THE EXAMPLE OF FRIENDSHIP
Bangladesh is one of the most fertile countries in the world, but also one of the most vulnerable. Between the Himalayas with its melting glaciers and its 600 rivers, Bangladesh is the second biggest delta of the world. This makes it the most exposed region to rising seas. Nearly a third of the country is susceptible to tidal inundation and 70% is flooded every year during heavy monsoons. This situation strongly affects the ecosystems and the exploitation of the already restricted natural resources.
It is also one of the poorest countries in the world and, with a population of 160 million, the most densely populated. According to the Government of Bangladesh, 20 million people may be displaced by 2050 because of climate change. Many of them are already migrating: 500,000 migrants are arriving every year in Dhaka, the already overcrowded capital.
THE FRIENDSHIP’S JOURNEY
In 2002, the NGO Friendship created a floating hospital: the Lifebuoy Friendship Hospital. Thus began Friendship’s journey towards reaching a seemingly impossible goal: carrying healthcare to the most remote and difficult-to-reach areas of Bangladesh, the so-called Chars, which thread the northern reaches of the Brahmaputra River, where 4 million people live.
Since then, Friendship has progressively developed a healthcare system to provide comprehensive quality health and information to the remote river-based communities of northern and southern Bangladesh. Two more floating hospitals were introduced: the Emirates Friendship Hospital in 2008 and the Rongdhonu Friendship Hospital, in 2012.
Starting from 2005, a system of mobile Satellite Clinics was set up, complemented by health workers to serve communities at the grassroots level. Presently, each month, approximately 250,000 persons are treated thanks to Friendship’s health program.
FROM HEALTHCARE TO AN INNOVATIVE AND INTEGRATED APPROACH TO DEVELOPMENT
Friendship is a needs-based organization, principled on a bottom-up approach, strongly rooted in the community level: it bases its work on the evolving needs of beneficiaries. For the last 15 years Friendship has been working on the basis that the ultra-poor are entitled to the same quality of service, care, and opportunity like others.
Friendship also recognizes that the problems are multi-faceted and interlinked. It is clear that economic welfare interventions can be effective only for a community who has access to healthcare and education; successful healthcare relies upon knowledge of basic hygiene and a sanitation infrastructure; education cannot be promoted successfully where students suffer from hunger; and improvements cannot be sustained if the results of people’s efforts are regularly wiped out by natural disasters.
Recognizing that the broader goal – enabling marginalized communities to improve their living conditions and gain control over their lives – requires more than healthcare support alone, Friendship has progressively built an integrated community development model which interlinks six programs.
Friendship has developed an innovative and highly recognized 3-Tier healthcare system. At its core are three hospital ships (Tier 1), supported by strong field level static and satellite clinics (Tier 2) and Friendship community medic-aides or FCMs (Tier 3). With this reliable and replicable system, Friendship presently serves approximately 3 million patients per year. Significant portions of the beneficiaries receive secondary level care in the hospital ships, and the static clinics.
The ships serve as primary care and secondary care centres. They are fully operational as hospitals providing care on average to 175 persons per ship per day. They serve as referral centres for the second and third tiers. Each ship is equipped with doctor services, gynecological services – including treatment of first level cervical cancer, path labs, X-rays, and two operation theatres performing surgical interventions for cataract extractions, orthopedic corrections, reconstructions and fistulas repairs. Except for a nominal token amount for the first time registration, the services are provided free of charge including operations and medicines.
The satellite clinics are mainly for primary health care, follow-ups and prevention. These are mobile teams manned by paramedics. They also identify community needs for health and refer patients to our hospitals. The services provided are teaching and training communities for better health, total package of services for M&C (Mother and Child), EPI (Extended Immunization Program), Nutrition and medicine dispersion as needed.
The FCMs are micro social entrepreneurs, whose services fill a vacuum in the community in which they live and enable them to earn a reasonable income. They are trained between three to five years in medical service delivery for over the counter medicines and for ensuring that primary medical services are available for the community even when the Friendship satellite clinics and hospital ships are not there.
This healthcare system is being further strengthened through the introduction of an in-house developed, smart-phone based, m-Health software enhancing the ability of the Friendship Community Medic Aides to diagnose, treat and, if need be, refer patients to another tier of the system. A satellite based telemedicine platform initiated by the Luxembourg Government in cooperation with SES, a leading satellite company, will allow Friendship to be linked with its remote working areas, enabling it to, interconnect its different hospitals, and initiate remote consultations and training programs.
More than 5,000 children, attend Friendship’s primary schools. The children follow the national curriculum syllabus and also receive lessons on ethical standards or citizens’ rights, preparing them to be responsible citizens in future.
In 2015, Friendship has started secondary education in 5 “chars” as a pilot model. On completing primary education, children from their schools are mostly unable to go for secondary level schooling outside their community. With the help of pre-recording of lessons by teachers of good private schools, solar panels and computers, the Friendship secondary education is a remote educational concept to reach migratory and out of main stream students.
In addition, 1,460 adolescents and adults attend Functional Literacy classes in Friendship’s 73 schools and education centres.
Disaster Management and Infrastructural Development (DMID)
Bangladesh is on the forefront of climate change whilst being one of the least equipped to deal with it. The DMID program works to increase disaster management capacity of remote and particularly disaster exposed populations. It is currently providing technical and logistics support to 70 communities for disaster preparedness. Post disaster relief including housing and sanitation, and flood shelters are part of the program. Additionally, 6 desalination plants have been established in salinity prone areas which can provide access to fresh drinking water to 80,000 people.
We also assist marginalized populations to mitigate the effects of poverty, natural disasters, and climate change through healthcare, trainings, saving plans, education, and disaster preparedness.
Sustainable Economic Development (SED)
Friendship has created an innovative system to enable ultra-poor access finance, through a model based on risk-sharing, interlinked with leasing for capital goods, cash, clearance of debts to middlemen, training, savings, and insurances against natural calamities. It endeavors to bring in a sustainable positive change for communities by providing training, identifying employment opportunities, and creating market linkages. Through its SED program over 2,500 poor farmers and fishermen have been helped and over 1000 Solar Home Systems (SHS) have been installed (on a leasing basis) in very poor households. Vocational training centres for weaving, dyeing and tailoring have trained over 1,000 women. Currently 94 women are directly employed in these centres.
Friendship’s Good Governance program endeavors to make underprivileged beneficiaries aware of their citizens’ rights and offer them access to justice and legal services. The rapidly growing program is presently implemented in 35 islands through its Friendship Civil Society Groups, its trained paralegals and Friendship Community Good Governance Aides. Roles and responsibilities of the local government bodies are taught and interactions between them and beneficiaries are organized.
In an attempt to preserve the oldest heritage of Bengal, passed down through over 5000 years of oral history, Friendship strives to save the skills of the builders of the traditional wooden boats of Bangladesh, whose craft is rapidly dying out with the onset of new technology. Friendship team has thus discovered and built replicas of 87 almost extinct boats, using its building techniques, and has arranged 17 national and international exhibitions to date.
THE EFFECTS OF THE FRIENDSHIP’S APPROACH
Friendship’s programs interconnect with each other to support an integrated approach to development. This stems from the understanding that no program can sustainably continue by trying to solve secondary needs before addressing primary ones.
This allows the organization to develop positive synergies in its day-to-day journey, and most importantly help to adapt its programs to identify needs. For instance, teachers from their education system facilitate the identification of children suffering from diseases and inform the doctors. Through the sustainable economic development program, households are able to access solar panels that allow the children to study after sunset thus, to obtain better results.
Initially, Friendship was primarily a service delivery organization. It is fully aware that governments have a prime responsibility for their citizens and that it is not for NGOs to substitute them or release them from their responsibilities. Friendship’s Good Governance program is a direct manifestation of this realization. However, for various reasons, such as, ability, geographical or financial restraints, government services are unable to reach out to certain communities. It is then for civil society organizations such as Friendship to fill the gaps till public authorities notice the conditions and are led to take over.
But for this, constant interaction with public authorities is required. Close cooperation between Friendship and public authorities thus exists on many programs, such as EPI (Extended Program for Immunization), family planning, cervical cancer prevention and treatment, introduction of the Friendship Code of Ethics and child rights in government schools, linkages for governance matters, shelter guideline development, etc. Friendship’s relations with public authorities are not confrontational; nor are they complacent. They build on the belief that only cooperation and complementarity can bring matters forward for the greater benefit of the most underprivileged.
WHAT ABOUT TOMORROW?
After developing a functional, replicable model of integrated interventions, Friendship is looking ahead to expanding their outreach. Without compromising on the quality and the essentials of their work and approach, they are looking at reaching others who need them, but they are also setting perimeters for expansion, bearing ethical values as the foremost guiding factor. They are also focusing on growth management, as Friendship has grown rapidly over the last few years. In order to manage this growth, they are now further strengthening their relationships with stakeholders, strengthening their methodologies for replication and helping, guiding and building the ability of their institution and people across all disciplines.
It is certainly part of Friendship’s ambition to make their system better known within the wider development community and to have others get inspired by it. Flexibility, close observation of the beneficiaries, changing needs as well as deep community involvement are key to the success of the model: thus, it cannot be implemented in all places and at all times in a monolithic manner. However, the approach, the way of doing and the mind-set behind it are the shaping factors and these are worth being adopted by others.
By Staff Reporter
Founded by Runa Khan, Friendship began its activities in 2002 with a floating-hospital to ensure access to health care for ultra-poor communities in Bangladesh. Since then, Friendship has extended its intervention to create what is a fully integrated development model and an innovative development model that is geared to engaging communities, and strengthening their resilience and dignity. Today it is developing its network internationally through entities established in Europe. Its approach is observed with curiosity and interest by other development actors.