Role of NGOs in Access to Health Care for the Slum People in Dhaka

Abstract

Health care services under any country's health system are a vital and phenomenal aspect and segment. Health is a basic requirement for human beings, and usually, this requirement must be fulfilled by a large organization like the government of one’s country. So, the government becomes the central, authoritarian, and automatic entity responsible for providing health care services to its people. Apart from the government, other entities like private hospitals, institutions, and NGOs play a vital role in providing health care services to everyone irrespective of race, ethnicity, community, gender/sex, rich, poor, etc. This study primarily focuses on NGOs’ role in describing and exploring access to health care services for the underserved and unprivileged people of urban slums through conducting an integrative mixed methods design. Thus, it meant both quantitative and qualitative methods were applied together to address the research questions of the study, especially taking survey samples, conducting FGDs on the greater Mirpur of three Thanas, like Pallabi, Rupnagar, and Vashantek areas of seven slums. The aforementioned areas for this research were chosen because Greater Mirpur is primarily populated and crowded with many slums. The sampling frame was formed from the target population, where every household was included and given a number. The nature of the initial survey sample or selection of households was a simple random sample, and a simple random sample was conducted through random digit numbers (RDNs). Then, males and females were chosen from every randomly selected household systematically. Data was also collected through in-depth interviews (personal interviews) from the stakeholders, doctors, executives, nurses, paramedics, and concerned people from the responsible and related NGOs working with the people of selected slums or study areas. A total number of respondents for the survey was selected, 764, but 722 were found for interviews, where males were 329 and females were 393 respondents from the slums above. 4 FGDs were carried out on the respondents from the surveyed areas and each FGD was composed of 9, 10, 10, 11 respondents at best and 40 respondents were as participants altogether in the FGD. Twenty in-depth interviews were conducted with doctors, administrators, programme managers, nurses, paramedics, and community service providers working with NGOs for the slum people. ix This research followed some relevant models or theories. The study followed the Health Belief Model, Diffusion of Innovation Theory, Andersen’s Health Services Use/Utilization Model, Parasuraman’s SERVQUAL (Service Quality) Model, and Robert Putnam’s Social Capital Theory. These models and theories helped me understand the central concepts of the research question and elicit answers. Seven hundred twenty-two respondents (95%) were found in the survey out of 764 respondents from the three Thanas of seven slums, where 54.4% of respondents were female and 45.6% of respondents were male. Age ranges (25-44) covered most respondents (57.1%). Most of the participants (92.4%) were married, and the majority (39.1%) of the respondents were part of ‘no education’, which meant illiterate. A more significant portion of the respondents (34.6%) were homemakers involved in household chores, and a vital proportion of participants (39.2%) were dependent on the income of their husbands, sons, and wives of the households. When considering visiting health care centres and using health care services, 31.7% of respondents said they visited NGOs' clinics, 30.9% visited government hospitals, and 29.6% visited nearby pharmacies. The study revealed that slum people mostly visited NGOs’ health services centres for their healthcare services. In considering NGOs’ indoor health care services, both Caesarian and regular delivery care (97.3% and 95.1%) held the first and second positions, respectively. Study revealed that the antenatal or emergency maternity health facilities, with 91.9 % and 91.1% respectively, which were considered the third most health facilities confirmed in the indoor system, and emergency neonatal and child health care, and emergency malnourished child health care facilities had 85.2% and 79.0% respectively. The hygienic programme became the highest choice (98.9%) of outdoor health care services. Health and nutrition (97.0%) ranked second among outdoor services. Both EPI and FP programmes had almost equal and close percentages of outdoor services (92.6% and 92.8%), respectively. Postnatal, adolescent, and Reproductive health had available facilities with (83.7%, 75.5%), child health care (67.8%), Diarrhoea and cholera (65.0%) services were available at outdoor systems, and these services were very common among NGOs. A qualitative study showed similar findings with more x detailed information regarding the NGOs’ health care services provided in indoor and outdoor health systems for the slum people. The study displayed that NGOs provided health care services through different systems, and 93.1% of participants received indoor and outdoor services through static clinics. Surprisingly, 92.3% of health beneficiaries acknowledged that CHWs/CSPs provided their health services from NGOs. 92% of respondents found their outdoor and doorstep health services through satellite clinics. Meanwhile, 85.2% of respondents received health care services through telehealth and telemedicine. Telehealth and telemedicine systems are rising through M-technology systems during the COVID-19 pandemic. This research denoted that NGOs provided health care services for the slum people through availability and affordability. EPI, maternal care (antenatal care, delivery care, and postnatal care services), FP programme, child health care, and health and nutrition programme. About 100% of respondents mentioned that EPI and ANC services were available, and 99% confessed that delivery care services, newborn/postnatal care, family planning, child health care, and health and nutrition care services were available and provided by NGOS. Other available health care services provided by NGOs were sanitation and hygiene services, adolescent and reproductive health services, diarrhoea and TB services. Study further observed that the community service provider (40.5%) and nearby static clinic (38.3%) were the primary regular sources of availability of health care services. For the affordability of health care services, 94.7% of respondents said that the most affordable service of the NGO was EPI immunization services. 93.0% of participants considered essential medicines the most inexpensive health items. Blood test services (89.4%), FP services (76.0%), and pregnancy strips (69.9%) were the affordable and reasonably priced services for the underserved slum people. The study disclosed that NGOs’ initiatives and grassroots approach impacted the use and access to their health care services. Such impact showed through the 11 sub variables of initiatives and the grassroots approach. The study showed that the NGOs’ initiatives (seven initiatives) and grassroots approach (doorstep services) were significantly associated with access to health care services. The study found NGOs’ initiatives and grassroots approach’s strong and significant association with affordable services (P<0.01), special health services (P< 0.000), doorstep services (P<0.05), xi engage responsible community leaders ( P<0.01), distribution of medical and medicine items (P< 0.01), Update slum dwellers with updated information ( P< 0.05), e-health technology (P< 0.00), BCC strategy (P< 0.05) were significantly associated with dependent variable access to health care services. These relations indicated that NGOs’ initiatives and grassroots approach ensured better use and access to health care services for the slum people. Qualitative findings are integrated with quantitative results, providing more comprehensive information. Based on mixed methods integrative findings, the study suggests that the government, donors, and policymakers synchronize their initiatives and grassroots-level services with the NGOs so that such initiatives and approaches, along with their services, may easily trace, reach slum people, and help them use and access health services. Quantitative findings were further examined by examining the associations and differences between the health care services of the Government and NGOs through the chi-square test of independence. These associations or differences were attempted to be shown by socio-demographic variables when receiving health services from the government and NGOs. The test indicated a significant association between the socio demographic variables and visiting or receiving the Government and NGOs' health services facilities. Especially, socio-demographic variables, sex, age, employment status, and income, had a significant association with visiting and receiving Government and NGOs health services facilities at the α=.01 level. The study displayed some vital findings based on two latent concepts, ‘BCC strategies of NGOs’ and ‘community supportive services’, by respective slum leaders. These two concepts were not included in the main study but played vital roles in using and accessing NGOs’ health care services. NGOs introduce and launch BCC strategies to carry out and implement health services in rural and urban slum areas. BCC strategies are used to curb fertility rate to prevent unwanted pregnancy, to reduce maternal and child morbidity and mortality rates, and to utilize the EPI and FP programmes with utmost effort. NGOs conducted BCC strategies in rural and urban slums through BCC materials, traditional media, and social media like Facebook, WhatsApp, interpersonal channels, communication, and community mobilization. A study conducted a multiple logistic regression model to see the association and impact of predictors (BCC strategies) on outcome (seeking health care behaviour/services). The study presented xii some BCC strategies or approaches significantly associated with the outcome variable (visiting or seeking health behaviour or services). Out of six BCC strategies or techniques, the study finds that predictors BCC materials (leaflet, sticker, and poster (P<0.00), traditional media (P< 0.05), and impersonal communications (P<0.033) were significantly associated with the dependent variable seeking health care services. However, qualitative findings disclosed more detailed information and insights on the prevalence and influence of social media on the attitude and practice of slum people regarding the use and access of NGOs’ health care services. Using Facebook, WhatsApp, and Messenger, as well as forming different groups, helped slum people interact with one another and become aware of the NGOs’ various health care facilities. The NGOs engage community supportive services ensured by the slum leaders who were to provide early information relating to health care services and create a network among the community people to share messages and information on the pandemic, viral, and seasonal health care services. Here, the study launched a logistic regression to demonstrate the relationships of predictors (community supportive services) with outcomes (use, access, and seeking NGOs’ health care services). The study endeavored to show an association of some community supportive services with using, accessing, and seeking NGOs’ health care services. Out of four community supportive services like access to early information on health services (P<0.012), community network to get access to health services (P< .000) alert pandemic and other diseases (P< .020), and convey messages to slum people for health, nutrition and hygiene awareness (P< .381) three supportive services were significantly associated with outcome using, accessing and seeking NGOs’ health care services. So, the study attempted to reveal that NGOs incessantly inspired slum leaders to persuade their slum communities to seek NGOs’ health care services. Qualitative results on community supportive services lifted quantitative findings. The survey study uncovered findings on the respondents’ perception of the health care services of NGOs. Respondents’ perception was considered and judged through the rating scale/Likert scale technique. This perception was measured based on the Quality Service Model. Respondents perception regarding the health services delivery of NGOs was measured with some quality of services like services with promptness and less waiting (Strongly agree 31.6%), services with affordability (20.2%), services with xiii strong and constant intercommunication (31.4%), listening to the health problems (25.6%), organized and clean infrastructure (30.7%), experienced and cooperative medical personnel (18.1%) and, promised and committed services (Agree 24.9%), Services provided with Reliability and Responsibility (30.2%), services with available facilities and personnel (25.8%), services with integrity and fairness (29.8%), insisting on the care of patients (29.2%), satisfactory diagnostic and logistic supports (27.1%). Respondents of slums believed, perceived, and confirmed that NGOs ensured the above-mentioned quality of services while delivering health care services to the slums. Slum people’s perception of NGOs’ health care services escalated the use and access to health care services. Most of the slum people who received NGOs’ health services were perceived and cajoled with NGOs' above-mentioned manners and attitude. The percentage believed and practiced that NGOs’ employees are different from other service providers, which propelled them to use and access NGOs’ health care services. Qualitative findings exclusively showed from the research question “what are the new areas of health care services or facilities undertaken by the NGOs for the slum people of this study. Findings revealed that the different NGOs have taken different initiatives to improve their health services and facilities. A study found that a few NGOs will partner with the government in preventive, promotional, and surveillance steps for COVID-19 vaccination. Others have already taken and will continue to take ‘Telehealth and telemedicine initiatives’ conducted for the maternal services (Antenatal, delivery, and postnatal services) during the COVID-19 and post-COVID-19. Few NGOs, especially BRAC, are intending to launch the “Vision Bangladesh Project” for the eye defective people at the district level with the government. The rest of the responsible NGOs will employ and engage CHWs/CSPs with special maternal health services training in rural and urban slums. The study demonstrated that the NGOs will provide the CHWs or CSPs with mobile phones and install various apps to form groups to update slum dwellers with health care messages and information. Some NGOs pledged to provide maternity health services with ultramodern technology and introduce multiple new diagnostic systems. This research demonstrated NGOs’ diverse roles and functions, by which they provided health care services to the underserved and unprivileged urban slum people. NGOs performed their health care services through these various roles and initiatives, and xiv healthcare services were provided to the slum people through multiple systems. The findings of this study revealed that NGOs carried out their services based on either partnership services with the government or project-based services through donors or stakeholders, and services provided to poor people through the collaboration of domestic or local stakeholders or sponsors. The study suggested and recommended more diverse and innovative roles and functions launched by the NGOs, the government, and donors to ensure more updated and modern health care service facilities for the slum people. The government should also increase and arrange more public and private partnership (PPP) projects with NGOs, or the government should engage NGOs with more projects like the UHCSDP to provide health care services to the urban slum poor.