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From households to hospital

a model for community-based primary health care
in response to arsenic poisoning in Bangladesh
Section I. What is your idea?
Through participatory learning and action, we will
develop strategies for primary health services
delivery and health seeking behaviors in response
to arsenic contamination of drinking water in rural
Bangladesh. This health care model will incorporate
nutrition, hygiene and reproductive health services
and facilities at different levels (from households to
hospital) that will be adapted to the socioeconomic
realities of marginalized communities.
Contamination of groundwater with arsenic, fluoride and
other elements poses major health risks in many parts
of the world, but it is in Bangladesh that the worst mass
poisoning in history is taking place. Geogenic arsenic, present in large parts of the
delta’s groundwater aquifers, is pumped up by two-thirds of all the tube-wells. Studies
have asserted that up to 77 million people have been drinking this 'slow poison' for many
years. Arsenic is chronically toxic and can lead to cancers and neurological disorders.
Since 2006, a collaboration between academic researchers, medical doctors,
development practitioners and communities has led to the implementation of safe
drinking water supplies and the provision of medical care for arsenicosis patients in the
Munshiganj district. Shifting to safe water is often insufficient to detoxify the body while
treatment is of no use unless people also have access to safe water. In 2013, we were
granted 4-year support from WaterAid to expand drinking water and sanitation projects
in the district. The establishment of Community Based Organizations (CBOs) forms the
basis of our approach. These maintain the infrastructures, but they are also encouraged
to engage in other primary health care activities, which is the focus of this proposal.
Since 2006, we have also developed protocols for the identification, diagnosis and
treatment of arsenicosis. A variety of treatments may help reverse arsenic poisoning in
early stages or relieve its symptoms. Poor and rural population sections are most
vulnerable. They cannot bear the costs private medical practitioners. Public hospitals are
often under-resourced and village practitioners are generally unaware of arsenicosis.
Furthermore, arsenicosis often worsens other diseases and vice versa. Mother and child
morbidity and mortality rates are high in these marginalized communities due to a lack of
access to guidance and support for improvements in nutrition, hygiene, family planning
and reproductive health. For them, access to safe water and to symptomatic treatment of
arsenicosis will not be effective without broader health improvements.
In 2013, we completed the construction of a clinic (at the sub-district level) with support
from the Japan Government. Its purpose is to help address existing inequities in the
above-mentioned primary health care services. We are currently looking for further
support towards:
1. understanding the current obstacles in health services delivery and health seeking
behaviors, and
2. designing a system of health care services and facilities adapted to the needs and
socioeconomic realities of marginalized communities.
Satellite clinic
Union level
Static clinic
Sub-district level
Health camp
Ward level
Paramedic care
Community level

We propose to implement the following activities in one union (currently the smallest
administrative area). A union is divided in 9 wards (each generally covering one village):
• Extend the reach of our clinic (static clinic at the sub-district level) by establishing a
satellite clinic at union-level, 9 ward-level health camps and a paramedic program at
the community level (see Figure above).
• Provide affordable and accessible primary health care services through the
development of a referral system that links local paramedic care, health camps,
physician care at satellite clinic, static clinic and tertiary partner hospital in Dhaka.
• Raise community awareness regarding nutrition, hygiene and reproductive health in
collaboration with CBOs (particularly for women as domestic care-givers) by
organizing training sessions (e.g. food gardens, first aid, hygiene and child feeding)
and by establishing a resource center at the satellite center.
• Improve local management of the health care system by engaging CBO members in
a trial to establish a non-profit, mutual, community-based health insurance scheme.
We will develop a model for replication elsewhere in Bangladesh and in other countries
facing similar challenges. We will share these experiences with other agencies working
on health, water and nutrition through (research) publications and workshops.
Section II. How will you test it?
Over the years, we have applied a range of Participatory Learning and Action tools to
assess water and health inequities and improvements. We will test our idea by:
• Monitoring health and nutritional changes and recording people’s subjective sense of
improvements. We will keep and analyze detailed patient profiles.
• Surveying changes in access to services, collecting qualitative data on health
seeking behavior, obstacles and benefits.
• Interviewing community members and CBOs about the uptake of promoted activities,
such as food gardens, first aid and insurance schemes.
If Phase 1 is successful, we will expand into the remaining unions in the sub-district. We
will select areas with different socioeconomic and health characteristics in order to refine
our implementation model and undertake follow-up studies on the relationships between
arsenicosis, nutrition, hygiene and health.
Budget Phase 1
Personnel (physicians, paramedics and various officers) 49,000
Travel (local transport, per diem and international travel) 4,700
Participatory learning and action (surveys, analysis and scientific reporting) 4,800
Workshops and meetings (planning, campaigning, advocacy, training, etc.) 4,900
Equipment 4,700
Supplies 2,900
TOTAL (EUR)) 71,000
Plan Phase 1 (18 months)
Recruitment, equipment, planning, staff training
Initial surveys (PLA) and CBO training
Establishing satellite clinic and resource center
Community training and awareness program
Operating health camps and satellite clinic
Progress reviews and meetings with other agencies
Final surveys (PLA), financial and scientific reporting