ICDDRB – Essential healthcare services for urban street dwellers
Recent ICDDR,B research revealed the extreme vulnerability of street dwellers in terms of their health needs and health-care seeking behaviours. Street dwellers are people who sleep on streets, railway terminals and platforms, bus stations, parks and open spaces, religious centres, construction sites around graveyards, and other public places. They are malnourished, routinely use illicit drugs and experience violence. There is no health service-delivery mechanism specifically tailored towards this marginalized group of people, as there is for other groups like slum dwellers, non-slum dwellers, and people living in hard-to-reach areas, and street dwellers are rarely accessing general essential healthcare services.
To begin addressing these health needs, ICDDR,B in collaboration with the Ministry of Health and Family Welfare (MOHFW), Dhaka City Corporation (DCC), 2nd Urban Primary Health Care Project (UPHCP), Bangladesh Railway, National Sports Council and non-government organizations launched a project funded by the German Technical Cooperation (GTZ), with the specific aim of developing a mechanism to provide essential healthcare services to urban street dwellers in Bangladesh.
The activities of the project included providing essential healthcare services to urban street dwellers through static and satellite clinics from 6:00 pm to 9:30 pm in three central locations of Dhaka city, with two paramedics (one female and male) providing the service. The locations are Karwan Bazar (static clinic), Kamlapur Railway Station and Mogdha Stadium (satellite clinics). Dhaka City Corporation provided a room at their Karwan Bazaar zone office for organizing the static clinic while Bangladesh Railway and National Sports Council provided suitable space at their premises for organizing satellite clinics.
A package of essential services (same package of HNPSP) is being provided to the street dwellers from the clinics at the evening time when the street dwellers are returning from work. All the components of primary health care are included as the components of essential services, with special focus on general health, reproductive and maternal health, child health, environmental issues, and health education and the service provision are free of cost. Services are being provided to the street dwellers who slept for last one week in the study areas. Patient cards are provided to all the clients so that it becomes easy to keep track in the subsequent visits.
For ensuring quality of services the paramedics were trained by the experts from the primary healthcare programme of MOHFW, Marie Stopes Clinic Society (MSCS) and ICDDR,B following the essential services delivery (ESD) protocol. As the street dwellers are extremely vulnerable groups, special focus were given during training of the paramedics so that they become non-judgmental in providing services to the street dwellers. The paramedics were also oriented on their attitude and motivational aspects for dealing with street dwellers. The activities of the clinics and service providers are being monitored and supervised by study investigators using standard checklist.
The drug sellers of local pharmacies are being utilized to inform street dwellers about availability of services for them through the clinics. Name and addresses of the clinics and type of services available in the two types of clinics have been provided to the drug sellers of the local pharmacies. They are being motivated to inform the street dwellers about availability of services in the clinics and also to motivate the street dwellers to go to the clinics for services. A well decorated rickshaw van is being used for carrying clinic staff and materials and for publicity purposes.
A system of referral linkage has been established from these clinics to nearer health facilities of MSCS, UPHCP and MOHFW. The paramedics refer the cases to these referral points and follow up is being done by a project staff on the cases to know what happened after referral.
Since the beginning of the project, there has been surprisingly a strong demand for services: 45 to 50 patients use the services each day, somehow more than half of the patients are women. The main complains of the patients visiting the clinics included: general health, STI/RTI, ANC, PNC, family planning methods, ARI, diarrhoea, dysentery and immunization.
In order to review and monitor the project activities and to start process about its sustainability a Project Management Committee (PMC) has been formed. The committee consists of the members from Directorate General of Health Services, Dhaka City Corporation, UPHCP, GTZ, Plan International, MSCS, Sajeda Foundation and ICDDR,B. The committee met twice and reviewed the performance of the project activities. Last PMC meeting decided that the committee will meet quarterly to review performance of the project and to guide the project implementation team.
The static and satellite clinics will be compared to each other in terms of their cost and effectiveness. This comparison will enable us to identify the model of choice-which is financially most affordable and programmatically most effective.
It is expected that after implementation of this 18 months project will develop a mechanism to provide essential healthcare services to urban street dwellers in Bangladesh.