SO< .%I err/ Vol 29 buo 12 pp 134J-1349 1989 0277-9536 89 SJOO+ 000 PrInted I" Gredt Bnkln All nghts reserved Copvrqht , 1989 Pergdmon Press plc

COMMUNITY HEALTH SERVICES AND HEALTH CARE UTILIZATION IN RURAL BANGLADESH

RUHUL AMIN.‘* SHIFIQA CHOWDHURY.?G M KAMAL' and J CHOWDHURY'

‘Institute for Urban Research. Morgan State Umverslty, Baltimore MD 21239, US A ‘King Saud University. Rlyadh, Saud) Arabia and ‘Associates for Commumty and Population Research, Dhaka.

Bangladesh

Abstract-The study. which IS based on datd from two household level health surveys conducted m 1976 and 1987 m the CompamganJ area of rural Bangladesh, examines the premise that the utlhzation of public hedlth care services can be Increased by mcreasmg the avallablhty and accessablhty of effective medlcmes to the public and by lmprovmg the dlsedse recognition and management by the health practmoners The results of the study suggest that the dvalldblhty and accessablhty of modern effective medlcmes through the provlslon of decentrahzed commumty-based rural health services by a well-tramed and well-managed field personnel structure. had an incremental Impact on the utlhzatlon of modern health care from a rural health center and Its subcenters The study further reveals that. m 1976 as well as in 1987. the overwhelmmg malorlty of the rural Banglddesh population were using modern Western medrcal practmoners, although most of these practltloners were mformally tramed or self-trained wlthout any formal medical degrees or trammg It IS concluded that the persons responsible for health program plannmg and health program lmplementatlon need to ensure that the access to basic pubhc health care services be mdde broad enough to cover the ma)orlty of the rural population through a system of decentrahzed curative and preventive services as well as through a system of adequate trammg and deployment of health professionals mcludlng trammg programs to Improve the quahty of medlcal services offered by the informal and self-tramed practltloners of modern medlcmes

kk \c~ords~ommumty-based health services, utlhzatron Bangladesh

INTRODb(YION

Inadequate access to modern health servtces and thetr

underutthzatlon have been the myor reasons for poor health condltlons m the developmg countries [I] Several layers of hlerarchlcally orgamzed Inefficient ‘top-down’ bureaucratic umts, shortage of trained health personnel, and absence of locality-based ade- quate pubhc health services have been perennial obstacles to the improvement of health condltlons m the developing countries However, m recent years, community-based programs have been adopted as the key strategy to make health services dccesslbie. affordable, and socially acceptable [2] Commumty- level health mltlatlves through the expansion of cura- tlve and preventative services to commumtles are mcreasmgly used to achieve universal access to health care [3] The present study seeks to assess the lmpdct of d commumty-based pilot health mterventlon pro- gram m rural Bangladesh, the CompamganJ Pllot Health ProJect (CPHP)

The CPHP was an autonomous demonstration program, Integrated with an existing governmental rural health center Jointly sponsored by the ChrIstIan Commlsslon for the Development of Bangladesh. a voluntary agency, and the government of Bangladesh, the CPHP made a maJor effort to integrate. expand, and decentrahze exlstmg govern- mental curative and preventive health services by operatmg and mvlgoratmg several geographically

*Address correspondence to Professor Ruhul Amm Instl- tute for Urban Research, Morgan State Umverslty, Armory Room 204. Baltimore. MD 21239. U S A

dispersed health subcenters with lmkages with a small hospital-based rural health center The subcenters worked as the outreach arms of the proJect from where curative and preventive services were strength- ened by a once-a-week vlslt by a qualified physlclan from the mam health center [4] The services at the subcenters included provlslon of basic medical health care, maternal and child health care. child Immumza- tlon and promotion of child nutrltlon and family plannmg The proJect developed a well-managed referral system m which field workers, who were regularly given supportive supervlslon and refreshers’ trammg by their supervisors, routmely recruited and referred clients at the heath centers for preventive and curative measures The CPHP continued until late 1980 and thereafter was taken over by the exlstmg government rural health system

HEALTH PROBLEMS AND HEALTH SERVICES IN BANGLADESH

Bangladesh. the eighth most populous country m the world, IS well-known for Its poverty and rapid populatron growth [5] With 84% of Its 109 5 mllhon people (estimated mid-1988) hvmg m villages and less than 0 IO ha of arable land per head, it 1s the most densely populated rural country m the world and its per capita income IS among the lowest m the world

The overall low level of development, the poor envlronmental condltlons, and Inadequate health faclhtles have all contributed to the persistence of poor health condltlons m rural Bangladesh Although the government of Bangladesh has declared a pohcy and taken the responslblhty of provldmg basic health

SW 29 12-c 1343

1344 RUHLL AMI\ et al

fdclhtles dt the doorsteps of the rural people [6], Lanous diseases such as diarrhea or tetanus. con- tlnue to be widely prevalent [7] Many of the SOCIO- economic and envu-onmental condltlons that give rise to poor health conditions are interdependent and mutually reinforcing, resultmg m a cumulative dlsad- cdntage for all famlhes Thrs 1s reflected m the continued high mortality levels across SOCIO- economic groups [8]

Recent attempts to expand lmmumzatlon to reduce morbidity. mortality dnd dlsablhty from various chlldhood diseases also did not produce any sigmfi- cant change m the existing condltlons because the overdll coverage of immunization still remains very IOU [6] Slmllarly. the inadequate services offered by the governmental health faclhtles as well ds the chronic shortage of drugs, medical supplies. equlp- ment. and tramed paramedical personnel contmue to be serious obstacles to the goal of provtdmg ‘health for all by the year 2000’ [4,9] Aggravatmg the situation IS the lack of relevant data on the prevalhng patterns of diseases and the effects of these diseases on mortdhty pattern The few studies that have been undertaken to-date reveal that existing modern medical facthtles are vastly underutilized m rural Bangladesh Thus, a WHO/UNICEF survey done m 1977 regarding diarrhea1 diseases shows that onI> 10% of Il.500 respondents consulted a government fdclhty at the time of serious Illness (IO] Slmllarly, Mosley [2] reported that two-thirds of pregnant women refused to accept tetanus toxoid even under home delivery and BhardwaJ and Paul [I I] found thdt hedlth subcenters were rarely used by the parents of deceased infants Given such low utlhzatlon of rural health services. what had been the lmpdct of a decentralized community-based health mterventlon program mitlated by the CPHP” Have there been any change m the health care utlhzatlon pattern during the operation of the CPHP and after Its mcorporatlon mto the existing governmental rural health system” What have been the trends and dlfferentlals m the utlhzdtlon of modern and traditional health practl- tloners? These are the questions that the present research sought to answer

DATA AND METHOD OF AN4LkSIS

The present study uses data from two surveys conducted m the CompamganJ area of rural Bangladesh While the first survey wds conducted m 1976 during the operation of a pilot comprehensive hedlth proJect. the CPHP the second survey NdS cdrrled out m 1%7--6yr after the pilot project wds incorporated mto the normal health cdre program of the government These two sets of ddtd-One during the operation of pilot project and another after Its mcorporatlon mto the government program-pro- vided an opportunity to see what happens after the pilot project IS incorporated mto the regular health program Random samples of 998 and 2020 house- holds from the entlre geographical area of Com- pamganj were selected m 1976 survey and m 1987 surveys, respectively More detailed descriptions of the surveys may be found elsewhere [I21

Since both the surveys were based on verbal report- mg and retrospective data. some cautions may be

I

Health care III rural Bdngladesh 1345

exercised m lnterpretlng the results of the data analy- SIS This IS becduse retrospective survey and verbal reporting from developmg countries are often sub- Jetted to age misreporting. InaCCUrate ClaSSlfiCatlOn of morbldltl cultural biases and so on

PREFERENCE AND LTILIZATION OF DIFFERENT TYPES OF HEALTH CARE SERVICES.

1976 AND 1987

Table 1 shows the overall soc1o-economic, demo- graphic and other differences m preference of differ- ent parallel medical practmoners for the years 1976 dnd 1987 Four types of providers of medlcmes are hsted m the table These are (1) formally tramed providers of modern medlcmes. who are either hold- ers of formal modern medical degrees from medical college< or paramedics who are formally tramed and employed by the government, (2) mformally tramed or self-trained providers of modern medlcmes with- out any formal medical degree or trammg. (3) homeo- pdthic providers who are outside the realm of modern medlcmes dnd (4) trdditional providers, such as herbal medicine providers or faith-healers

Both m 1976 and 1987, a large majority of the respondents preferred providers of modern medlcme, as evident m their choices of formally tramed as well ds mformdlly trdmed providers of modern medlcmes However. preference for formally tramed providers of modern medicine was much higher m 1976 than m 1987 In 1976. It was about four times as much ds in 1987 Only d small percentage of respondents ranging betueen 0 4 and 2 7X, expressed a prefer- ence for homeopathlc or tradItIonal mdlgenous medicme

Table I further shows that the preference for formally tramed modern practltloners was posltlvely. dnd the preference for mformally tramed modern practitioners &as negatively, associdted with SOCIO- cconomlc status as reflected m household’s education or occupatlonal status Slmlldrly, preference for both the formal dnd informal practitioners of modern medicine was posltlvely associated with those wlthm one mile of the mam government health center, with the exception of 1976 when the preference for formal modern practltloners was negatively associated ulth ulthm one mile of the mam government health center

On the other hand. although contact by health workers uds positively associated with the preference for formal practltloners of modern medicine. no such relauonshlp was found between mformal modern practitioners and contact by health workers Overall. soclo-economic status and proxlmlty to health center seemed to have promoted preference for formal modern practltloners. formal and informal modern prdctltloners were much more widely preferred than were homeopathlc and other tradltlonal prac- tltioners

The pattern of actual utlhzatlon of different paral- lel medlcal practltloners are shown m Table 2 The data m the table shows that the overall rate of utlhzdtlon of modern providers hardly changed be-

tween 1976 and 1987 However among the modern providers. utlhzatlon of formal modern pro\ lders were higher m 1976 than m 1987 Thus, m 1976, the utlhzatlon of formally tramed modern providers WdS

almost twice as much as m 1987 On the other hdnd. while no maJor socIo-economic difference. as mea- sured by household head’s education and occupation. was observed m the utlhzatlon of formall! tramed modern providers m 1976. the relatlonshlp between the soclo-economic status and the utlhzatlon of for- mally tramed modern providers became somewhdt posltlve m 1987

The 1976 soclo-economic difference m the utlhzd- tlon of formally tramed modern providers as well as their increased utlhzatlon. could be attributed to the increased geographical accesslblhty of governmental rural health services mltlated under the decentralized auxllhary subcenters of CPHP The dlscontmuatlon of the same decentralized subcenters dnd then services under 1987 government set-up might have reduced the service coverage. reversing the soclo- economic convergence and the increased coverage of service utlhzatlon achieved under CPHP

No maJor soclo-economic difference m the UtlhZd-

tlon of informally trdmed modern providers UdS

observed either m 1976 or 1987 Slm~larly. no major soclo-economic difference m the utlhzatlon of trade- tlonal health care providers. such ds herbal medicine practltloners or faith-healers, was observed. dlthough the relatIonshIp between the utlllzdtlon of homeo- pathlc practmoners dnd socio-economic Status tended to be posltlve

Table 2 further shows that the sick persons whose houses were wlthm one mile of the mam government health center. male sick persons, or persons dbove age 5 were more hkely to be taken to the formal modern health services for medlcal treatment This seems to be true both m 1976 and 1987 It IS to be noted that a slgmficant proportion of children were tdken to homeopathlc providers, reflecting the latter’s easy accessibility. low cost. and simpleness of the small doses of medlcmes Overall, proxlmlty to modern health faclhtles promoted both preference and actual use of formally tramed modern medlcdl providers because of difficulty of commumcatlons and hmlted geographicdl moblhty of the rural residents

Polvtomous 1og11 regressron results on health care

preference and urrkarron. 1976 and 1987

Smce net effect of an independent varidble on preference and utlhzatlon of health care services cannot be gauged from Tables I and 2 because of other confoundmg variables, we have further ana- lyzed the datd within a multlvarlate framework The statIstIcal technique adopted for this IS a polytomous logit regression because of categorlcal nature of our dependent variables Furthermore. these estimates of the effects of independent variables by using poly- tomous loglt regression have enabled us to dvold problems of heteroscedastlclty and to calculate Joint outcomes of separate events [I31 The categories of the dependent variables are (I) preferrers or users of formal modern health services, which include govern- mental rural health center staffed by formally qualified licensed physlclans, (2) preferrers or users of mformally tramed or self-tramed modern allopathlc

Yea

an

d he

&h

are

whz

&w

n so

urw

1976

19

87

Per

~enl

dls

lrlbu

tlon

Per

cent

dls

trlh

uclo

n

For

mdt

ln

form

dt

Oth

er

For

mal

In

form

dt

Oth

er

All

mod

ern

mr1

dern

H

omeo

path

tr

ddltl

ondt

A

ll m

oder

n m

oder

n H

omeo

pdlh

tr

ddltl

ondt

N

pr

”vld

er\

prw

der\

pm

vKle

r\

pr”w

der\

pr

owde

rq

N

prow

der\

pr

owde

rs

prow

der5

pr

ovid

ers

prow

ders

II X

”/“’

I I 4

”,:>

12

91%

5 7%

t 5 x

:/o

2020

I l

6S

70 2

IX

0 32

2

16 5

15

6 34

9

7x 6

19

0 41

7

67 I

I(, 4

27

5

66 3

12

3

28 I

70

4

21 2

31

5

75 5

I9

4 76

4

I56

I6 3

II t

18 9

140

I2 7

tx

n

8 9%

43

96

6X

4 9

tt 9

54

II

742

1278

IO16

9x

4

1102

35

0 56

2

X76

2X

9

46X

69

7

377

203

5x5

66 4

7X

44

6

55

74 2

IO

5

46 2

x3

72 4

99

47

4

66

IO 0

90

43

I

X0

II 8

x3

42 6

It

6 6X

5

II 2

47 5

34

71 3

to

9 52 I

12

x5

92

R5

91

93

104

71

175

76 0

24

0

27 4

10

9 II

I

5Y6

74 3

I3

x

45 4

57

94

29

2 72

9

15x

30 4

72

19

5

305

IX 0

72

51

I

66

I3

I 69

X

IO 2

16

5

35 2

37

14

X

1119

67 X

IX

44 2

83

75

911

70 5

II

I

31 5

61

15

2 I9

09

II 8

96

46 2

I 0

9 0

254

76 4

I6

6

77 8

39

IX

t

III

61 2

72

35 I

II 7

72

508

6X I

II

I

29 5

746

172

35 5

45

65

t64

I54

447

I573

676

54

454

x5

12 7

IO I

456

69

x7

91

Ldnd

oune

ra

or o

(her

s 65

7

*May

no

t su

m 1

” 10

0% b

ecdu

x ot

erc

tuw

n of

pe

rcen

,dge

s “I

- re

\p”n

denl

c no

t us

ing

any

he&

h c~

rc p

row

dcrs

S

ourc

e C

omp.

mlg

dnt

Hea

lth

Pro

~ec

r S

urve

y 19

76

and

Com

pdm

gnq

Hea

lth

Cdr

e U

hh7d

cl”n

S

urve

y,

t9X

I

%

_-

., _

___-

. _

___

__-

.“I

- _-

_ .

_,-

__

_

,,,,-

_-

_-

__-.

-___

-.

.1

.-

_ -

-1

Health cdre In rural Bangladesh I347

health services hlthout any licenses. (3) preferrers or users of homeopathlc health services. (4) preferrers or users of tradltlonal health services such as herbal practitioners or tradltlonal healers, and (5) nonusers of any health service

The beta coefficients from our final models of the polytomous regresslon equations are presented m Tables 3 and 4 The beta coefficients represent the log odds of bemg m one category relative to another specified category It may be helpful to remember that d coefficient of I 0 mdlcates a 2 7 times higher hkehhood of bemg m the first category versus the second As another example. a coefficient of 0 50 corresponds to an observation bemg I 6 times more likely to be m category I than m category 2 Equa- tlons m Table 3 Include the followmg comparisons (I) modern mformdl health service versus non- modern health service (I e homeopathlc and tradl- tlonal health cervices) and (2) modern formal health services versus modern informal health services Slml- lar equations are also mcluded m Table 4. with the exception of mcluslon of an additional equation which IS use of any health service (modern or other- wise) versus nonuse of health service Smce sex and age of sick person 1s not relevant for preference response, which was mostly collected from a female respondent m a household not necessarily bemg the reported sick person wlthm the last weeks (which 1s the dependent variable m Table 3) both of these barrabIes have been excluded m Table 4 On the other hand, contact by health worker has been excluded from Tdble 4 for its anomalous reldtionshlp with the actual utlhzatlon of health services

The results of the multlvarlate analyses m Tables 3 and 4 are consistent with those of Tables I and 2 Thus. it seems that preference dnd utlhzatlon of modern formal health services were more slgmficantly and posltlvely associated with soclo-economic status m 1987 than m 1976. that proxlmlty to mam govern- mental health center promoted use of formal modern health services, and that male sick persons and persons above age 5 were more likely to receive modern health care services

DISCISSION

In this article we have presented data dnd findmgs on the utlhzatlon of traditional and modern health

services as well as the impact of a commumty-based decentrahzed pllot health mterventlon project. CPHP, both during Its operation and after Its mcor- poratlon mto the normal rural health services of the government of Bangaldesh A central findmg m this study 1s that an overwhelmmg malorlty of the rural population m our study area used modern medical practltloners. although most of these practltloners were mformally trained without any formal medical degree or trammg The study also reveals that the utlhzatlon rate of formal modern providers was higher m 1976 than m 1987 Since the CPHP was the mam source of formal modern providers m 1976, this higher utlhzatlon of formal modern providers might have been due to the Improved services offered by CPHP In other words, decentrahzatlon dnd high quality of rural health services provided by the CPHP m 1976 (41 might have increased the geographical dccesslbility. as well as offered an alternative type of provider to the users who were perhaps hlthertofore limited by the fact that only mformally tramed modern practltloners or tradltlonal practltloners were wlthm their reach On the other hand. the general scahng down of CPHP’s services and the deteriord- tlon of their quality m I987 might have lowered the utlhzatlon of formally trained modern providers This IS consistent with hmlted actlvltles observed at the health subcenters of the present study area m the post-CPHP period [14], as well as under-staffing dnd inadequate supplies of medlcmes and equipments m other rural health centers elsewhere m the country

(151 On the other hand. the present study shows that,

compared to 1976. utlhzatlon rate of Informal mod- ern providers increased m 1987 This might have been due to the recent government pohcy of encouragmg increased productlon of some modern medlcmes, such as chemotherapeutic agents and antlblotlcs wlthm the country [6, 151, making them more acces- sable through mformally tramed or self-tramed providers of modern medlcmes Compared to homeo- pathlc and other traditional medlcmes, quick and effective results often associated with modern medicines might also have made the latter attracttve to the potential users of modern medlcmes Earher studies also found that modern medlcmes were widely used m rural Bangladesh [15, 161 and that the use of indigenous medlcmes were fast dechmng, although

1976 19x7

lnformdl modern Formal modern lnformdl modern Formal modern \s “S “S “S

nonmodern InformA modern nonmodern mformdl modern

Educated household heddt -0 237 0 040 -0 382 Ldndouner or nonworkmg ~1~s

OCLUpdt10n: -0 524 0 3938 0 475 Contacted by he&h worker -0 453 0 275’ -0 880 Wllhm one mile of man gobernmem

hedllh cenlerb -0 X65* I 368* 0 197 COtISIdm 3 346 -0 773 2 454 Model Cht-square 26 3 38 8 97 111 I6 16 I6

l p<oo5

tThe ruppreaed category 1s no educdhon :The ruppreared category 1s landless dgncultural laborers or household uorkers 4Suppressed category 15 above one mile

Source CompdmgdnJ Hedlth Protect Survey 1976 dnd CompdmgdnJ He&h Care Uuhzrt~on Survey. 1987

0 492’

0 444* -0 566

0 723’ -2494 I2 5 I6

I976 19X7 ____

InformJ modern Formal modern user\ lnformdl modern Formal modern

Household hedd 5 educduont 0 14Y -0 Xl -0 060 0 244’ -0 079

Ldnd o~+ner or nonxorhmg CldSS oKupdtron: 0 309* 0081 -0 249 0 353’ 0 70”

Male users 0 429’ 0 670’ -0 264 1281’ -0079 Ape proup O-5 -0 455* -0 6X4* -0 I24 2 23X* -0 9x2* Age group h-l+ -0 299 -0 288 0 267 1510’ -0 62X* Wlthm one mile of

mdm government hedlth center‘ -0 004 -0 220 0491’ 0 242 0 001

Con%mt 0 627 0 786 -0 392 - I 0.55 I 4x0 Model Chl-aqudre 50 4 34 4 30 5 94 I 30 0 (0 48 48 48 4x 4s

‘P<OO5 tThe supprwed c&rgorq IC no educduon :The supprexd cdtegory I\ Idndles\ rlgr~~ullurdl Idborerc or houxhold worker\ bThe suppressed category 1s age-group dbo\e I4 ’ Supprewzd category I\ above one mllr Source Compdnqdnj Health PrOJeCt Surwq 1976 .ind Compdm&q He&h Cdre Ut~hz&on Sur\e\ 1987

0 035

0 1’2 0 OX4

-0 174 0 2x’)

0 307 - I 749 10 : 48

some use of homeopathlc and other tradltlonal medlcmes persisted [ 151

The reduced soclo-economic differences m the use of formally tramed modern prdctltloners m 1976 compared to 1987, also noted earlier. can be ex- piamed by the type of modern medical services thd1 were developed under the CPHP dnd Its decentralized auxllhary subcenters [4] Thus. m 1976. CPHP’s wider efforts to reach lower socto-economic strata with comprehensive preventative and curative health cdre services free of any cost. might hdve resulted in increased use of formally tramed practltloners m the lower socio-economic strata narrowing their gap in use with those m the higher soclo-strata On the other hand. the dlscontmuatlon of the same decentrdhzed efforts under gocernment set-up In 1987 might hd\e resulted m the decreased use of the rural health center’s services by the lower soclo-economic strata In other words. while the very success of the CPHP s decentralized efforts in 1976 might hdve ndrrowed soclo-economic differences m formal he&h care util-

lzatlon by making It equltdbiy avdllable across SOCIO-

economic groups, the possible constrdmts m supplies and services for the lower socIo-economic strata In 1987 under the exlstmg governmental health services might have led to the reemergence of the posltlve relatlonshlp between socio-economic stdtus dnd use of formal health providers This pattern dnd trend IS. again, compatible with the exlstmg mequltles m ac- cess to formal modern providers ,md expected effects of an effective decentrahzdtion health care program that cdn ehmmdte these rnequltles and increase the coverage of formal modern medical services [9]

Earher studies also found that m rural Bangladesh most of the people had little access to formal providers of modern medlclnes thdt mformal providers were heavily utlhzed because of their dvdllablhty and socidl access, that modern medlcmes uere kery popular and that modern health resources were found to be mequltably dlstrlbuted [9. 15-171 The CPHP might have overcome man) of these obstdcles by provldmg a decentralized system of delivery of primary he&h care m rural Bangladesh

By mcreasmg its dccesslbihty to rural people with basic primary health care free of cost. CPHP might have provided a larger choice to the rur;il people especially the poor vllldgers, leading to Its mcredsmg utlhzatlon This shows that. despite poor economic condltlons of Bangladesh. it IS possible to redch rural door-steps with basic primary health care alth It> mcreased utlhzatlon The pohcy lmphcatlon which IS derived from these findings Is that the persons respon- sable for hedlth program plannmg and hedlth pro- grdm lmplementatlon need to ensure that the dccc% to basic pubhc health cdre services can be made brodd enough to cover the mdJor]ty of the rurdi populdtlon through a system of decentrahzed curative and pre- \entl\e services These decentrahzed services should be further strengthened by d system of ddequdtc trammg. deployment, and supervlslon of health pro- fesstonaL including d trammg program to Improve the quahty of the medical ser\lces offered by the informal dnd self-trained practltloners of modern medicines

4tA~u /~&enw~fc--This research wds sponsored by the U S AID Reseach Program for Hlstorlcally Black Colleges and Universities The ProJect was funded by U S AID Grdnt No DAN 5053-G-SS-6025-00, to Morgdn State University Bdltlmore. Maryldnd I dm especldll!, indebted to Floyd O’Qumn and Juhus Prince for their helpful com- ments on 611 edrher drdft of this pdper

REFERENCES

Ecdns A Jr er ol Hedlth cdre m the developmg world problems of scarcity and chotce. Shdttuck Lecture Dehvered before the Buuniennml Meerrng ofrhe Mmw- cherrr Medrtal Sorwr~, Boston. Mdsb , 1981, Tdylor C E Stages of plannmg process In Htdrir Plunnrn~ Quulrrarw Aspects and Quantltaluc Technryuc~c (EdIted by Remke W A ) Johns Hopktns University Press. Baltimore. Md , 1972. King M Merhtul Cure m Del d- oprng Counrrler Oxford Umversity Press Ndwobl

I966 Mosleq W H Chtld surwval research pohcy Popul Derl Rel Suppl IO, 3-23 1984

Health care m rural Bangladesh 1349

3 Umverstty of Ghand Department of Commumty Health Danfa ProJect Fmdl Report The Ddnfd Com- prehenstve Rural Health and Famtly Plannmg ProJect Accra. Ghana, 1978 Taylor E E el al Chrld and Maternal Healrh Senrtes m Rural Indra Vol 2 Johns Hopkins Umverstty Press Balttmore. Md . 1983

4 Zaman W A Publrc Particlparron WI Detelopnlenr und Heulth Programs Le~sont from Rural Banpladech. pp 207-210 Umverstty Press of America. Neu York. 1984

5 Arthur W B and McN~coll G An analyttcal survey of populatton and development m Bangladesh Popul Det I Ret 4, 1978

6 Government of Bdngladesh Thud Five-Year Plan (1980-1985). Plannmg Commtsslon Dhaka Bangla- desh. 1985. Government of Bangladesh ProJect Docu- ment for the National Dtarrhoeal Dtsedse Control Programme 1983-85 to 1986-90 Mmtstry of Health Dhaka, Bangladesh, 1983 Government of Bangla- desh Bangladesh Health Services Report Director General of Health Servtces, Dhaka Bangladesh 1985

9 Gtsh 0 Health dnd family pldnmng serclces m Bdngladesh d study of mequaht) fnr J H/~/I Scrr 11, 2633281 1981 Islam K and Bdchmdn S PHC m Bdngladesh-too much to ask’ Sot SC I Mrd 17, 1463-1896 1983

IO Shoda J Medm J B dnd Chta W A Survey m rural Bdngladesh on dlarrhoeal morbldlty v.dter usage dnd related factors First Report Dhdka Banglddesh. 1977

1 I BhardwaJ S M and Paul B K Medtcdl pluralism dnd infant mortality m a rural ared of Bangladesh Sot Sc1 &fed 23, 1003-1010 1986

I2 Amm R Health care utlhzatlon morbtdtty dnd infant mortality in rural Bangladesh Report submttted to U S AID Washmgton. DC 1988 Chowdhury S Deter- mmants of health care utilization m rural Banglddesh Unpublished PhD dlssertatton School of Hygiene dnd Public Health Johns Houkms Umversitv Baltimore

7 McCormack W M and Curlm G T Infectious dts- eases their spread and control In Dwwer m Banglu- desh (Edtted by Chen L ) Oxford Umverstty Press New York, 1973, Northrup R S Health manpower and orgamzatton In Dmarrer m Bangladesh (Edited by Chen L ) Oxford Umverstty Press, New York 1973

8 Amm R Infant and child mortahty m Bangladesh J blosoc Scr 20, 59965. 1988

Md. 1988 I3 Hanushek E A and Jackson J E Sra~r~~rtal Verhodr

for Socul Srlenrut Academic Press. Nevk York 1977 I4 Amm R Personal observatton durmg field trips m

CompdmganJ Banglddesh 1987 I5 Ashraf A et al Health disedse and hedlth cdre in rurdl

Bangladesh Sot Scl Med 16, 2041-2054 1982 16 Claqum P Prtvate health care providers in rural

Bangladesh Sot Scr Med ISB, 153-157. 1981 17 Sarder A M and Chen L C Dlstrtbutlon and chardc-

teristics of non-government hedlth prdctltioners in d

rural ared of Bangladesh Sot .%I Mcd 15A. 54?- 550 1981