Primary healthcare system, despite serving large populations daily, suffer from poor infrastructure, insufficient space, weak governance and unclear administrative structures.by Abu Muhammad Zakir Hussain
THIS article reflects on the primary healthcare infrastructure that exists at the peripheral level in the rural and urban areas of Bangladesh, and reviews the recommendations made in the erstwhile Health Sector Reform Commission report, submitted on May 5, 2025, to the then interim government, along with additional comments and suggestions for managing primary healthcare in Bangladesh.
Background condition
To begin with the primary healthcare infrastructure of Bangladesh, primary healthcare infrastructure includes, according to the Commission report, domiciliary and community outpost-based facilities (120,000 health outposts and 34,000 satellite clinics under the Health and Family Planning Directorates respectively), community clinics and union-level health facilities — namely union health sub-centres, family welfare centres and union-level maternal and child welfare centres. The latter two are managed by the Family Planning Department.
Bangladesh has 4,578 unions and 495 upazilas. Of the unions, 1,362 have union sub-centres (USCs), many in a dilapidated condition, while about 3,291 have family welfare centres (FWCs). As some unions have both, a number remain without any facility. Around 162 unions have maternal and child welfare centres (MCWCs), mostly with at least 10 beds, a few with 30 beds, with plans to expand these to 50-bed facilities nationwide.
Most union sub-centres lack physicians, as posted medical officers are often withdrawn to upazila health complexes or district hospitals. Family welfare centres (with one post) and maternal and child welfare centres (with two posts) also suffer from shortages, as about 400 of the 1,120 physician posts in the Directorate General of Family Planning remain vacant. In practice, union sub-centres and Family welfare centres are led by Sub-Assistant Community Medical Officers, who sometimes inappropriately use the title ‘MO’ to support private practice. Even if all posts were filled, two-thirds of the family welfare centres and maternal and child welfare centres would still lack physicians. Maternal and child welfare centres are largely non-functional due to the absence of consultants, and complicated cases are referred to upazila or district hospitals rather than to the Family Planning Department’s own maternal and child welfare centres, which themselves lack specialist support.
According to the World Health Organisation, achieving Sustainable Development Goal 3 requires 4.45 healthcare providers per 1,000 population, in a ratio of 1:3:5 for physicians, nurses and paramedics. This implies around 15 physicians for a union of 30,000 people. Even when including field workers — such as family welfare visitors, midwives, health assistants, family welfare assistants and community health care providers — the workforce remains less than one-fifth of the requirement. Physician and nurse posts stand at roughly half and one-third of required levels, respectively, with 20–40 per cent vacancies at any given time. Distribution is also inequitable.
Urban primary healthcare infrastructure remains largely undeveloped. Although all 12 city corporations and 329 municipalities have health departments, many lack qualified personnel and trained managers; some are even led by non-health professionals. For over two decades, the Asian Development Bank has supported urban health projects through the Ministry of Local Government, Rural Development & Cooperatives, despite the ministry’s mandate not explicitly including health. Local government institutions have been assigned healthcare responsibilities under relevant Acts (2009 and 2010) without adequate capacity-building. Projects have been managed centrally rather than through local health departments, raising concerns about sustainability once external support ends.
Beyond staffing shortages, service quality is affected by inadequate training, poor service conditions and politicised recruitment processes, often lacking psychological assessment. Coordination among frontline workers — community health care providers, health assistants and family welfare assistants — is weak, resulting in duplication of services and inefficiency. Community clinics, despite serving large populations daily, suffer from poor infrastructure, insufficient space, weak governance and unclear administrative structures. Many facilities are dilapidated or non-functional, and staff remain underpaid relative to comparable professions such as primary school teachers.
What the Reform Commission recommended and what else may be done
IN ADDITION to addressing these systemic challenges, the Commission recommended recruiting two staff members for each community clinic and merging the three categories of frontline workers under a unified role with a common job description. Dividing catchment populations among them would enable more focused care and longer engagement with service recipients. The Commission proposed renaming community clinics as “first-level health centres” and frontline workers as “Community Health Promoters.” It also recommended establishing two permanent health outposts per clinic to reduce reliance on home visits, which have proven inefficient.
The Commission further suggested abolishing the Community Clinic Health Support Trust Act of 2018, which separated clinics from the mainstream primary healthcare system, creating additional fragmentation. Alternatively, the Trust could be expanded and restructured to cover all primary healthcare infrastructure, with a mandate for coordination, guidance and accountability.
Other recommendations include deploying medical assistants on a trial basis in clinics lacking staff, enhancing training for qualified field workers and creating career progression pathways for community health care providers. Greater collaboration with non-governmental organisations and contracting in or out services in urban areas were also proposed as cost-effective strategies. Incentives, including salary enhancements of 30–100 per cent for professionals in remote areas, were recommended to improve recruitment and retention.
Union-level health facilities were envisioned as the hub of primary healthcare services, requiring strengthening in infrastructure, logistics, finance and human resources. The Commission proposed integrating health and family planning services under a unified Directorate General of Public Health or Primary Health Care (DG, PH/PHC). This integration would streamline service delivery and reduce institutional fragmentation.
Reformed union facilities would provide first-line clinical care, referral services and oversight of preventive and promotive health activities. Each would require at least three physicians, four nurses and midwives, diagnostic and pharmacy staff, support personnel and adequate infrastructure, including residential facilities for non-local staff.
A reconstituted oversight body — possibly evolving from the existing Trust into a statutory commission — would ensure accountability, monitoring and quality assurance. The Commission also recommended appointing additional director generals to oversee specialised areas such as family planning, geriatric care, rehabilitation and social welfare, and integrating local government health departments into the national primary healthcare framework.
Finally, the broader mandate of public health justifies the proposed Directorate General of Public Health or Primary Health Care structure. Public health encompasses disease prevention, surveillance and emergency response, requiring legal authority to mobilise resources across sectors during crises. A comprehensive legal framework would enable coordinated action across institutions, ensuring preparedness and effective response to epidemics and pandemics, with primary healthcare as the foundation.
Dr Abu Muhammad Zakir Hussain is chairman of the Community Clinic Health Support Trust. He was a member of the Health Sector Reform Commission; Director of Primary Health Care, Directorate General of Health Services; Regional Advisor to the World Health Organisation; and Staff Consultant to the Asian Development Bank.
