Subarna Akter lost her first baby while giving birth at home about three years ago when she was 19.
The moment she went into labour in the middle of a September night, the local midwife found the parturition to be complex, so she advised Subarna's family to shift her to a health facility for safe delivery.
Subarna had to stay the night at home and see her child could not be saved.
No healthcare centre for child delivery was there at Chhatir Char Union, an area under Nikli Upazila in Kishoreganj, which becomes a detached island surrounded by vast haor (marshland) water during the monsoon.
The closest healthcare facility providing maternity services is 20 kilometres away from Chhatir Char and there are no other means of transportsother than boats to cross the haor called JansairHaor.
"I lost my first baby at birth as I couldn't take my wife to a doctor or trained maternity health service provider. There was no transport available at dead of night,"Toriqul Islam, 28, an office assistant at a local Madrashah and husband of Subarna, told The Financial Express.
He recalled that the weather was stormy and no boatman wanted to cross the raging haor. "My wife went into shock after giving birth to the child who eventually died," he said. "I was also in fear of losing my wife but luckily in the early morning we managed to take her to a hospital in Kishoreganj town."
The couple did not take any risk during the second time of pregnancy. The mother gave birth to a boy through C-section at a private maternity clinic in Kishoreganj last year.
The only health facility at the hard-to-reach Chhatir Char is a state-run Community Clinic (CC), set up in 2014, which can only provide basic health consultation and few free medicines for common diseases.
Such centres are primary healthcare facilities at the grassroots level that carry out the government's mass vaccination programmes, provide basic maternal and neonatal healthcare, family planning activities, food and nutrition awareness.
This correspondent found no 'Community Health Care Provider' (CHCP) at Chhatir Char during a recent visit. Local people said the designated healthcare provider had been absent for more than one and a half years.
The centre has shortage of health workers, necessary medical equipment, medicines and proper infrastructure. A health assistant there, Md Omar Faruk said due to poor condition of the building, distance from the town, and lack of proper connectivity, the CHCPs do not want to stay in places like Chhatir Char.
Three health centres are expected to be set up in each union or for every 6,000 population, local Union Parishad (UP) Member Md Shafikul Islam said as he complained that Chhatir Char has only one Community Clinic although it has around 15,000 inhabitants. There is no Union Health and Family Welfare Centre in Chhatir Char which, the public representative argued, is a much needed infrastructure for better functioning of the centre and improving health of the locals.
The people manage to go to Nikli by road during the dry season, he said, but "the rainy season comes as a death trap for critical patients."
If the government provides a water ambulance for the union, lives of critical patients, especially pregnant women and elderly people, can be saved, Saddam Hossain, a local Community Volunteer of EUCSO project, told the FE.
A vast haor region spreads over the country's north-eastern part, covering administrative districts of Kishoreganj, Netrokona, Sunamganj, Habiganj, and some parts of Moulvibazar and Sylhet.
People still struggle due to deficiency in basic healthcare services remote villages, char (river island) areas, coastal belt, and hilly areas, say public healthcare advocates.
Ensuring quality health service delivery at grassroots level is considered critical for attaining health-related targets of Sustainable Development Goals (SDGs) by 2030.
The SDGs' Goal-3 has set targets to 'ensure healthy lives and promote well-being for all at all ages' by reducing maternal and child mortality, ensuring skilled birth attendance, ending all preventable deaths under five years of age, fighting communicable diseases like AIDS, tuberculosis, malaria, hepatitis, ensuring universal access to sexual and reproductive care, family planning and education.
To achieve these targets, development activists suggest,
Bangladesh needs to establish an ecosystem in government service delivery in rural areas through close cooperation among local government institutions, NGOs and local communities.
Community clinics are one of the key factors that contributed to Bangladesh's health sector success in meeting the UN Millennium Development Goals (MDGs).
There are a total of 13,907 such clinics operational in the country and the government has taken a project to build 4,500 more clinics in the next couple of years, according to the Health Bulletin-2019 published by Directorate General of Health Services (DGHS) in June, 2020.
The World Health Organisation (WHO) has placed Bangladesh at the second from the bottom in South Asia, in terms of doctor-patient ratio - at about 5.26:10,000.
And the concentration of doctors is urban centres, leaving rural areas out of essential health service coverage.The doctor-patient ratio is 7:77 in India and 9:75 in Pakistan.
Bangladesh also falls behind all South Asian neighbours in nurses-patient ratio - the country has only 3.06 nurses to serve every 10,000 people.
However, Bangladesh is improving, and currently ahead of India, Pakistan, Nepal, and Afghanistan in providing access to quality healthcare to citizens, revealed a study by British medical journal The Lancet in 2018. Bangladesh was ranked 133rd among 195 countries in providing access to quality healthcare.
Despite progress in primary healthcare, only 21 per cent of Bangladeshi pregnant women receive at least four antenatal care (ANC) visits, 31 per cent of births are delivered at health facilities, and skilled birth attendants assist 41 per cent of women during childbirth.
Currently, maternal mortality ratio in the country is 173 deaths per 100,000 live births, according to UN Maternal Mortality Estimation Inter-agency Group (MMEIG). The rate was 434 in 2000.
The target set in the SDGs is to bring it down to 70 by 2030.
Neonatal mortality rate in the country is 17.1 deaths per 1,000 live births while under-five mortality rate is 30.2 deaths per 1,000 live births, according to 2018 UN Interagency Group on Mortality Estimates. Under the SDGs, all countries are aiming to reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births and under-5 mortality to at least as low as 25 deaths per 1,000 live births.
Alarmingly, maternal death rate has increased by 9.4 per cent, neonatal (0-28 days old) death by 9.9 per cent and child mortality by 13 per cent in the pandemic-hit year of 2020, However, according to a United Nations Children's Fund (Unicef) report published in collaboration with WHO and United Nations Population Fund (UNFPA) in March, 2021.
A social audit report published by the OXFAM in Bangladesh and Centre for Policy Dialogue (CPD) in December, 2019, under a project titled 'Enhancing the participation of community based organisations(CBOs) and CSOs in democratic governance in Bangladesh', focussed some hurdles towards providing health services at underprivileged areas.
Absence of local beneficiaries in policy-making process, lack of accountability and transparency in government services, improper infrastructure, shortage of trained human resources, scarcity of medical equipment and shortage of medicines are among the setbacks in ensuring healthcare in rural Bangladesh, said the report.
Carried out in Sandwip Upazila of Chattogram and some parts of Barguna, the social audit found that about half of the service recipients did not get necessary free medicines allocated for them while there were also allegations of realising money from beneficiaries for the services meant to be free of cost.
Most of the community clinics carryout family planning programmes with half of the required health workers, who, do not visit households very often in the plea of shortage of workforce, according to field-level experience.
Lack of awareness on the part of service recipients was also observed. The social audit made some recommendations to improve overall service quality of the community clinics that include ensuring appointment of quality, skilled and sufficient number of caregivers in vacant posts, maintaining regular supply of life-saving medicines, monitoring and evaluating them at Upazila and Union level, and raising public awareness.
The report also suggested that introduction of i emergency maternity services at all community clinics could reduce maternal and neonatal death, easing birth complexity, and disseminating proper food and nutrition related information to mothers.
The NGOs and local community-based organisations can also play a significant role in this regard, the report added.
Development advocates also suggest, the local health service providers can help institutionalise the 'Citizen-led Social Audit'to improve the quality of the services and hold the service providers accountableto the community people.
