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Bangladesh Journal of Bioethics 2016; 7(2):1-13  
 

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Original Article 

 

A Study on Service Availability and Readiness Assessment of Non-

Communicable Diseases Using the WHO Tool for Gazipur District in 

Bangladesh 

 

Running Title: Service availability and Readiness assessment of NCDs 

 

Mohammad Rashedul Islam1, Shamima Parvin Laskar2, Darryl Macer3  

1. Assistant Director, Research and Training Monitoring Department, Bangladesh 

College of Physicians and Surgeons, Mohakhali, Dhaka, Bangladesh.   

Email: mrislam96@gmail.com  

2. Professor & Head, Department of Anatomy, MH Samorita Hospital & Medical 

College, 117 Tejgaon, Love Road, Dhaka-1208, Bangladesh. 

3. President, American University of Sovereign Nations, San Carlos, Arizona, USA. 

 

Abstract: Non-communicable diseases (NCDs) disproportionately affect low and 

middle-income countries where nearly three quarters of NCD deaths occur. 

Bangladesh is also in NCD burden. This cross-sectional study was done on 50 health 

facilities centres at Gazipur district in Bangladesh from July 2015 to December 2015 

to introduce SARA for better monitoring and evaluation of non-communicable 

diseases health service delivery. The General Service readiness index score was 

61.52% refers to the fact that about 62% of all the facilities were ready to provide 

general services like basic amenities, basic equipment, standard precautions for 

infection prevention, and diagnostic capacity and essential medicines to the patients. 

But in case of non-communicable diseases, among all the health facilities 40% had 

chronic respiratory disease and cardiovascular diseases diagnosis/ management and 

only 32% had availability of diabetes diagnosis/management. Overall readiness score 

was 52% in chronic respiratory disease, 73% in cardiovascular disease and 70% in 

diabetes. Therefore, service availability and readiness of the health facilities to 

provide NCD related health services were not up to the mark for facing future targets.  

A full-scale census survey of all the facilities of the study area would give a better 

understanding of the availability and service readiness.  

 

Key Words: Service availability, Service readiness, Non-communicable diseases, 

SARA tool, Bangladesh 

 

Introduction: The four main types of non-communicable diseases are cardiovascular 

diseases, cancers, chronic respiratory diseases and diabetes. Non-communicable 

diseases (NCDs) kill 38 million people each year. NCDs already affect low- and 

middle-income countries disproportionately where nearly three quarters of NCD 



2 

 

deaths occur. Responsible risk factors include ageing, rapid unplanned urbanization, 

and the globalization of unhealthy lifestyles. For example, globalization of unhealthy 

lifestyles like unhealthy diets may show up in individuals as raised blood pressure, 

increased blood glucose, elevated blood lipids, and obesity. These are called 

'intermediate risk factors' which can lead to cardiovascular disease, a NCD1. 

 

All people irrespective of age, sex and regions are affected by NCDs. But evidence 

shows that 16 million of all deaths attributed to non-communicable diseases (NCDs) 

occur before the age of 70. Of these "premature" deaths, 82% occurred in low- and 

middle-income countries. Children, adults and the elderly are all vulnerable to the risk 

factors that contribute to NCDs, whether from unhealthy diets, excess salt intake, 

physical inactivity, exposure to tobacco smoke or the effects of the harmful use of 

alcohol2.  

 

NCDs threaten progress towards the UN Millennium Development Goals and post-

2015 development agenda (Sustainable Development Goals). Poverty is closely 

linked with NCDs. The rapid rise in NCDs is predicted to impede poverty reduction 

initiatives in low-income countries, particularly by increasing household costs 

associated with health care3. Vulnerable and socially disadvantaged people get sicker 

and die sooner than people of higher social positions, especially because they are at 

greater risk of being exposed to harmful products, such as tobacco or unhealthy food, 

and have limited access to health services4 . 

 

In low-resource settings, out pocket expenditure for cardiovascular diseases, cancers, 

diabetes or chronic lung diseases can quickly drain household resources, driving 

families into poverty. The exorbitant costs of NCDs, including often lengthy and 

expensive treatment and loss of breadwinners, are forcing millions of people into 

poverty annually, stifling development. In many countries, harmful drinking and 

unhealthy diet and lifestyles occur both in higher and lower income groups. However, 

high-income groups can access services and products that protect them from the 

greatest risks while lower-income groups can often not afford such products and 

services5.  

 

A comprehensive approach for all sectors including health is needed to lessen the 

impact of NCDs on individuals and society. An important way to reduce NCDs is to 

focus on lessening the risk factors associated with these diseases. Low-cost solutions 

exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy 

diet and physical inactivity, and the harmful use of alcohol) and map the epidemic of 

NCDs and their risk factors. Other ways to reduce NCDs are high impact essential 

NCD interventions that can be delivered through a primary health-care approach to 

strengthen early detection and timely treatment. Evidence shows that such 

interventions are excellent economic investments because, if applied to patients early, 

can reduce the need for more expensive treatment. These measures can be 



3 

 

implemented in various resource levels. The greatest impact can be achieved by 

creating healthy public policies that promote NCD prevention and control and 

reorienting health systems to address the needs of people with such diseases. Lower-

income countries generally have lower capacity for the prevention and control of 

NCDs. High-income countries are nearly four times more likely to have NCD services 

covered by health insurance than low-income countries. Countries with inadequate 

health insurance coverage are unlikely to provide universal access to essential NCD 

interventions1. 

 

WHO proposed Global action plan for the prevention and control of NCDs 2013-

2020 to reduce the number of premature deaths from NCDs by 25% by 2025 through 

nine voluntary global targets such as tobacco use, harmful use of alcohol, unhealthy 

diet and physical inactivity that increase people's risk of developing these diseases6. 

 

Bangladesh faces double burden of diseases – both CDs & NCDs. But, in Bangladesh 

NCD burden is rapidly increasing due to social transition, unhealthy dietary habit & 

rapid urbanization. In terms of the number of lives lost due to ill-health and disability, 

NCDs account for 61% of the total disease burden. The under-privileged communities 

in the country are bearing the heaviest toll of this burden7,8. 

 

Core to the SARA framework is the strengthening of a common platform for 

monitoring, evaluation and review for National Health System. SARA is designed to 

function as a systematic tool to support annual verification of data and service 

delivery at the facility level. SARA provides evidence based data on health system 

progress to inform the annual health sector review, identify gaps and weaknesses 

responsible for sub- optimal service provision and intervention coverage that need to 

be addressed, provide a baseline for planning and monitoring scale-up intervention for 

service delivery improvement9. No assessment has been conducted so far in 

Bangladesh to monitor, review and evaluate NCD related health service delivery 

using SARA.  Thus, the present study aimed to introduce SARA for better monitoring 

and evaluation of NCD related health service delivery in Gazipur, Bangladesh. 

 

Research Question: What is the status of service availability and readiness 

assessment on non-communicable diseases for Gazipur District in Bangladesh? 

 

General Objective: The objective of this assessment is to strengthen monitor-review-

act system for non-communicable diseases health service delivery in Gazipur using 

SARA.  

Specific objectives 

• To find out service availability for providing NCD health services using 

SARA tool. 

• To assess facility readiness for providing NCD health services using SARA 

tool 



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Ethical Implication: This study is very much important regarding to ethical aspects. 

Health is a basic need and according to goal 3 of sustainable development Goals 

(SDGs) “Ensure healthy lives and promote well-being for all at all ages”10 must 

warrant. So, health service delivery should be made affordable and accessible to all.  

Methodology: This cross-sectional study was done from July 2015 to December 2015 

on 50 health facilities during Masters of Bioethics and Global Public Health 

(MBGPH) in AUSN. Two Upazila’s (Kapasia and Sreepur) from Gazipur district 

were considered as assessment area. Different types of health facilities (Upazila 

Health Complex [UHC], Union Sub-centers [USC], Community Clinic [CC] and 

Private hospital [PH]) were included in the study11-13. This two Upazilas were selected 

by multistage sampling. Then a sampling frame was done from both upazilas 

including public and private facilities. From this stratified random sampling was done. 

Private clinics having both inpatient and outpatient departments were included in this 

study. Private clinics with only diagnostic facilities were excluded from this study. 

 

Brief Description of Assessment Tool: Service Availability and Readiness 

Assessment (SARA) Indicators: The Service Availability and Readiness Assessment 

(SARA) survey is used to measure progress in health system strengthening over time 

comprising a set of core indicators on key inputs and outputs of the health system. 

Tracer indicators aim to provide objective information about whether or not a facility 

meets the required conditions to support provision of basic or specific services with a 

consistent level of quality and quantity. Summary or composite indicators, also called 

indices, can be used to summarize and communicate information about multiple 

indicators and domains of indicators. Indices can be used for general and service 

specific availability and readiness. 

 

Service Availability refers to the physical presence of the delivery of services, 

encompassing health infrastructure, core health personnel, and service utilization. 

This does not include more complex dimensions such as geographic barriers, travel 

time, and user behavior, which require more complex input data. Service availability 

is described by an index using the three areas of tracer indicators. This is made 

possible by expressing the indicators as a percentage score compared with a target or 

benchmark, then taking the mean of the area scores. 

 

General Service Readiness refers to the overall capacity of health facilities to provide 

general health services. Readiness is defined as the availability of components 

required to provide services such as basic amenities, basic equipment, standard 

precautions, laboratory tests, and medicines and commodities. General service 

readiness is described by an index using the five general service readiness domains. A 

score is generated per domain based on the number of domain elements present, then 



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an overall general readiness score is calculated based on the mean of the five 

domains. 

 

Service Specific Readiness refers to the ability of health facilities to offer a specific 

service and the capacity to provide that service measured through selected tracer 

items that include trained staff, guidelines, equipment, diagnostic capacity, and 

medicines and commodities. 

 

SARA is a health facility assessment tool designed to assess and monitor the service 

availability and readiness of the health sector and to generate evidence to support the 

planning and managing of a health system. SARA is designed as a systematic survey 

to generate a set of tracer indicators of service availability and readiness. The survey 

objective is to generate reliable and regular information on service delivery (such as 

the availability of key human and infrastructure resources), on the availability of basic 

equipment, basic amenities, essential medicines, and diagnostic capacities, and on the 

readiness of health facilities to provide basic health-care interventions relating to 

NCDs. 

 

Data Collection: Data collection was done for two weeks from April 01 to April 15, 

2015 using paper based questionnaire. Total 50 health facility was visited from which 

25 were from Kapasia and the other 25 were from Sreepur. From these 50 facilities, 

there were 2 Upazila Health Complex, 4 Union Sub-centers, 30 Community clinics 

and 14 private clinics. Administrative head of every health facility was interviewed 

thoroughly. As an example, Upazila Health and Family Planning Officer (UH&FPO) 

was interviewed at UHC and Community Health Care Provider (CHCP) was 

interviewed at CC. 

 

Moreover, people related with different health services were also asked detailed 

questions where needed. For example, in Upazila Health Complex, EPI technician 

was asked questions on vaccine carrier and temperature monitoring of refrigerator, 

whereas storekeeper was asked question on availability and stock out of medicines. At 

Community Clinic, CHCP were asked questions about Antenatal care and Family 

Welfare Assistant (FWA) gave information on Family Planning Services. Data that 

was collected from Community Clinics and Union Sub-centers were cross verified at 

Upazila Health Complex with Statistician who is responsible for entering data in 

District Health Information System-2 (DHIS-2) software. The interviews were done 

in such a way that almost all the unions of both Upazilas were covered.  

 

Data Entry and Quality Assurance: Before formal data collection, the questionnaire 

was modified according to the feedback from the consultative meeting with the 

steering committee members. To ensure data quality, SARA team conducted a pretest 

in Gazipur Upazila Health Complex and its surrounding villages for facility 

assessment and community readiness. Data collectors were trained at two stages to 



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ensure quality data collection, firstly before pretesting to familiarize and how to use 

the tools and secondly, immediately prior to the main survey with the tools adapted 

based on field experience. Senior team members monitored and rechecked data on 

random basis at different check points-data collection, data entry and cleaning. 

Finally, data were entered on Microsoft Excel immediately after the data collection 

which helped to guard against wrong data entry. For facility assessment, calculation 

of different domain score and readiness score was done manually.  

 

Ethical Consideration: Ethical aspects of the study were taken into account in a 

fairly linear way. At first, Ethical review committee of American University of 

Sovereign Nations reviewed this study proposal. On the other hand, verbal consent 

was taken from every key informant prior to data collection. All questionnaires were 

kept in a safe and secure place in order to ensure confidentiality. Coding was done. 

Only the researcher has access to those questionnaires in case of cross checking or 

validating any data if needed. 

 

Limitations and Challenges: One of the limitations of the present study is that the 

study sites of this assessment were one of the high performing areas in terms of health 

indicators and it might introduce selection bias. As we have selected a sample of 

health facilities from the study area instead of a census of all the facilities, Service 

Availability data might not give us accurate measure. We had to face a few challenges 

while conducting the assessment. Some community clinics and the union sub centers 

are located in hard to reach area where transports were not available and 

communication system was very poor. Managing time was a hard job because the 

government facilities work up to 2.30 P.M. So, interviewing the doctors were 

challenging because of the interruption of the patients. So, each interview took more 

time than we expected. It was hard to interview the key informants (KI) as we had to 

go to their work place to take their schedule and then go to them again for taking 

interview. 

 

Results: General Service Readiness Index includes Basic amenities, Basic equipment, 

Standard precautions for infection prevention, Diagnostic capacity and Essential 

medicines. Tracer indicators for basic amenities are Power source, Improved water 

source within 500 meters of facility, Consultation room with auditory and visual 

privacy for patient consultations, Access to adequate sanitation facilities for clients, 

Communication equipment (phone or SW radio), Computer with email/Internet 

access and Emergency transportation. Tracer indicators for basic equipment are Adult 

scale, Child scale, Thermometer, Stethoscope, Blood pressure apparatus and Light 

source. Tracer indicators for Standard precautions for infection prevention are Safe 

final disposal of sharps, Safe final disposal of infectious waste, Appropriate storage of 

sharps waste, Appropriate storage of infectious waste, Disinfectant, Single use - 

standard disposable or auto-disable syringes Soap and running water or alcohol based 

hand rub Latex gloves and Guidelines for standard precautions. Tracer indicators for 



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diagnostic capacity are Haemoglobin, Blood glucose, Malaria diagnostic capacity, 

Urine dipstick- protein, Urine dipstick- glucose, HIV diagnostic capacity, Syphilis 

rapid test and Urine test for pregnancy. Tracer indicators for essential medicines are 

Amitriptyline tablet, Amoxicillin suspension, Amoxicillin tablet, Ampicillin injection, 

Gentamicin injection, Ceftriaxone injection, Salbutamol inhaler, Beclomethasone  

inhaler, Enalapril tablet or alternative ACE inhibitor, Amlodipine tablet or alternative 

calcium channel blocker, Simvastatin 20 mg capsule/tablet, Glibenclamide tablet, 

Metformin tablet, Insulin regular, Omeprazole tablet or alternative, Oral rehydration 

solution, Paracetamol tablet, Zinc sulphate tablet, Ibuprofen tablet and Fluoxetine 

tablet.  

 

The General Service readiness index for Kapasia and Sreepur Upazila was 62% where 

highest contributor was basic equipment domain (89%) and lowest contributor was 

diagnostic capacity (36%) of all the health facilities [Figure 1]. General service 

readiness index score by facility type was highest in Upazila health complex that was 

90% and lowest in community clinic that was 46%. No diagnostic mean score was 

noted in union sub center [Figure 2]. 

 

Diabetes service availability means Types of service offered: Diabetes diagnosis and/ 

or management. Tracer indicators for diabetes service readiness are Trained staff and 

guidelines - Guidelines for diabetes diagnosis and treatment and Staff trained in 

diabetes diagnosis and treatment; Equipment- Blood pressure apparatus, Adult scale, 

Measuring tape (height board/ stadiometre); Diagnostics- Blood glucose, Urine 

dipstick- protein, Urine dipstick- ketones; Medicines and commodities- Metformin 

tab, Glibenclamide tab, Insulin injectable and Glucose injectable solution. 

 

Cardiovascular disease service availability means Types of services offered 

cardiovascular disease diagnosis and/or management. Tracer indicators for 

Cardiovascular disease service readiness are Trained staff and guidelines-  Guidelines 

for diagnosis and treatment of chronic cardiovascular conditions and Staff trained in 

diagnosis and management of chronic cardiovascular conditions; Equipment- 

Stethoscope, Blood pressure apparatus, Adult scale; Medicines and commodities- 

ACE inhibitors (e.g. enalapril), Thiazides, Beta blockers (e.g. atenolol), Calcium 

channel blockers (e.g. amlodipine), Aspirin cap/tabs, Metformin cap/tabs and 

Oxygen. 

 

Chronic respiratory disease service availability means Types of services offered 

Chronic respiratory disease diagnosis and/or management. Tracer indicators for 

Chronic respiratory disease service readiness are Trained staff and guidelines-  

Guidelines for diagnosis and management of CRD and Staff trained in diagnosis and 

management of CRD; Equipment- Stethoscope, Peak flow meter, Spacers for 

inhalers; Medicines and commodities- Salbutamol inhaler, Beclomethasone inhaler, 

Prednisolone cap/tabs, Hydrocortisone cap/tabs, Epinephrine injectable and Oxygen. 



8 

 

The bar graph shows that about half of the health facilities in Gazipur district offered 

Cardiovascular and Chronic respiratory disease diagnosis/management (40%), One 

third offered Diabetes diagnosis/ management (32%) [Figure 3]. The bar graph shows 

that Overall readiness score was only 52% in chronic respiratory disease, 73% in 

cardiovascular disease and 70% in diabetes. But readiness score about staff and 

guideline was very poor only 5% for both chronic respiratory and cardiovascular 

diseases and 13% for diabetes [Figure 4]. 

 

General service readiness index and domain scores (n=50) 

61.52%

72.57%

88.66%

67.78%

35.50%
43.11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General service

readiness index

Basic amenities

mean score

Basic

equipment

mean score

Standard

precautions

mean score

Diagnostics

mean score

Essential

medicines

mean score

D
o

m
a

in
 s

co
re

General service readiness index and its domain

 
Figure 1: General Service readiness index and domain scores 

 

 

General service readiness index and domain scores, by facility type (n=50) 

61.52%

72.57%

88.66%

67.78%

35.50%
43.11%

89.72%

100% 100% 100%

87.50%

61.11%
53.17%

71.43%

83.33%
77.78%

0%

33.33%

45.68%

71.43%

83.33%

44.45%

12.50%
16.67%

86.07%

71.43%

100%

71.43%

87.50%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6

D
o

m
a

in
 s

co
re

General service readiness index and its domain, by facility type

Total UHC USC CC Private Clinics

 
Figure 2: General service readiness index and domain scores, by facility type 

 

 



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Availability of non-communicable disease services  

32%

40%

40%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Diabetes diagnosis/management

Cardiovascular disease diagnosis/management

Chronic respiratory disease diagnosis/management

Percentage of availability

N
o

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 c

o
m

m
u

n
ic

a
b

le
 d

is
e

a
se

 s
e

rv
ic

e
s

 

Figure 3: Availability of non-communicable disease services 

 

 

Readiness to provide non-communicable disease services  

70%

13%

79%

100%

69%
73%

5%

95%

80%

52%

5%

50%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

O
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ra

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in
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ss

S
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Readiness domain

Diabetes

diagnosis/management

Cardiovascular disease

diagnosis/management

Chronic respiratory

disease

diagnosis/management

Figure 4: Readiness to provide non-communicable disease services 

 

 



10 

 

Discussion: For Facility Readiness Assessment, Basic amenities domain readiness 

score of 73% indicates that about two-third of the facilities in the study area had basic 

conveniences including adequate sanitation facilities, room with privacy, improved 

water source etc. Although 100% facilities had communication equipment and 64% 

had computer with internet, only 40% (2 UHC, 4 USC and 14 Private Hospitals) had 

adequate power source to use them properly. Overall readiness score for basic 

equipment domain 89% refers that most of the health facilities had necessary 

equipment needed to provide services to the people. However, uses of that equipment 

were not seen by the study team while observing the health care providers when 

patients came to seek any service.  

 

Only 4% facilities of Kapasia and Sreepur had guideline which is need for Standard 

precautions for infection prevention. This is reflected in their daily practice as well. 

Although almost 92% facilities had appropriate storage of infectious and sharp waste, 

many of them told that they submitted their used needle to the Upazila Health 

Complex for final disposal. Overall domain score of 43% for essential medicine 

indicates that in the present area 43% facilities had essential medicines. But it is 

alarming that only 28% had all the essential medicines available at the time of this 

assessment. The reason for this shortage was inadequate supply of medicines for a 

quarter. In every community clinic in Kapasia Upazila there was no supply of any 

medicine over last three months. However, in some cases unnecessary use of 

medicine by the patients could also cause shortage of medicine.  

 

For example, a 60-year-old woman in a community clinic came to take medicine. 

Then the CHCP asked her what was her problem? Women replied, “I have no 

problem right now, just wanted to take some medicine as I did not take medicine for 

last three weeks”. Patient was happy for getting treatment and the community clinic 

was known to every person of the community. CHCP could not give answer 

appropriately how many drops make one milliliter (Field observation). General 

Service readiness index score 62% refers to the fact that 62% of all the facilities of the 

study area were ready to provide general services like basic amenities, basic 

equipment, standard precautions for infection prevention, and diagnostic capacity and 

essential medicines to the patients. 

 

As only 2 UHC and few Private Hospital had diagnostic capacity and all basic 

amenities, the overall percentage became low. But in case of non-communicable 

diseases, among all the health facilities 40% had chronic respiratory disease and 

cardiovascular diseases diagnosis/ management and only 32% had availability of 

diabetes diagnosis/management. Overall readiness score was only 52% in chronic 

respiratory disease, 73% in cardiovascular disease and 70% in diabetes.  

 

According to “iceberg of phenomenon” of disease, a great portion of people are 

undiagnosed or underdiagnosed14. We all know that most of the chronic diseases are 



11 

 

not curable, but in most cases these are preventable. So, primary prevention should be 

adopted initially15. Due to epidemiological transition of diseases non-communicable 

diseases are increasing day by day16. Community clinics should be strengthened. It 

may be a better center of preventive care. In this study, according to SARA guideline 

we did not consider community clinic. Because still now these community clinics are 

not functioning in many cases due to proper logistic support. In many cases these are 

functioning only in paper document. In case of SARA questionnaire, we consider here 

primary care physician. In case of cancers-there is no answer. Only VIA test for 

cervical cancer screening is done in Upazila health complex. In case of mental health 

issue, we didn’t get proper data. 

 

Conclusion: Despite all the bottlenecks identified in the study area, overall service 

availability and readiness of the health facilities to provide NCD related health 

services were below the acceptable range. At the same time community people were 

also aware of services that were available related to NCD related health services. A 

full-scale census survey of all the facilities of the study area would give a better 

understanding of the availability and service readiness. Thus, the findings could 

significantly contribute to the overall improvement of NCD related health not only in 

Bangladesh but also in global platform. Finally, all these efforts will act as a catalyst 

in achieving the better health for future Bangladesh. 

 

Recommendations: Strengthening accountability of the supervisor/inspectors who 

visit community clinics and Union Sub-Centers. Because, often they do not comment 

about capacity of the health worker to deliver certain services and also do not care 

about the stock out of medicines. Persuade the policy makers to create a mandate for 

Private Health facilities in order to share their data with Government MIS 

departments and also for public view. Standardizing and modifying all different types 

of Registers according to the format they are supposed to fill up in DHIS-2. Introduce 

strict rules that make health workers preserve Guidelines of training at health facility 

rather than their own home. All CHCP should be trained up properly regarding their 

service. Some Community clinics have no medicine more than three months. It is 

necessary to ensure proper supply of medicine for maintaining treatment whole the 

year. Treatment should be given by at least primary care physician at all levels. More 

frequent training on DHIS- 2, especially for HA to enter data in DHIS-2 and did not 

get adequate training. Enhance coordination among CHCP, HA and FWA. Equipping 

all community clinics with electricity or any other alternative power source. For 

example, solar panel establishment. 

 

Author’s contribution: 

1st author developed the conceptual idea, data collection, data analysis, compilation of 

results and manuscript writing. 2nd author develops the manuscript for publication and 

meticulous corrections of the article. 3rd author gives intellectual inputs in developing 

the concept of the manuscript. 



12 

 

 

Conflict of Interest: Declared none.  

 

Acknowledgement: Special thanks to Dr. Md. Hafiz Uddin, UH&FPO, Kapasia 

UHC and Dr. S.M Mahmudul Haque, UH&FPO, Sreepur UHC, Ms. Samsunnahar, 

Head Assistant of Kapasia UHC, Ms. Jakia Sultana Jesmin, SSN of Kapasia UHC and 

Mr. Md. Aman Ullah, Statistician of Sreepur UHC, Ms. Farida Yeasmin, SSN of 

Sreepur UHC for their support during the data collection period. I would like to 

express my thanks to all respondents and all others who were directly and indirectly 

help me.  

 

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