However, I developing. also learned other forms of community development I was really impressed by this program and feel such as micro finance moving from the individual to motivated to study more. I intend to keep this feeling in community conversion. my memory, making effort for the future. I have worked as a public health nurse in Finally, I want to say I am grateful to all the people Japan; I always recognized that a person’s skill is who supported me. I would like to thank the staff of this empowerment. I think Primary Health Care (PHC) is program for their efforts in making the arrangements a method of improving (developing) the community for this trip.
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31 Learning About International Health through Bangladesh
Kanako Koyama
1. Introduction them high awareness. To reach this state, there was a I went to Bangladesh on a field trip from August 3rd process of discussing the problems in the community, for to August 25th, 2009. The purpose of the trip was for example, finding out about the problem clearly and how informed consideration when we analyze a problem in to deal with it, with the assistance of an NGO. I thought the future to find a solution, through inspection of model this process was the crux of the matter for making a health projects in Bangladesh. It was my first visit there. valuable community organization. However, there are similar aspects, like the atmosphere When they face a problem they should perceive that of the city and food compared to Nepal where I have it is not normal, that it is a real problem, and understand been as a volunteer. For that reason, I could sometimes it so that it can be tackled. Through this they will be able feel familiarity with this country. Though it was a short to implement what they can do themselves. It is easy time, I could learn from participants’ opinions about the to say, but it is so difficult to put into practice. They health system and actually I acquired many things though need to express their own thinking and get to know I cannot record everything here. That’s why I have tried many different opinions from others in the process of to narrow the topic and would like to mention especially discussion. In addition, they try to understand and share the most impressive things and where I want to go in the others’ thought. This helps them deal with their problems future as an MPH student. more easily and also to cooperate with each other. If they realize they can handle things themselves, it makes for 2. The Strong Power of Community strong community power and organization in attacking a The most amazing thing for me was the high problem. I have just observed it fragmentarily. However, awareness of participants in the various health projects. I was so impressed by their community power. There Especially in JICA’s Safe Motherhood Promotion is no doubt that the part of supervisor, both foreign and Project, there is CmSS (Community Support System) Bangladeshi, is important in the process of making a which involves local people with their own experience strong community. regarding maternal death during pregnancy or delivery “If they feel a sense of ownership, and support from trying to avoid death. The women can reach out early people they respect, then there will be an incentive and and identify with hospitalized pregnant women in bad motivation to maintain it.” [Basch 1999: 221] condition who may already have had the death of two When thinking of sustainability, not only motivation children. That is the advantage of an organization with of participants but also support is necessary. Moreover community members because their own stories can relate there cannot lack a good relationship between community to the patients’ own situation. These experiences give and supporter. I could learn consciousness and incentive
32 for the project of both sides through observing it, in significance. Through this, I recognize again that what addition to how the relationship of community and matters most is the principle when building a strong supporter work to achieve their goal of health. I thought health system managed by many different organizations. by observing the project that considering how to deal with a problem is simple, but running it takes huge 4. Discussion energy of individual and community. Firstly, I would like to mention about how to make use of what I learned during the trip as an MPH student, 3. The Importance of Organizations Collaborating with but it is difficult to say in few words. For that reason Each Other I will mention only the essential points I learned for The government of Bangladesh provides health understanding the classes in the second semester: services, but NGOs also provide a lot of health services. Health Project Management, Social Research Methods, It seems to me, that there are two health care lines or Economics, etc. systems of Government and that of NGOs. For that For instance, in the BRAC Micro Finance Program, reason, the way the health system works in this country they struggle with the problem of poor people by is confusing. I wonder how the people select and get providing projects for educating them on how to earn services among the many providers that exist. It is money, rather than approaching the realm of health care. ordinary for local people, but for me it was difficult I could understand there are many ways to approach at first to understand the intermingling of many health, not only by dealing directly with health issues, organizations. but also with intervention of economics, education, When I understand new things I always want to and other factors. On the contrary, connecting health, have a general outline, and after that move on to the education and economic matters from the bottom up is specific parts. I studied the health system before visiting an important key to the whole. I could easily understand Bangladesh, then observed ongoing health projects. the many ways of such intervention in the health problem Through my observation I thought that the health system through learning about model health projects. I can link itself does not matter so much to the local people; they my study in the next term with these experiences in really care only about what services they can get. For Bangladesh. When I did volunteer work in Nepal I could them, the kinds of services there are is a serious problem not understand the relationship between government and more than who gives it, the government workers or NGO donors; however, now I understand more than before. workers. However, when I took a step back during the Learning many viewpoints about tackling the health field work and thought of my aims, my point of view problem helps me consider International Health and changed, and I could understand how the problems are research more realistically. tackled and how the organizations collaborate with each Secondly, one thing I regretted is about language. other. It is difficult to provide services to every person Language has subtle shades of meaning and when through one organization, even if it is the government. translated into English sometimes it does not have Even the big NGO BRAC cannot provide for every exactly the same meaning. I would like to have area where there are people who need health care. In understood directly what people were saying in their this situation I think collaboration, cooperation, respect own language; it is better than through interpretation. for each other, and making an effective place to carry Their faces were similar to Nepali, which is why I felt out the forte of each organization are matters of great a dilemma. However, it takes time to acquire, so I will
33 want to learn the language as well as the culture and 5. Conclusion and Acknowledgements society for my next year of internship. I have already learned the fundamentals of Thirdly, in ICDDR,B Matlab it was a very great international health and how to deal with the problem opportunity for me, since I do not have experience in our earlier classes, and in addition, by seeing with in field survey, to learn how to collect data through my own eyes, feeling and using my senses, I could management of it. The surveillance at Matlab is quite understand more deeply. In fact I could digest those systematic and a cohort study. Not only do they do impressions, to use the right word. I have been feeling research, they provide health services as well, using the frustrated because there are so many assignments so results of their data collection. For that reason, I will that sometimes before really understanding one, another want to reconsider in my research how my results would assignment has to be done. The great thing is I could be reflected among the local people. finally digest as my own what I observed throughout “By observing the successes and noting the failures this field trip. It might just be saying that “one look in other countries, by adapting and referring to local truly is better than a hundred words”; however, it is conditions, through imagination, practice, evaluation, true that I could learn and feel in reality. Classes of the and comparison, the international health worker can first semester were readjusted and I am now ready for become a true collaborator for the benefit of all peoples. the second semester. The field trips were fruitful and I The world is indeed full of paradoxes, but it is these that rediscovered my feeling about why I wanted to study provide our most exciting challenges.” [Basch 1999: 507 international health as I felt the energy of local people in - 508] a developing country. Finally, in order to form a viewpoint and cultivate At the end of this report, I would like to express my ways to think as a whole about what international health gratitude to Mrs. Miyachi who guided us every day in is, I learned about health systems and how to deal with spite of difficult situations in arranging our schedule, the problem through one model country, Bangladesh. I the professors of BRAC and their staff, JICA, UNICEF, really felt it is not enough experience for me, and there ICDDR,B, and Prof. Watanabe and Dr. Inuo who taught are many things I do not know. According to the words us feasibility study, and the administrative staff. I would above, we can accumulate competence through many like to say thank you again to all who supported our field experiences. I am in the process of doing that, and these trip. experience bring me one step closer to becoming an international health professional. Basch, F Paul 1999 Textbook of International Health, NewYork: Oxford University Press.
34 Learning and Challenge in Bangladesh
Naomi Takagi
Introduction residents. This makes it possible to utilize health services Many men were leaning on a fence, staring at us all for community residents. BRAC implements delivery as we came out of Dhaka Airport. Struck by their eyes, crisis management 24 hours a day. we got on a bus for our hotel. On the way to the hotel, The Safe Motherhood Promotion Project, a project of there were so many passengers and cars and three- the Ministry of Health and Family Welfare (MoHFW), wheeled cycles like Japanese rikisha. The streets were supported by Japan International Cooperation Agency crowded with them. It was the first day of our field (JICA), has taken a keen interest in maternal health study in Bangladesh, a thickly peopled country. issues. We could observe a Community Support System Through the field study, I learned a lot of things such (CmSS) activity and understand how it does a lot to deal as ways to enhance health, the medical service system for with the three delays. In ICDDR,B in Matlab, I observed the inhabitants, what support is needed, what factors are the activity of a referral system from primary health care involved in maternal and child healthcare efforts, while to tertiary medical care. It was a meaningful experience considering international, cultural, and social indicators. to know specific efforts needed for a referral system. I saw clear challenges for the future in my learning. I I could appreciate the medical service system each want to show this in my report as follows. project had, BRAC, ICDDR,B and JICA. I learned Bangladesh is promoting the improvement of the medical 1. Enhancement of health and medical service: care delivery system. Local residents have a pressing need regarding the three delays for a system in which their voices are heard, so as to The Bangladesh Government defines its objective as affect policy in their community. Reinforcement of the the reduction of the Maternal Mortality Rate (MMR) and spirit of cooperation is one of the significant roles for the Infant Mortality Rate (IMR) in its Health, Nutrition, coordinators. and Population Sector Program (HNPSP). Both MMR and IMR are declining year by year, but they remain 2. What support should be high in comparison to developed countries.Therefore, Regardless of the large amount of aid from within the Bangladesh Government, BRAC and ICDDR,B have and without, Bangladesh is disadvantaged. There are a started the development of human resources and have lot of beggars and many women holding children made established a system of reproductive health service for us understand through gestures that they didn’t have local residents. In BRAC’s Shasthya Shebika, community anything to eat. This could be due to the Government’s health volunteers, and Shusthya Kormis, health workers weak financial footing. The Ministry of Health and promote health education and family planning for local Family Welfare (MoHFW) is divided into two sections,
35 one of which is Health and the other, Family Planning. especially has done research for more than 40 years There seems to be a lack of cooperation between the two about dynamic trends in population and economic sections. Therefore, management becomes inefficient circumstances. A Community Health Research Worker and complicated, a situation that cannot easily be (CHRW) develops Personal Data Assistance (PDA), changed. which she plans to use for local residents on a trial basis. NGOs fulfill an important complement to the Every CHRW could use PDA and convert to a paperless Government’s role. The Government relies on the NGOs, system in the near future. but Bangladesh is rife with corruption, which seems to We could observe how a resident’s life could be result in a vicious circle. There is a dilemma between a researched by CHRW data processing. It is an important policy of independence and of support in Bangladesh. experience for us for understanding a surveillance It would take a long time to solve the problem because system. Such systematizing fills the need to get the of the historical background, including colonial rule. I situation in perspective and to accumulate information would like to deepen my perceptions on how support and from back to early times. independence should interact. 5. Cultural, social, religious factors 3. Importance of a comprehensive approach When we consider international health, we have to BRAC is one of the biggest NGOs in the world. understand the cultural, social and religious background BRAC can have a greater influence on Government in Bangladesh. I studied cultural and medical because of its enormity. BRAC has developed a anthropology in the first semester and always looked comprehensive approach for poor people. BRAC offers back to that class during our stay in Bangladesh. education and provides a house and livestock, like cows The Islamic religion has an important effect upon or goats, for the ultra poor. They are given many kinds not only daily life but also health care or health-related of help by BRAC. After they have graduated from the behavior. For example, home base infant delivery is category of the ultra poor, they participate in a Micro more than 80% in Bangladesh. Many women don’t want Credit System. The interest rate is 15% and the rate of to go to hospital for their delivery. This problem is not repayment is 99.3%. only in having access to hospital, but also has cultural To release the ultra poor from their extreme and religious aspects that cannot be overlooked. We condition, some support must be withheld from the have to recognize the considerable impact of religious less poor. It is therefore necessary to define the ultra views when we think about the quality of healthcare and poor clearly. Moreover, it is important that support for personnel development. economic independence is comprehensive. Through the BRAC approach, I could see the need for people to Closing become independent. As mentioned above, we had an informative program for three weeks. It was a good experience for me. 4. System of surveillance Moreover, I could meet a lot of people who work hard The main activities of ICDDR,B include not only for a developing country. That was also an important treatment for diarrhea and other infection, but also over- aspect of our field study. I had a wonderful experience, all child health, vaccination, nutrition, reproductive although at the same time I suffered heartache during the health, and other related areas. ICDDR,B in Matlab three weeks when I saw the ultra poor, who made me feel
36 sad. I felt sorry at the children’s warm welcome given us Japanese, dancing and singing for tourists after much practicing. I felt disconsolate when I had to walk past a beggar. It made me think a lot about the imbalance, injustice, and absurdity all over the world. I benefitted a lot from Bangladesh during this time. I think I would like to give back something to developing countries. To prepare for such an occasion, I want to be proactive in studying during the next semester and never cease trying to improve my mind.
37 Complexities regarding International Health seen through the Experiences in Bangladesh
Junichi Tanaka
First, Bangladesh is a country in South Asia with a 1. Learning How to Understand the Health System and population of 158,570,000 people, around 40% of the Support in the Country Japanese land. It is placed as an LLDC (Least among The Bangladesh health system was much more Less Developed Countries) globally, but it maintains a complicated than I expected from my previous study. high economic growth rate, and is referred to as an “honor The national health policy is planned in form consistent student” of the LLDC. On the other hand, corruption with PRSP (Poverty Reduction Strategy Program) and an increasing spread of natural disasters, especially as HNPSP (Health Nutrition and Population Sector floods, happen almost every year and are still a problem. Program) and the achievement of MDGs is raised as a The progress of MDGs (Millennium Development pillar of these aims. MOHFW (Ministry of Health and Goals) about health is almost smooth and the mortality Family Welfare), which is not only on the central level, rate of children under five years old has decreased to 65 but also the community level, is completely divided into (per 1000 live births) in 2007 from 144 in 1990, and the two sections. DGFP carries out family planning and maternal mortality rate to 320 (per 100,000 live births) in performs medical care related to prenatal care, but the 2005 from 480 in 1990. In addition, in cases excluding vertical administration system in the country obstructs MDG related problems, there have been problems of cooperation with DGHS, which became a problem. It arsenic tainted drinking water, death by drowning due to is a case of duplicate care, but I was very surprised that floods, and increasing life-style related diseases, through the buildings themselves were separate. However, at the health transition. community level, each health worker (HA and FWA) In this internship, I assumed as a personal aim two affiliated with each bureau should be able to cooperate, points: understanding the economic support for the poor so this presented a complicated aspect. and understanding the health system in a developing In this internship, I learned a practical aspect, country. The former was because I felt through prior through lectures and visits in the field, of the support learning that the vertical administration system of the that BRAC, JICA, and UNICEF give to the Bangladesh Bangladesh Government is a problem. The latter was health system. However, it was only in SMPP (Safe because I was able to get this valuable opportunity to Motherhood Promotion Project) of JICA that support know about economic support first hand, which I was which could strengthen horizontal cooperation at the only able to know through reading until now. Also, administrative level was seen. This project administers as a third problem, I want to report the impressions I a committee to strengthen horizontal cooperation at felt during this internship regarding the health worker a central level, a district level, and an Upazila level, situation. and builds CmSS (Community Support System) of an
38 inhabitant-participation type to maintain unity in the developing countries in the future. case of emergency care. This trial is very important in order to build a support system involving inhabitants’ 2. Learning about Economic Support for the Poor participation and promoting horizontal cooperation I was able to observe micro credit and the fact of reinforcement. I hope this project will scale up and spread the ultra poor support by BRAC as a training program to other projects and the national system in the future. related to poverty reduction. Poverty reduction and I asked various people in charge of each organization international health have an inseparable relationship and what they thought about support to the government, it is said that poverty is the cause and result of ill health. but it is very difficult to support a government which It was unexpected that there are few areas where the ultra is rife with corruption, and I heard that there are many poor are crowded and several ultra poor households live voices for reconciliation about this point. I felt very close to the ordinary and moderately poor households in disappointed about that. In addition, no well-organized the village. I heard that the people who live in the areas report was given about the actual situation of private called “chore” and “monga” are the poorest, but was not hospitals, which are important health facilities in this able to really observe their life. Even if a certain woman country. I thought that it was a very important thing to is recognized as ultra poor, it does not mean that all such know the actual situation of those institutions because people will get support. It seemed that only a person most government doctors tend to work at both private with the possibility of paying interest and repaying their and government hospitals, and the reliability of the debt could borrow money. I was surprised to hear that government health facilities is low. Yet lectures about a user can commit suicide over the failed payment of a the private sector were not included in this internship, debt. And I had a strong impression that BRAC cannot and in each place we visited, correct information was not be described merely by the term NGO. But actually provided when I asked for private sector information. there are many women whose lives have stood up again It is thought that this problem is related to the medical through micro credit, and it is a fact that micro credit is a information system that does not function effectively. strong friend of the weak. The MIS of MOHFW was not ready, and the DGHS and About the return rate of the debt, they maintained DGFP had their own MIS without mutual cooperation. a very high return rate of 99.3 - 99.5% according to a The evils of the vertical administration system appeared report for these past several years, but was it that the here, and it was a situation where it is difficult to grasp criteria for selection of the program users is strict and correct health information without a system which a user does not propose participation voluntarily, and gathers information about the private sector. MOHFW that the staff of BRAC researched and found likely should establish MIS immediately not to waste the users. I felt that such a method might be the secret of information that has been collected through hardship. maintaining this high return rate, but I had doubts about In addition, I regretted that I was not able to cover all whether the person who really needed the program the medical facilities from the first to the third level in received it. Micro credit is not a mere humanitarian Bangladesh, not to be able to observe them. However, support, and I understand that there is a business side on the whole, I had a good opportunity to understand that achieves profit and produces activity funds for the health system of a developing country through this BRAC. In addition, I was surprised that street children internship, and it was a valuable experience for us who and beggars are able to earn necessary expenses at the are concerned about the solution of health problems of same level as a rikisha worker. The thought that naturally
39 they will be poor is wrong, and I felt that I must reflect is difficult to overturn old customs and sense of values, on my own past conduct. I was able to understand that it so that words express it by saying such things as “the is important that I give support without being influenced corruption is Bangladesh culture”. However, for us, by preconceptions. people in the world should be able to live a healthy life with equity. Therefore, it is important that international 3. Learning about a Miscellany of Health Workers organizations and NGOs prepare steps for self-support Although the subject of health workers is included in to achieve its aim. An international organization and an the health system I mentioned above, I decided to report NGO perform various kinds of support in developing on it individually because I felt, through this internship, countries. Through this training, I could understand that that the diversity among health workers constitutes a it is important which road the government receiving aid big problem. I studied it in this short-term field training is going to walk in the future and by what methods. As mainly about an institution related to MNCH, and I was for the various stakeholders who are active in places surprised that a wide range of health workers perform to promote international health, each should carry out medical care. It is a desirable thing that there are a lot of support with its various expectations. I felt that the health workers that the community can contact to achieve various stakeholders, who are moving with action toward the aims of HNPSP and MDGs. However, I worry about the common aim of achieving MDGs, cannot prepare how the government will unify them when that aim such steps. Their function should be replaced by the is achieved in the future. In addition, the existence of Government, and the supporters should leave Bangladesh such a wide variety of health workers disturbs technical before long. Furthermore, even if an NGO is domestic, uniformity and as a result, long-term accomplishment is with origins in the country, it is not sure that it will a concern. Moreover, the employment of professionals continue support forever. such as doctors or nurses is not carried out with foresight, It is very important that I was able to know the and vacancies become an outstanding condition in each present conditions in Bangladesh of the various institution. It is necessary that the government leads stakeholders holding complicated connections with the system and that the quantity and quality of health each other, when we think about international health workers improves. development in the future. Through this internship, I could understand the importance of developing 4. Future Problems and Prospects the inhabitants participation type of project and of Because there was no opportunity in this training to understanding the culture of the target country, its really talk with the persons concerned in the government, government, and the international organizations and I was not able to know what kind of steering could be NGOs that operate there, and to share the same aim and thought about so that the Bangladesh Government now grow. I want dependent on international support and the support of the to make use of NGO could act independently in the future. Bangladesh this experience is advancing steadily toward the accomplishments of in a long-term MDGs, but this seems to be a result of temporary support internship and by various stakeholders now. I have the impression that a in the future longer time is needed for the Government to lead and for activity of the a Bangladeshi health policy to make changes smoothly. It next year.
40 Powers in Bangladesh
Miyuki Tsuruoka
Surrounded by heavy air and a strange smell, I there is no help for it. Once we go away from the traffic found myself at the airport exit. I could see innumerable jams in Dhaka, we see beautiful scenery with a lot of silhouettes lining the outside of the fence there. People green and water. People are a little shy, full of curiosity were leaning on the fence, though I couldn’t make and warm-hearted. I thought again, “This is also out their faces. We got into a car and went out into Bangladesh.” their world. The sky was overcast. “Rikisya”, compact vehicles with three wheels, and large cars were moving We could see many kinds of activities with an in disorderly fashion. A lot of people were crossing the advisor from the Government: BRAC, which is one street. “This is Bangladesh...” I thought. Then I became a of the largest NGOs in the world, a kind of world little nervous about my three weeks there. organization, UNICEF, JICA which supports the Government, ICDDR,B which is an international In 1971 Bangladesh was born through a war of research center, and Ekmattra which is a local NGO. independence that took the lives of three million. Its Each of them tackled the problems of their own subjects population density is one of the highest in the world. with common aims for improving society. The constitution of the Government is weak, largely Here are some discoveries we made, one of the supported by many other countries and a lot of NGOs. most important goals of this internship, in a successful Systems in Bangladesh seem to be in chaos, as the traffic project. First is the appropriate division of human in Dhaka City. According to many health indexes in resources. Second is participation by local people. And Bangladesh, they have made great achievements. On last is sustainability. We learned about each point of each the other hand, there is a big problem due to the various project and had opportunities to see the smiles of the gaps in the socio-economic levels and the conditions people and a part of their lives. of health service coverage among the people. After a squall, the roads change into a pond and traffic jams are 1. Safe Motherhood Promotion Project (SMPP) getting worse. In that road like a pond, tidy cars, rikisya, In SMPP by JICA, I was impressed with their and compact cars are competing with each other. Then activities for strengthening the horizontal lines in a beggars surround the cars waiting at the traffic lights. vertical government system. In Bangladesh, the Ministry If they cared about others, they would not go ahead of Health has two departments, Health and Family when pedestrians are trying to cross the street and the Planning. It has been said that cooperation with each pedestrians would wait their turn, too, but nobody seems other is important. Especially in maternal neonatal to care about the other people. It seems irrational, but care and child health it is stressed that continuum and
41 comprehensive care are important. The Department of and Microfinance to tackle poverty in rural areas and Health provides general medical care, maternal delivery cities. Now they have grown bigger and run a sewing services, immunization, and so on. Meanwhile, the factory, bank, university, and other endeavors. They are Department of Family Welfare also provides maternal one of the largest NGOs in the world and operate like a neonatal care and child health care, with a focus on huge company. Motivation is an important point I found family planning. Both departments’ jobs overlap in the in various programs like health, education, hygiene, community, where Union, Upazila, and District, for economic independence, and human rights. They give example, have similar facilities and staff. It seems that people an opportunity to be involved in a nice loop and the overlapping services are good for people because have achieved continuous participation by local people. they can get double services. In fact, overlapping For example, the Water and Hygiene Program in which causes lack of facilities and staff in other needy areas, village people take part through a committee with resulting in inadequate services. While it is said that representatives of the old and young, men and women. appropriate services, human resources distribution, and They enlighten each other and try to solve their problems decentralization are important, the Government cannot together. do anything because of its own power struggle. In SMPP they deal with the “Three Delays” 3. Ekmattra (knowledge, transfer, provision of services) in cases of “Ekmattra” means “one common line.” It is an obstetric emergencies. They have established steering NGO and has two main aims. One is to educate and committees in the Government, District and Upazila empower vulnerable people and the other is to enlighten areas. On the community level, they set up a community the wealthy. Six years ago Bengalis and Japanese support system (CmSS) organized by rural people met in Dhaka University. They sympathized with the themselves for supporting pregnant women. Local people about social problems in Bangladesh and started people have regular meetings and register pregnant Ekmattra. At the beginning they established open-air women, manage funds, and prepare a transfer system for classes for street children. They promoted cultivation of emergency cases. SMPP arranges cooperation between aesthetic sensitivity by singing, playing, and dancing. CmSS and the Government for continuing activities by Literacy education and life style education were also CmSS even after the project period ends. In addition, provided. as a target for the third delay of obstetrics emergency, After that they built a shelter home for children. SMPP promotes improving the quality of services in Among children under 10 years old who continued open- health facilities. SMPP assists the obstetric emergency air classes for more than six months, if they hoped to live team in each hospital. They carry out their action plan, there, they could do so with their parents’ permission. then monitor the cases themselves. We could see support We visited the shelter home and talked with a Japanese for establishing organizations with rural people and its staff member who began Ekmattra. After that we played effect on them for continuing activities on their own. with children living in the shelter home. Fourteen children live there together with staff except for school 2. BRAC time. They have to obey the rules there. Learning the BRAC was established in 1972 by several persons, basic rules in society, they are preparing for life back in including today’s leader, Mr. Abed. They have dealt with society. They meet their parents once a month. A lot of many kinds of problems; for instance, spreading ORS children are drawn to leave their hometowns for Dhaka.
42 They have suffered with their parents and believe “I can hour’s thrilling drive, we arrived at ICDDR,B Mattlab do it in Dhaka!!!” Most of them don’t go to school and Health Research Centre. ICDDR,B is an international live in the street as beggars or get into child labor, like research center. They have a Health and Demographic becoming newsboys. It is not necessarily hard for them. Surveillance System in Matlab. Since the center was They can use all their time as they want. It’s rather a established as a cholera research center in 1963, they hardship for them than a heaven to live with someone, have researched with a statistical way for providing get a job, and expand their own world by studying. They effective health services to people. Babies who are born have to overcome such trials and feel the necessity to in Matlab and people who move to Matlab are registered. learn and have a strong will, if they want to continue All of them have ID and personal health records. In their life in the shelter home. I was impressed by those Matlab, a particular area, there is a reasonable medical stories. system. An adequate referral system is established from Then an “academy” is now under construction. After primary to tertiary needs. We can see various health children graduate from the shelter home, they can learn services from basic support, like health education and practical skills there for jobs, English conversation, immunization, to medical care for extremely premature computer skills, traditional sewing, sweet-making, and so infants. An additional registration system collects on. They will also run a dairy farm and poultry farm for individual health information. There was not such a funds to run the center. Children will be supported and clean facility in any other area. The proportion of home given opportunities for jobs. delivery is one-fouth in Matlab, although it is four-fifths There are some resources for running Ekmattra, for in all of Bangladesh. The mission of ICDDR,B is to make instance, foster parents, donations, original goods sales, clear relations between environment and humans. Then and mass media business. A film business, which is they can establish evidence-based health services. A lot produced by the Bengali staff, was especially interesting. of money and technology are invested there to make an One of the organizers produced a film about street ideal society. That’s why Matlab seemed a special area children’s lives. It aims not only at getting funds, but also in Bangladesh. It is our hope that universal, practical and at enlightening the wealthy. Organizers hope to refer their effective health services are detected and scaled up. work later on to people who graduate from the academy and will lead things themselves in the future. I could see These three weeks made me learn about the state of the great ideas for building a continuous cycle also in health in Bangladesh. When I study one country, finding this activity. There is great potential in Bangladesh. out what kind of resources I should use, which indexes I was encouraged by the smiling children with a are useful, then what I have to consider... are things I’ve future and with the passionate staff. I hope to visit the also learned. I could understand and feel the meaning academy someday. of population health indexes that I had learned about in the first semester. In addition, I found difficulties 4. ICDDR,B from knowing one country from different angles. All About 60 km from Dhaka and turning from the main countries have deep history and culture. For us who visit road, we could see beautiful scenery with water and one country from another area, it is impossible to grasp greenery. The car jolted along a narrow road, asphalted even the surface. but a bit bumpy. Whenever a large bus passed, we worried about the car falling into a pond. After one Tiny babies being provided “kangaroo care”, skin-
43 to-skin care with their mothers, surprised me very much. essential care should not be lost. That is my wish. If they were born in Japan, almost all of them would be There are many kinds of jobs in international health. in incubators and supported by respirators. Of course it One is saving lives of people who are right in front of is not clear how their health will develop in the future, them. Another is tackling improvement of health systems but I was moved by their life force. So I have got hints to for reducing the gaps between people. And still another consider the effectiveness of essential neonatal care. is trying to detect effective services by researching from In next year’s internship, I want to utilize my the social and medical sides. knowledge and the way I’ve learned. Then I’d like to be I appreciate all the efforts by the people who gave aware of the people’s hope by spending much time with me this chance to go to Bangladesh. I’ll consider what them. Someday essential neonatal care will be natural I will do and what I should do, as I think over this field all over the world. And babies who can survive with work again and again.
44 What I Learned in Bangladesh
Sayaka Toyoshima
BRAC, “MADE IN BANGLADESH”... that was following observations. the biggest impact for me. The people who are in this I had never heard the name BRAC until I entered this country, which is an aid recipient, are helping their graduate course. I had been familiar only with NGOs or families and neighbors for themselves. Although they are UN organizations like JICA, UNICEF, or WHO, so the still receiving various donations from many countries, existence of BRAC, the very biggest NGO in the world, BRAC, the biggest NGO that is not only in Bangladesh was really news to me. The activities of BRAC based but also all over the world, is “made in Bangladesh”... it on the will of Mr. Abed, the founder, aim at helping is still not easy to believe. the development of Bangladesh by helping community Bangladesh. It was my first trip to South Asia, members and their neighbors to learn to help themselves and I didn’t have any image of that country, but now and each other. The scope of their work is very large I can understand why we had to study in Bangladesh, and the coverage and growth are nothing short of eye- not in other developing countries. However, at that popping, although of course it is obviously not possible time, I was uninterested in it even during our group to be able to maintain perfect performance with regard to work. For me, for some reason, Bangladesh was not a all of their activities. I cannot find another word except very fascinating country. Fortunately, that attitude was “so fabulous!!” to describe them with regard to their knocked out of my brain soon after our first visit to style and their steadfast policy. BRAC. “What a huge building this is! Is this BRAC, and is that an NGO...?” Furthermore, since I got back four BRAC has various technical terms of its own. years ago from Vietnam after working with the Japan For instance, if I talk about a Skilled Birth Attendant, Overseas Cooperation Volunteers, I went to several there are various categories and names within that overseas countries, but not for travel, just to study the term. This issue is not only BRAC, but also includes language there. I did not study the country’s background the governmental area, and the situation sometimes beforehand like I did for this field trip, and I did not made me confused. However, in my opinion, it is not get any feedback about how I had gotten through to the important what name or ranking a person who helps local people, what feeling I was able to communicate. with birthing has, as long as she/he can do it in a safe On this field study, though, I could, and thanks to this, I way for every mother and baby. Yet my main concern could do a recapitulation with my classmates of our daily remains whether they, especially SS, with or without a experiences. My thoughts are still alive in my brain and low literacy level, can help home deliveries safely. The heart in a stable way, not just as a past memory. I would main principle or axis for development is the mother’s like to relate what I learned during this field trip in the and the child’s health. This is a common principle of
45 NGOs and government, and they aim at safe delivery holding them close for 24 hours a day. What pretty and in medical facilities, but are they concerned about the good care! Although the nurse and pediatrician explained mothers’ comfort and feelings? And how is the workers’ to me that they had no other way without incubators, for attitude regarding hospitality for patients? With regard me, this kangaroo care has always been the original basis to this, I would like to mention JICA’s support. JICA of all neonatal care, and I would use this method in the is “made in Japan”, therefore their collaboration stance field. is very thoughtful and warm-hearted. Japanese nursing style gives importance to the patients’ individuality and And as to taking part in ICDDR,B., and BRAC’s quality of life. They are good at keeping respect for their activities with MCH, I have a question about them. They partners and traditional life, so they are familiar with are pushing a project to deliver in hospital facilities, not adapting their good style of care to whatever situation at home. This is common sense and easy to understand. or place. By bringing our methods to the local style, the I can catch the reason why they must push that plan Japanese style acquires new life and at the same time a hard to decrease the maternal mortality rate. However, I new local style is also developed. I learned this from my would like to mention the mother’s efficacy for delivery. observation. It is clear from the mothers’ and fathers’ Originally, why did Bangladesh women have to do child- class in MCHTI also. This is probably a really new bearing in their homes so far? Was it because of poverty, trial for Bangladesh, especially as a Muslim country. lack of accessibility, distrust in government hospitals, Unfortunately, I had no opportunity to see that there with and so on...? In brief, they had no alternative for delivery. my own eyes, so this impression is only what I got from Also, a TBA was always around, which is an important their booklet, yet I was able to find a new direction in fact as well. Actually, were all women the same? Weren’t Bangladesh maternal care and this is really a gift from there women who wanted to give birth to their baby collaboration with Japan. JICA’s target is comprehensive, at home? I can’t stop thinking this because I know the and they are focusing on the “Three Delays”, and on good points of delivering at home, even though I know structuring a referral system for solving the issues from this choice is available only under the best conditions the grassroots level to the district level, not picking up for child-bearing. As I mentioned before, if they could only one aspect. I heartily expect the Rikisha ambulance support mothers in their skilled way to deliver at home, to work efficiently and help many mothers and babies, couldn’t the moment for bearing the child be better for so that they do not need to die like before. the mother who labors at home by any chance? If they delivered in a hospital and could get reputable care by My best place was ICDDR,B Matlab. In Japan, SS or SK, nevertheless they would have to be discharged kangaroo care gives mothers a lot of experience in just in one or two days anyway, and must return home from feeling their babies’ meaningful, living presence. And the hospital over poor roads. The community is very yet there, this has always been practiced as a treatment much a neighborly place, from a different aspect, and for vulnerable newborns. I already knew this method delivering at home with a loving family, neighbors, is appropriate to enable premature babies to grow up, and a reliable skilled birth attendant... is that so bad for but in Japan, we do not need to continue this type of them and for Bangladesh? I would like to hear and know care daily, thanks to our having many incubators. All their real feelings someday. If they think it is nice to the babies there were smaller than normal and weaker, go to a hospital, that is fine with me, too, because the but their faces looked contented through their mothers’ most important point is how the mother feels about it. I
46 wonder how they would answer me? As a midwife, this and government is very complicated. In my opinion, is the big “homework” that my experience in Matlab BRAC has grown too big for the government, and for gave me. It was a very fruitful trip for me. that reason alone, the atmosphere is not so mild between them both. For instance, I could call the Government’s When we think of the direction of aid or development role “Major” and the NGOs’ role “Minor”. However, the of a still developing country, we tend to think of the circle in Bangladesh is not round in shape because some domestic type (government aspect) and the international areas stand out, while other parts are dented. This occurs type (NGOs from overseas’ aspect). Both angles are from each organization having its own direction. To easy to confront and understand. However, while in destroy the Government’s stronghold is not the intention Bangladesh, we could get the idea about a third type of the NGOs; their good points supplement the other. of aid along with the government and the international The Government supervises from the sky and the NGOs NGOs, that is, “domestic NGOs” like BRAC. It is very intervene from the ground. If they could cooperate more interesting and a brand new viewpoint. The reputation fully with each other’s work, the circle of Bangladesh or evaluation of each of them and the dissimilar styles of could turn into a perfectly rounded shape. Although I cooperation among the various organizations give rise to am not sure on which side I will work, whether NGO or many different opinions. I observed many programs of government or other, the things that I learned through BRAC and others through this trip without any bias, but this field trip will be a good bridge for working smoothly rather with the panoramic view of a student, so I will try as an expert between NGOs and government in the to write the conclusions I thought about as follows: future. The state of the relationships between the NGOs
47 Gleanings from Three Weeks’ Stay in Bangladesh
Akiko Nagata
First of all, I want to express my appreciation to women are too big to ignore, the gender gap issue is all the organizations and institutions where I visited, addressed in Bangladesh. for kindly receiving us, and to BRAC and Nagasaki University for supporting and coordinating this internship Question 2: What is the Scale of BRAC? trip, especially to the two coordinators, Mr. Rajib Nakib BRAC is said to be the largest NGO in the world, and Mrs. Kaori Miyachi for taking care of us every day. which operates not only NGO activities, but also The aim of this short-term internship was to learn business and research activities such as manufacturing, the situation in Bangladesh, one of the developing agriculture, IT, finance, and a University. It reported an countries in the world. We visited various organizations annual expenditure of 535 million USD in 2008 (27% such as BRAC, which is working to reduce poverty in of all expenditure met by donor contribution), and it Bangladesh and is said to be the biggest NGO in the is increasing year by year. It is about one 20th of the world, UNICEF, the Government of Bangladesh, and Bangladesh Government’s annual budget in 2008-2009. JICA’s Bangladesh office, and all the others. Then I had BRAC activities aim to improve the quality of life four main questions during the period in Bangladesh, among poor people living in rural areas or urban slums, which I will try to report clearly hereinafter. so they have established a nation-wide organizational structure with regional offices and branch offices, Question 1: Why do so many projects make women the namely, 4,584 field offices and 21 training centers. target for development? There are 51,914 employees and 63,932 teaching staff, Traditionally, family structure in Bangladesh has a total of 117,067, and community health workers and been patriarchal regardless of what religion is practiced. volunteers total 80,000. Therefore, it was assumed that men have higher status BRAC operates various programs, divided into four than women in society, which required that women stick categories: to men and must never interfere with them. 111 Economic development (including Microfinance); This affects women’s life expectancy, which is 222 Human development (Health, Education, and lower than men’s, especially in rural areas, even though Adolescent Care); biologically women should be able to live longer than 333 Social and Legal Empowerment; men. Also, there is a big gender difference in literacy and 444 Environmental care. marriage age, so it is very difficult to get the opportunity But it is impossible that BRAC distribute their for women’s social advancement in that country. services to all citizens in Bangladesh equally, because of Because the domestic disparities between men and limited resources. Therefore, when they start a project,
48 they survey to select an area which has greater needs. and NGOs in Bangladesh. As for the HNPSP mid-term This is good, but it means that sometimes they leave out appraisal, the following three challenges were suggested: an area which has moderate needs. 1) taking more consideration of the poor and I could not find a clear answer on how NGOs strengthening maternal health; cooperate and coordinate to provide equal service in a 2) strengthening the health system; community. 3) strengthening administrative skills in MOHFW. Regarding the last factor, the vertically structured Question 3: Why is Health Program Operation so administrative set-up is addressed. In Bangladesh, Complicated? mother and child health improvement is one of the most There are some factors that bring about the important programs. Nevertheless, the administrative complicated health program in Bangladesh, for instance, section is split into two bureaus, Director of General so many related organizations in the health sector, fragile Health Service and Director General of Family Welfare. ownership, and a vertically-structured administrative set- This brings about the above-mentioned situations. up have been pointed out as causes. I did not get an answer to why and when they made The first factor, that so many related organizations two bureaus in MOHFW. But it is true that Bangladesh are in the health sector currently, is common in the is one of the countries where family planning strategy developing country. After independence, there were has succeeded, and I imagine the separation was in many assistance-supported people in Bangladesh. order to make a peaceful compromise over the previous Consequently, related parties realized the importance condition. Then I cannot say it is absolutely wrong. It of aid donor coordination, so they formed a donor seems to be a reform of sorts. consortium. In a 2001 report, there were at least 13 At the end of this question, it was not clear for me international organizations, 18 bilateral cooperation how the GOB and many NGOs cooperate in operating agencies, and more than 400 NGOs working in the health a comprehensive health plan. From our briefings, I sector there. understand that the GOB is trying to stimulate contracting Regarding the second factor, fragile ownership, the out projects to NGOs and the BRAC chairman is a first factor led to making the Health and Population member of the advisory commission on development Sector Strategy in 1997 among MOHFW (Ministry issues for setting up the policy at a national level. But of Health and Family Welfare) and donors. However, still I’m not clear about the field level cooperation and donors took the initiative for the strategy, so it was coordination among the organizations, the cause of my difficult for the MOHFW to assert authority at that time. seeing some challenges in this field. In addition, it was pointed out that the MOHFW had inadequate coordination and standards of transparency Question 4: What about Microcredit / Microfinance? and disclosure, overlapping organizational structure, a Bangladesh is famous for its success with customary protocol of delay (it is said that corruption and Microcredit / Microfinance in the fight against poverty in commotion obstruct any motion for streamlining). the world. I reviewed some literature about Microfinance According to briefing by health program staff in to understand more on this question. charge at JICA Bangladesh Office, the current Health, Microcredit is a small loan which aims at poverty Nutrition and Population Sector Program (HNPSP) will alleviation. Usually “Microfinance” is used to refer to continue until 2010 after having cooperated with donors Microcredit, Microsaving and Microinsurance combined.
49 Many financial organizations and NGOs have operated 222 Prosperity we shall bring to our families. Microcredit projects in Bangladesh since the 1980s. 333 We shall not live in dilapidated houses. We shall Consequently, more than thirty million households repair our houses and work towards constructing became Microcredit borrowers in recent years. 85% of new houses at the earliest. all borrowers are women. Compared to 1987, in 1999 444 We shall grow vegetables all the year round. We the prevalence of people who borrow money from shall eat plenty of them and sell the surplus. friends declined from 37% to 1%, while borrowing from 555 During the plantation seasons, we shall plant as Microcredit since its institution increased from 3% to many seedlings as possible. 33.2%. We were told that it is due to low interest rate. 666 We shall plan to keep our families small. We shall For instance, BRAC put the annual interest rate at 15% minimize our expenditures. We shall look after our compared to 120% of non-credited financial institutes. health. This makes for keeping a high rate of repayment at 92- 777 We shall educate our children and ensure that they 99%. can earn money to pay for their education. There are five points about Microcredit in a lot of 888 We shall always keep our children and the reading matter on the subject in Grameen Bank: environment clean. 1) membership requiring recognized status as poor; 999 We shall build and use pit-latrines. 2) a solidarity group of five members; 1111 We shall drink water from tube wells. If it is not 3) a first loan for two group members after a one-month available, we shall boil water or use alum. observation period (incl. one week’s training); 1111 We shall not take any dowry at our sons’ weddings, 4) a repayment period of one year; neither shall we give any dowry at our daughters 5) duty to participate in weekly meetings and make wedding. We shall keep our centre free from weekly repayments for 50 weeks. the curse of dowry. We shall not practice child Moreover, the Grameen Bank Microcredit activity marriage. provides not only financial activities, but also non-profit/ 1111 We shall not inflict any injustice on anyone, neither social activities for poverty alleviation. They respond shall we allow anyone to do so. to a form called Sixteen Decisions at the beginning of 1111 We shall collectively undertake bigger investments each weekly meeting, and then have a discussion session for higher incomes. with all participants about one chosen topic. Through 1111 We shall always be ready to help each other. If this activity, borrowers learn how to use and earn money, anyone is in difficulty, we shall all help him or her. keep motivated to improve their life and change behavior 1111 If we come to know of any breach of discipline in in such ways as being punctual, keeping promises, and any centre, we shall all go there and help restore other points. It was easy to understand what they mean discipline. by “go for it” when I read the Sixteen Decisions. Hence 1111 We shall take part in all social activities collectively. borrowers get the positive feeling that the most valuable In other papers, they mentioned some challenges thing they are receiving is improved personal capacity, to Microcredit. Grameen Bank II, which is the more network support, and self-esteem, rather than the income. adaptable one, arose from this system in 2002. The points 111 We shall follow and advance the four principles of are: as follows. Grameen Bank --- Discipline, Unity, Courage and 1) Regarding an individual’s accountability to repay, Hard work – in all walks of out lives. they have established a more flexible group member
50 system. now on. 2) Borrowers can choose the amount of the loan and My other challenge is to maintain more physical how to repay as suits their needs. strength, as Dr. Yanagi said in his lecture, because I had a 3) There is emphasis on saving. faulty condition sometimes during the period. 4) There is more participation for extremely poor Well, at the end of the trip it became clear how I people; they started to support beggars in 2003. should prepare for the next long internship period. Microcredit is really developing day by day for poverty alleviation. I cannot cover all the information
51 What I Learned during the Field Trip
Mami Hitachi
1. Introduction CHWs of NGOs, and Community Health Research My Field trip Program was a precious experience Workers (CHRWs) of the International Center for for me to know what is being done to improve health in Diarrheal Research, Bangladesh (ICDDR,B). They have a developing country, Bangladesh. Though I have been involvement with residents directly and many people can to Bangladesh before to meet friends, this time with a receive services. The SS, SK and CHRWs are all women different purpose I went to the country regarded as a because of concern for religious and cultural values. model for improving the nation’s health in spite of its In Japan, individuals register by visiting a government still being a developing country. I visited places in the office, but in Bangladesh, some people like CHRWs visit medical sector and observed activities which would be homes directly and register the individuals. In developing impossible to visit during ordinary travel. countries, the personal registration system is not well arranged, and lack of access to information is a problem. 2. Some Specific Things I Learned Though Bangladesh has the same problems, in the places In Bangladesh in 2004, infant mortality rate (IMR) where I visited, SS, SK, and CHRWs visit each family was 52 (per 1,000 live births) and the under-five child and follow them up, updating information and referring mortality rate (U5MR) was 74 (per 1,000 live births). to the next stage when necessary. I was surprised by that. These data have been improving since the 90s. Though In Japan, we can get information whenever we want it. Bangladesh is one of the LLDC in South Asian countries, However, it is difficult to get information if we try to get the averages for IMR and U5MR in Bangladesh are access to it by ourselves, and sometimes we get confused much better than those of other LLDP and South Asia by too much information. Consequently, a personal and almost the same as LDC, which shows IMR at 54 registration system for each country has good and bad and U5MR at 79. Furthermore, the total fertility rate points. I could learn that the problems mentioned above (TFR) is 2.9 while it is 4.7 for other LLDCs. This means were resolved by CHWs who care about the religion they have succeeded in family planning (FP) by putting and culture as they visit the families, which is a very into effect a population policy from 1972 and a family important point. planning policy from 1995. In Bangladesh, the maternal mortality rate (MMR) in High vaccine coverage is one of the factors in 1990 was 570 (per 100,000) and 380 in 2007. However, these successes. Furthermore the factor of high vaccine maternal health made a smaller improvement than child coverage is due to the work of Community Health health, though the goal of MMR was to achieve 143 Workers (CHWs) acting as volunteers, Shasthya MDGs. In addition, a low percentage of hospital delivery Shebika (SS) and Shasthya Kormi (SK) of BRAC, is also a problem. The Bangladesh Demographic Health
52 Suvey said the percentage of hospital deliveries is 20% for different NGOs in a small area. In that case, some in the country. However in Matlab, which is the research residents can choose the services they require or they site of ICDDR,B, it is 80% and CHRWs who don’t have can be given certain services. It is unequal that some medical licenses play an important role. Furthermore, people improve their health by these services and others they explain about FP and it seems that pregnant women who need support don’t receive any services at all. I get more information than Japanese women. By visiting think we should make efforts to give support to as many there, I learned that they can protect health during people as possible. Another problem is that counterparts pregnancy even if they don’t have a medical license, and have to make reports for donors, which disturbs their it is very important to utilize local human resources who most important work. I think they need cooperation know the community well. and communication among the different organizations. Through the field trip study of the Microfinance Though I heard that JICA staff started a coordination of Program, Human Rights and Legal Education Program, organizations, I think the Government has to do that in and the Ultra Poor Program I could observe other factors the future. regarding the success of health improvement. It is said Third, it is about sustainability: I visited government that the empowerment of women affects child health and hospitals and I heard that medical treatment is all free I could understand this by seeing participants’ smiles in Bangladesh. For example, at the Mother and Child while meeting graduates of the Ultra Poor Program. Welfare Center (MCWC), which is a district level hospital and located in Narsinghdi, patients don’t need to 3. What I Learned about Difficulties for Health pay for medical care even if a pregnancy needs delivery Improvement by Cesarean section. I was very surprised at that because During the field trip, I could also learn about I thought the Government couldn’t afford medical problems concerning the health policy of the Bangladesh costs, and many people couldn’t afford medical care in Government. First, the Health Ministry is divided into developing countries. At the same time, I worried about two departments, Health and Family Planning, and the dangers of free cost because there are good and bad their job sometimes overlaps. Though this problem has points. For example, in Japan, some people don’t need to been pointed out for a long time and many people are pay for medical care, which means they can get medical aware of it, it causes inefficient programs, but to bring care whenever they need it and thereby medical costs them together is not a realistic solution because these swell. However, it is said that people avoid care at a departments each have a long history. I think that respect government hospital because of the staff’s bad attitude. for each other’s opinion and an improved basis are very I wonder if the Government can keep a free care system important, not integration. I may meet the same situation when more people are going to public hospitals because when I work in the field, so I want to keep such an open chronic diseases are increasing in Bangladesh. Also, there attitude. is always a possibility of a change of policy because an Second, I noticed the lack of communication Administration changes every five years in Bangladesh. I between government, international organizations, and think keeping a free cost system is very difficult because NGOs. In Bangladesh, many organizations are working of many barriers. In addition, some people try to promote to solve health problems and sometimes their services health by charging for better care. Therefore I think the overlap in the same area, while some people living in the Government should control the burden of medical costs South can’t get any services. Actually I saw many signs according to economic status.
53 ICDDR,B’s Health Demographic Survey System 4. Lessons of the Entire Field Trip (HDSS) also does research about reproductive health and In this program, I asked many questions and often provides information. There are about 225,000 people heard the word, “because of Muslim”, as responses. or 1,500 families under surveillance. Each person has a Islam is deeply rooted in the Bangladeshi’s life. Islam is Registered ID (RID) which never changes and a Current the heart and soul for them and a norm of life. Therefore, ID (CID) which changes with marriage, moving, and so it is inseparable from them. In foreign countries, what on. CHRWs visit families every two months and collect we consider common sense is not adopted, so we have data which are processed and stored in facilities. Lessons to try to understand and respect the customs and cultural learnt from research in Matlab have been used for values which make up their thinking. That is a first step policy formulation in Bangladesh. I was very surprised in working to improve health in developing countries. to see CHRWs visit every house and follow up from I learned that the worker keeping in good shape birth to death. These data are more detailed and timely is basic and very important for working in developing than in Japan. However, I worry about sustainability countries. If one gets ill, it causes delays of schedule and of HDSS because these funds depend on support from disturbs many people. I have to pay more attention to my foreign countries. I think the Government needs to take health than usual, since it is easy to get sick because of responsibility for sustainable funding. differences of climate and food. In Bangladesh, there are more activities to improve In the field, I could learn a lot for comparing with health than I expected, and sometimes it seemed more what I learned in classroom lectures, though three weeks advanced than in other developing countries. Though was short. I would like to make the best use of this Bangladesh is one of the LLDC and they need support, experience for activities as a JOCV in Niger. In addition, I think participation by Bangladeshi and the use of local I want to consider more about definite plans to resolve resources are very important to actually improve health. problems that I found in the field, because this time I Throughout the field trip program I could learn that couldn’t find all the solutions. donors, like us, work behind the scenes and local people need to play a leading part.
54 The Power of NGOs
Shiho Hirano
1. Lessons learned Motherhood Promotion Project in Narsinghdi. This Three weeks’ field trip in Bangladesh gave project backs the Community Support System (CmSS) at me valuable chances to observe and learn about the community level to prevent three delays concerning the Bangladesh health system as well as programs maternal death in any obstetric emergency. According provided by international organizations, the Bangladesh to a CmSS member interview, death of relatives and government, bilateral countries and local NGOs. consciousness of need to protect pregnant women in the Nagasaki University MPH group visited several places community are their strong motivation. from August 4th - 25th. Through our trip, I was mainly In addition, community volunteers called Shasthya interested in learning the following two points. First Shebika (SS) work hard in each area. Similarly in is the community approach methods that involve Ghana, there are community health volunteers, called community members in the program, because I had a Community Based Service Agent (CBS) . Motivating difficult experience in motivating community members. CBS to work effectively was also our concern. Working in the Rural Health Improvement project in Recognition by community members as a helpful person Ghana, I was mainly involved in organizing, training strongly encourages SS to work hard. and monitoring the women’s microfinance activity and Organizing a committee to tackle some problems faced difficulty in continuing the community’s activities in community also needs effective approaches. A JICA there, since members’ motivation fell down after several expert explained that Care Bangladesh spent six months months. Community intervention approach to motivate motivating community members before starting CmSS. people is one of my learning targets. I was interested in the 6-month curriculum and the way Both BRAC and JICA are providing programs to approach people but unfortunately, we didn’t have a in communities. We observed community members chance to talk with Care staff. Probably, pushing along participate actively and spontaneously in the program. by inches to motivate people is necessary for the success At BRAC’s microfinance program, peer pressure among of community based programs. five members works effectively for refunding money, and Secondly, I was interested in youth development in 2008, the microfinance program achieved a 99.3% programs delivered at BRAC Adolescent Development recovery rate. Besides, BRAC offers a high interest rate center, Kishori Kendo, BRAC’s program for adolescents on members’ savings, which motivates members to save to provide emotional education, dancing, health problem money. A weekly repayment system also ensures high discussion, and job training. This program is held in the recovery rate. afternoon twice a week in elementary schools. It is a On the other hand, JICA implements the Safe meaningful program for adolescent nurturing because
55 it provides opportunities for youth to develop skills and security to the poor. These are some reasons we saw capacities. I hope more youth will develop their skills many beggars in the capital. On the other hand, Ghana and possibilities through this program. is a more self-sufficiency society. Most people living in Through our field observation, I was impressed rural areas can have something to eat from their farms. by JICA and BRAC’s programs, though I got the Ghanaian society has a strong relationship with relatives impression that very poor community members tend and clan. Hence, we didn’t see any beggars in Ghana. to receive support from different agencies passively. In Discussing whether life in Ghana can be described the Philippines, where I used to work, there is a word, as “water shortage”, by contrast, most of the land in “People’s Power”. It means people have more power to rural Bangladesh is covered with plenty of water. Due to influence government and there are many local NGOs water shortage, the guinea worm eradication program in actively working on a grassroots level. Empowerment northern Ghana faced difficulty in controlling people’s of very poor people will be the next target to achieve behavior, and one solution, digging a tube well, was quite further development in Bangladesh. To achieve this expensive (more than 10,000 US dollars). Surprisingly, target, BRAC’s adolescent program will help to empower digging a tube well in Bangladesh is quite affordable future generations. Bangladesh has many development (2000 TK) and we observed most houses in Shanagar potentials such as being politically peaceful, having high village had their own tube well. economic growth rate, massive reduction of poverty, In Bangladesh, plenty of water brings both good high elementary school enrollment rate for both sexes, points, including fattened harvests and reduction of and good acceptance of family planning in the country. women’s work of fetching water from far places, and bad points, including flood, and a bad sanitation environment. 2. Impressions Sanitation intervention in public places might have My impressions of this field trip are classified into positive impact on preventing water-related diseases. two points. Firstly, our classes in first semester were very useful for understanding each topic in the field. Many new words and theories, including the three delays 3. Way forward on maternal and neonatal death, Emergency Obstetric One useful approach for community intervention Care (EmOC), Kangaroo care, and Referral system were was given us from BRAC history. BRAC organized particularly useful. It was a meaningful opportunity for a committee to help understanding of its aims and me to observe how these theories relate to mothers and programs in its early times. This approach was attempted children’s life. when BRAC realized that community members were Secondly, I was able to see Bangladesh society afraid to accept BRAC because they thought BRAC from the point of view of comparing African society. would force them to convert to Christianity. Forming Bangladesh is similar to Ghana in sending relatives a committee in the community would help acceptance abroad to support family. Unlike Ghana, however, there of organizations by community members as well as were many beggars in Bangladesh. Ekmattra’s activist, implementing the programs effectively. Mr. Watanabe, informed us that beggars in Dhaka Community intervention approaches by BRAC and are able to earn same or more than general workers. JICA will be valuable if I am in a position to plan and Moreover, Bangladesh religion, Islam, has a donation implement a community based program in the future. As system called “Jakat”. This system works as social I mentioned earlier, I was interested in the microfinance
56 program. I am hoping to get involved more in this program and to learn more in the future. I also wish to observe microfinance programs in African countries. This field trip gave me a chance to know health programs being implemented in another country. Through this program, I was able to have a concrete image about the field and I learned a lot of new words and phrases used in public health. I am sure that it will help me to understand the classes in the latter term. Lastly, I would like to thank Mr. Rajib and Assistant Prof. Miyachi for marvelous arrangements. In addition to the above coordinators, BRAC University, JICA, UNICEF, ICDDR,B, and Ekmattra made great efforts to support our field trip. I appreciate their kindness.
57 After Field Trip in Bangladesh
Tomoko Masunaga
Through the field trip to Bangladesh, we learned conducted with involvement of the community people. about the health and sanitation system and its situation Let’s look at the case of health problems. Under the in Bangladesh by visiting facilities and program sites of BRAC Health Program (BHP), they place a Shasthya the NGO BRAC and JICA’s projects, as well as activities Shebika (SS) in a community. SS is a female health conducted by UNICEF or the Ministry of Health and volunteer selected from the community. These volunteers Family Welfare of the Bangladesh government. work in the front lines of BHP providing treatment of In addition to health and sanitation problems, we some common diseases, referring severe patients for could understand the situation regarding social problems better services, and identifying TB patients by going there, including poverty and street children, and the from door to door in the community. activities offered for solving them. Additionally, Shasthya Kormi (SK) workers each In this report, I want to describe the activities of support and supervise about 10 SSs. SK is paid work, not BRAC, ICDDR,B, and Ekmattra, which were impressive volunteer. Of course, SKs are also female. for me, and tell my ideas about my observations. In the village we visited, SS and SK called together about 20 women in the area in one house 1. BRAC and held a Health Forum. There, SK gave a lecture to BRAC is the largest NGO not only in Bangladesh, participants directly. The content of the lecture included but in the world. During the field trip, we visited the immunization, sanitation, family planning, hand BRAC center, BRAC University, and some project sites. washing, and other related topics. When an SK asked the In the project sites, we learned about Micro-finance, and participants some questions, they answered actively. This a class for women in the community about human rights shows that the Health Forum has been held repeatedly laws. We also learned about a Mother and Child Health and people have already acquired some knowledge about program and prenatal care at the BRAC Health Center in health. It was just a model case and I cannot adopt the the community, a clinic in an urban slum area, support method in every country just now, but I hope that this for the ultra poor, and a water and hygiene program. We type of education will expand from now on. also visited schools run by BRAC. Giving better service at an upgraded hospital is I was amazed at the wide-ranging activities of another of BRAC’S activities. We visited this upgraded BRAC, one of the NGOs working in Bangladesh. It BRAC Health Center which is specifically concerned launches programs about health and nutrition, family with Mother and Child Health (MCH). planning, hygiene and poverty, and other related things In this BRAC Health Center, there was an everywhere in Bangladesh, and every program is examination room, a delivery room, an operating room
58 used for Caesarean operations, and also 15 beds for to “Aarong”, the department store run by BRAC. The hospitalization. prices are not cheap; however, the quality of products is The center covers an area whose population is 600 good, and we could get a lot of different stuff. In Aarong, thousand people and 100 deliveries are performed every almost all of the customers looked like rich people. month there. For people in the community, the existence I don’t want to accept that there is an apparent gap of the upgraded hospital for MCH is very important between rich and poor, but the structure of the money and useful. As a facility in one of the still developing from rich people flowing to the poor is identical in any countries, the center was well furnished with great society nowadays, I think. equipment. As an aside, I one day visited BRAC’s Limb & Brace On the other hand, I saw absorbent cotton with center, which was not in our schedule. Although the blood on it in a trash box without being separated from center was small, it took on the role of making artificial other wastes, and some used glass vials (a small glass limbs and braces and also of rehabilitation after starting container for medicine) in a refrigerator without being to use the limb. The center offered limbs of good quality covered. I was surprised to see these things because at low cost. In developing countries, the most important in Japanese clinical practice, such things are never health problem is primary health care and Bangladesh is acceptable. I realized the differences between Japanese also trying to attain the MDGs. medical practice and that of developing countries. However there are many handicapped people in I already mentioned that BRAC’s activity is not Bangladesh. It may be difficult for governments of limited to the health sector. Among the many projects, developing countries to deal with rehabilitation at the the attempt for primary education is remarkable. BRAC present moment. Even in such a situation, BRAC has has built about 25,000 pre-primary schools and about taken action in favor of handicapped people, which told 38,000 primary schools all over the country. School fees me that BRAC is an organization with foresight. and other costs are free and the educational level is high. About BRAC, the most amazing thing for me was The environment of BRAC’s school is attractive not its influence. We saw BRAC name plates everywhere only for children from poor families, but also moderate in Bangladesh. The MPH course of BRAC University families. We went to a BRAC pre-primary facility and has many great professors and brilliant students from a BRAC primary school. Though we couldn’t stay there all over the world in spite of the country being one of for a long time and couldn’t observe classes in detail, the developing counties. It shows us that BRAC is an students tried to show us their efforts; moreover, their influential organization and that many people place their cheerful expressions were so impressive. In the primary expectations on it, trusting in the great capabilities of school, some students told us their dreams and many of BRAC. People around the world may pay attention to them want to be doctors or teachers. I fervently hoped Bangladesh through BRAC’s activities. that any social or economic difficulties would never obstruct their way toward their dreams. 2. ICDDR,B BRAC has another face as an enterprise besides that ICDDR,B started in 1960 as a Cholera Research of the NGO. By producing and selling products, it gains Laboratory. It became ICDDR,B in 1978. Now, it is a profits to finance its activities. BRAC’s way of fund non-profit and non-governmental international research management can be useful for other NGOs. organization. Its three activities are research, education During our stay in Bangladesh, I sometimes went and training, and service.
59 At first we visited ICDDR,B in Dhaka. The building The Sub-Center Clinic, an upper-grade hospital was wonderful. In the building, there was a large room takes in-patients from the Fixed Site Clinic in emergency for hospitalization with many cots for cholera (special situations. It has referral service using “rikisha” (tricycle beds for cholera patients, with an opening in the middle for carrying passengers, one of the most popular vehicles so that the feces drops into a pan beneath). There in Bangladesh). In the Sub -center, they treat diarrhea at are many other patients as well. I was very surprised no cost in addition to other MCH services. with the number of patients. The ward was not large A much higher grade facility is Matlab Hospital. enough to accommodate all the patients, so some had to The residents in Matlab can take services of MCH, camp temporarily outside the room. Depending on the perinatal care and diarrhea treatment in Matlab hospital severity of each case, patients were sorted into camp for free. In this hospital there was a room for controlling accommodation, ward room, or place for injection of the information collected by DSS and also a laboratory. intravenous fluids. There was another ward for patients in Regarding the scale of DSS and its well arranged the recovery stage where they could become accustomed facilities, I couldn’t believe it was a rural area in to oral nutrition. Bangladesh. The hospital rooms were more beautiful than I After visiting there, my impression of ICDDR,B imagined. However the distance between the beds was changed from “just a research organization mainly very close, without any partition. The scene of a large targeting diarrhea” to “an excellent organization for room full of beds was the same as the picture we saw in research and medical care”. a class before the field trip. I wondered how hygienic the On the other hand, I felt the limitations caused by room was. People like us can come in and go out easily, difficulty of scaling up the research and health services and with the family caring for the patients, the room to other areas and questioned its sustainability due to the would not be very clean. funds being mainly from donations. If they are faced with Even so, the facility must be very useful for the the limitations of the project, can people in Matlab get patients because they can take treatment intensively at no health services of the same quality? If Bangladesh started cost. I felt that ICDDR,B has contributed to the treatment to give the same level of health services all over the of cholera and reduced the deaths from cholera. country, what would happen to Matlab’s people? These ICDDR,B in Matlab was even more amazing for me. questions may be needless. However, when people think There suddenly emerged a wonderful building in a rural about the necessity of equal and stable health service for area. In Matlab, DSS (Domestic Surveillance System) all people in Bangladesh, the questions could show some is well established. ICDDR,B has a system using barriers. Community Research Health Workers (CRHW), who visit from house to house to collect data in detail. Later, 3. Ekmattra the data will be stored and managed for a long time. Ekmattra is an association whose goal is giving ICDDR,B also takes in Community Health Workers street children the opportunity for rehabilitation into (CHW) who offer health services in their community, society and human development through three steps. In operating from the Fixed Site Clinic. As they don’t the first step, they give street children an opportunity have medical background, they take special training for education in open-air classes, in order to lead to the so that they can give MCH specific services including second step. In the second step, they give the children a immunization and health checks for children. preparation period to get back into society through living
60 together in a facility called a shelter home. The third change can be brought to Bangladesh. step is an ongoing project. In this step, they will give the children who finish the second step an opportunity 4. At the end for acquiring some skills in the training school called an It was a very precious experience for me to see and academy so that the children can live independently. know the various facilities and programs directly. To Ekmattra also aims to make funds by itself, and at involve the community people and to understand their the same time it stimulates people in Bangladesh to solve needs seem to be the important keys for success of one the problems by themselves. project. We visited the shelter home of the second step, In Bangladesh, various organizations are developing where we met children who lived there. They greeted us their own projects on different sites, which made me politely, introduced themselves in excellent English, as somewhat confused. Now every project seems to be well as taking care of our meals. From their politeness going its separate way. From now on, how can various and friendliness, I totally couldn’t believe that the organizations cooperate with each other? And how will children were living in the street until recently. they integrate their projects? I’m very interested in the “For the children living an easy life on the street, way to scale up each project through some kind of over- the shelter home, where they had to go by the rules, is all coordination. not paradise.” said Mr. Watanabe, one of the founder of Finally, another thing that I felt in Bangladesh was Ekmattra. the wide gap between people. The scene of modern and Even if the street children are standing at the tall buildings and zinc-roofed houses mixed together in bottom of the society, they may find fun by themselves. one town seemed symbolic. I could see that there were Nevertheless, I must say it is a hard situation in which the large differences even among the poor people. street children could be targets of exploitation by adults I wonder how much support reaches the poorest or the environment where the children live prevents them people. It may be difficult to involve the people who from having dreams. are at the very bottom of society. However, I felt that I think it is an important first step for both the for reducing the gap, it must be necessary to construct a children and adults in the country to be given the sustainable system which guarantees that the people most opportunity to really understand that the environment in in need can receive the appropriate services. the street is strange, and that it is by their own hands that
61 62 Student Group Presentation
23rd August, 2009 Presentation at BRAC University
65 66 67 68 Organizations Visited
■BRAC http://www.brac.net/ BRAC Centre 75 Mohakhali, Dhaka, Bangladesh Tel: + 880-2-9881265, 8824180-7. Ext: 2155, 2158, 2159, 2161
■ICDDR,B http://www.icddrb.org 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212 (GPO Box 128, Dhaka 1000), Bangladesh [email protected] Tel: +(880-2) 8860523-32 Fax: +(880-2) 882 3116, 882 6050, 881 2530, 881 1568
■James P. Grant School of Public Health, BRAC University http://sph.bracu.ac.bd/ BRAC University 66 Mohakhali, Dhaka 1212, Bangladesh Tel: + 880-2-8824051 Extension - 4164 Fax: + 880-2-8810383
■JICA Bangladesh Office http://www.jica.go.jp/bangladesh/ JICA BANGLADESH OFFICE UDAY TOWER (7th floor), Plot No.57 & 57/A, Gulshan Avenue (south), Circle-1, Dhaka-1212, Bangladesh Tel: + 880-2-9891897
■UNICEF Bangladesh Office http://www.unicef.org/bangladesh/ P.O. Box 58, Dhaka - 1000, Bangladesh UNICEF BSL Office Complex, 3rd Floor (Dhaka Sheraton Hotel Annex,1, Minto Road, Ramna, Dhaka, Bangladesh Tel : + 880-2-933-6701 to 933.6720
■EKMATTRA (Bangladesh NGO for street children) http://www.ekmattra.org/ House-18, Block-F, Eastern Housing, Pollobi, Mirpur-11.1/2, Dhaka-1216
69 70 Afterword
It has been two years since the establishment of the MPH course in Nagasaki University, and this field trip is the second one. There are many unique points about this MPH course, and one of them is the variety of students, such as having overseas experience as NGO workers and with JOCV, as well as working and volunteering in Japan. It was a very fruitful time for me, too, spending three weeks intensively with these students while sharing experiences and developing each one’s skills.
As you have seen from their reports and notes taken during the different sessions, the students all felt that this field trip was successful beyond the diversities of their backgrounds. In these three weeks, we could undergo a number of experiences typical of Bangladesh daily life, like the world famous traffic jam of Dhaka, heavy tropical rains, flat tires, and sweltering heat and humid weather! The environment was harder than we had estimated because it was totally different from the situation in Japan; however, students worked hard to observe as many project sites as possible and to prepare their presentation, sometimes until midnight. Their efforts and energy were very admirable.
This field trip is quite different from other travel or an ordinary study tour, because the mission of our MPH course is “to provide specialized knowledge and skills to future international health professionals in order to work cooperatively with the international community for global health issues”; and then the students had learned about these issues already at school in the first semester before visiting Bangladesh. With this knowledge they viewed many activities carried out by international organizations and NGOs and had direct communication with poor people, mothers and babies, and people who need help. These opportunities have surely provided many insights for students to realize the importance of international health and to consider their future work. Apart from the study at school, we fixed a one-day leader and one class reporter for each day of the trip to improve logistical skills, which are also important for working in international health in the future.
We would like to express our great appreciation to BRAC and BRAC University, especially to the James P. Grant School of Public Health. Without their help, this field trip could not have been successful. Special thanks also to Professor Anwar Islam (Associate Dean and Director of JPGSPH), Dr. Fara Mahjabeen Ahmed, and Mr. Nakib Rajib Ahmed. And many thanks to Dr. Md. Abdus Sabur. (Support office of the Ministry of Health and Family Welfare), Ms. Midori Sato (UNICEF), Mr. Eiichiro Sho (JICA Senior Representative), Ms. Saeda Makimoto (JICA Officer), Mr. Katsumi Ishii (JICA Health Advisor), Ms. Sachie Yoshimura (JICA Project Leader), Ms. Akiko Endo (JICA Expert), Mr. Kenji Yokoi (JICA Coordinator), Mr. Yoshiki Watanabe (Ekmattra) and other staff and volunteers who helped us so much.
In addition, for their support of our field trip to Bangladesh, I would like to thank Professor Aoki and other staff members here in Japan. It has been challenging as a Japanese graduate school to organize this type of field trip abroad in terms of security management, but I hope this report will help in the development of human resources for the field of international health.
Kaori Miyachi Assistant Professor, Graduate School of International Health Development Nagasaki University 71 Field Trip Report 2009 ©
Edited by Kaori Miyachi, Yoshito Kawakatsu & Tomoko Masunaga and students of MPH
Produced by Graduate School of International Health Development, Nagasaki University
1-12-4 Sakamoto, Nagasaki-shi, 852-8523
Tel: 095-819-7008
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Printed 1 February, 2010
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