As is the case in other developing countries, palliative care remains a major unmet need in Bangladesh. Shahaduz Zaman and colleagues present a project undertaken to provide community-based palliative care to people living in two slum towns in Bangladesh

Ahmed, Nezamuddin

Jahan, Ferdous

Ur Rashid, Mamun

Zaman, Shahaduz

English

Enlighten

      Zaman, S., Ahmed, N., Ur Rashid, M. and Jahan, F. (2017) Palliative care for slum population: a case from Bangladesh. European Journal of Palliative Care, 24(4), pp. 156-160.     This document is held under copyright by Hayward Group Ltd, publisher of the European Journal of Palliative Care. It may be downloaded for single academic use only. Reproduction for any other purpose is not allowed. For further information, please contact the journal by clicking here.   http://eprints.gla.ac.uk/144475/             Deposited on: 15 September 2017                       Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk | www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)156service developmentSPalliative care for slumpopulations: A case from BangladeshS as is the case in other developing countries, palliative care remains a major unmet need inBangladesh. Shahaduz Zaman, Nezamuddin Ahmed,Mamun Ur Rashid and Ferdous Jahan present a projectundertaken to provide community-based palliative careto people living in two slum towns in Bangladesh.S Inhabitants of Korail Slum livingunder an open sky inMarch 2017. The slumhas experienced two major fires – in March this year andDecember 2016 – each of whichdestroyed severalhundred shanties.raKiB hasan/alamyCopyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.ukhe World Health Assembly hasrecommended that countriesintegrate evidence-based, cost-effectiveand equitable palliative care services inthe continuum of care, across all levels,with emphasis on primary, communityand home-based care.1 Bangladesh is inStage 3a on the world palliative caredevelopmental map, which means thatsome isolated palliative care services andtraining provision exist here.2 However, arecent situation analysis revealed thatalthough Bangladesh has approximately600,000 incurable patients at any point intime, at present it has only six capital cityDhaka-based comprehensive palliativecare programmes, which altogetherserved fewer than 1,500 patients in 2013.3The same study found that 75% of cancerpatients experienced pain, and more than90% of health professionals did not haveany training in pain management orpalliative care.in 2007, Bangabandhu Sheikh Mujib MedicalUniversity (BSMMU) in Dhaka, which is the onlymedical university in the country, recognisedpalliative care as one of its key objectives andbegan to provide some rudimentary services. A Centre for Palliative Care (CPC) was formallyestablished in 2011. this was a most remarkablebreakthrough among the few palliative careinitiatives in Bangladesh. in 2011, 15 inpatientbeds were created in the centre. in 2015, the CPCinitiated a pilot project to extend its activities intotwo urban slums in Dhaka, the Agargaon andKorail slums, in collaboration with the WorldwideHospice Palliative Care Alliance (WHPCA). Goals of the slum palliative care projectOf Bangladesh’s population of 160 million, it isestimated that 2.23 million people – many ofthem elderly – are currently living in over 9,000slums.4 Slum life is characterised by crampedconditions, lack of access to clean water, poordrainage, flooding, infections, exploitation andextreme poverty. the pilot project initiated byBSMMU mainly focused on the provision ofpalliative care to elderly people in the Agargaonand Korail slums. it was jointly funded byBSMMU and the WHPCA, with additionalcontributions from the rotary Club ofMetropolitan Dhaka and the AfzalunnessaFoundation. it was taken forward through acommunity-driven, public health approach, with the following specific goals:● to undertake a situation and needs analysis ofolder people, and their caregivers, who requirepalliative care and assess the current careprovision by family, community members andrelevant organisations.● to identify and forge partnerships withcommunity health workers, grassroot networksfor health and older people, and other relevantorganisations working in the two urban slums.● to undertake a sensitisation programme toincrease understanding and awareness ofpalliative care in the slums, includingdeveloping an activist group of older people.● to print 200 copies of the Palliative Caretoolkit in Bengali – the toolkit was originallyproduced in English by Help the Hospices (now Hospice UK) in 2008.● to train six to eight Palliative Care Assistants(PCAs) from the communities to provide careand refer for further medical care, using thePalliative Care toolkit.● to establish a homecare outreach palliative careservice in the two slums, comprising nursingstaff and trained assistants.● to provide treatment and support to 100palliative care patients and theircaregivers/family members.● to demonstrate an effective model of palliativecare for older people in an urban slum, throughthe production of a final evaluation report.At the beginning of the pilot project, CPCBangladesh conducted a rapid situation analysiswww.ejpc.eu.com |European Journal of Palliative Care | 2017; 24(4) 157service development&Shahaduz Zamanphd research Fellow(global interventionat the End of lifeproject)1NezamuddinAhmed md Fcps mBBsprofessor ofpalliative medicine 2Mamun Ur Rashidmss Executivedirector3Ferdous Jahan phdprofessor of publicadminstration 41 school ofinterdisciplinarystudies, dumfriescampus, university ofglasgow, dumfries,scotland2 centre for palliativecare, Bangabandhusheikh mujib medicaluniversity, dhaka,Bangladesh3 developmentresearch initiative,dhaka, Bangladesh4 department of publicadministration,university of dhaka,dhaka, BangladeshTTable 1. Support and care provided by the projectCategory Services and support provided Frequencyhealth support • regular follow-up • medicine supply • Emergency health service• routine check-upregular basiscare support • Wound care, helping in shower, nail cutting, hair cutting, home cleaning etc.• counselling to shocked/bereaved family membersBased on necessityFood support • rice (5 kg) • peas (2 kg) • sugar (1 kg) • salt (1 kg) • Edible oil (1 kg) monthlyFestival support new clothes, blankets, special food during festival timeadditional support Exercise machines, cataract operation and other medical services Based on necessityCopyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.ukto select programme beneficiaries and develop anoperation strategy. Activities began by meetingwith teachers and committee members of twoschools in the slums to discuss the objectives ofthe project. During the meetings, support wassought for introductions to the slum dwellers,and experiences of working in the slums wereshared. the feasibility of the project activities wasalso discussed and feedback obtained. Followingthe meetings, a two-day sensitisation programmewas organised with people in the two slums,targeting the parents of the students. the PCArecruits underwent a thorough trainingprogramme on palliative care, following astructured curriculum: six weeks of classroomteaching, followed by six weeks in the hospitalward and then 12 weeks spent mostly on homevisits in the slum under supervision.Support and care provided by the projectEight young women were trained as ‘vanguards’,and took on the role of PCAs. these femalevolunteers in the community were trained toprovide home-based palliative care, includingphysical, social, psychological and spiritual care,to their patients. table 1 (see page 157)  shows thesupport and care provided by the PCAs to thepatients. Various medical services, includingemergency health services, were provided bynurses and doctors.Evaluation of the projectAn independent evaluation of the project wascarried out one year after inception by a localresearch organisation called Developmentresearch initiative (dri) under the supervision ofShahaduz Zaman, a research fellow at theUniversity of Glasgow. the evaluation study wascarried out using various qualitative techniques,including in-depth interviews with projectbeneficiaries, key informant interviews withproject managers and community leaders, andfocus group discussions with PCAs,complemented by demographic, medical andservice-related quantitative data reviewingsecondary sources. Qualitative data were analysedmanually using framework approach. theevaluation had three dimensions: themanagement of the project; the effects of theproject on the beneficiary’s life; and sustainability.A total of 106 patients and their familiesbenefited from the project during the first sixmonths. the majority (62.3%) were female; the| www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)158service developmentS One of the pilot project’s eightPalliative CareAssistants attendsto the palliative careneeds of an elderlywoman in KorailSlum, with hercolleagues from the Centre forPalliative Care.cEntrE For palliativEcarE/BangaBandhushEiKh muJiB mEdicalunivErsityCopyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.ukaverage age was 66.8 years (female patients) and71.9 (male). Eighty per cent of the beneficiarieswere illiterate, with an average income of US$180per month. the patients received essentialmedicines, various forms of care and foodassistance. the beneficiaries were selectedthrough a rapid Situation Analysis by consultingwith community-based organisations in the slumand involving local adolescents. Selectingappropriate beneficiaries was challenging in thebeginning. the evaluation showed that, initially,the project did not follow strict criteria forselecting beneficiaries. As time progressed, theproject personnel endeavoured to correct theirown mistakes and became more effective intargeting their resources. However, in the context of extreme poverty, and a complete lackof health services, it became very difficult for theproject to determine the inclusion criteria for thepalliative care beneficiary – this is something thatdemands a discussion in the broader palliativecare community.in the beginning, the people within thecommunity were uncooperative. in addition, due to the absence of previous relevant experience,the project personnel had to proceed through a‘learning by doing’ approach. initially, the PCAsexperienced some resistance to their work in thecommunity, but they are now largely accepted andplay a pivotal role in the project. the beneficiarieshold the services PCAs provide to them in highregard. the beneficiaries were found to be highlysatisfied with the medical, social and food supportprovided to them by the project. As one elderlymale patient said of himself and his wife: ‘Both of us are old now and there is no one to look after us. We take care of each other,but when both of us get sick, then there is no one left to take care of us in this shanty.Girls [PCAs] from the office visit our homeregularly and look after us. They spend agood time with us, talk to us freely and weshare our thoughts with each other. They are like family to us.’the study revealed that almost all thebeneficiaries found that their self-confidence and self-esteem increased after joining thisproject. During one discussion, a femalebeneficiary observed:‘I have confidence now … nothing willhappen if my son or daughter do not lookwww.ejpc.eu.com |European Journal of Palliative Care | 2017; 24(4) 159service developmentS Today, Korail Slum,Dhaka’s largest, seenhere across BananiLake, is estimated tohave in the region of40,000 residents;most of them live inshanties constructedfrom bamboo frameswith corrugated tinwalls and roofs.palash Khan/alamyCopyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.ukafter me … I have the confidence that thesepeople from the office are beside me … theywill surely support me if anything happens.’the project also has changed somecommunity perceptions. For example, oneshopkeeper remarked:‘The rice and peas for project beneficiariesare bought from my shop. I don’t take profit from them because they are doing a good job.’Questions remain, however, about whether the project is sustainable. the PCAs are the keymovers of the project and much depends on them.When asked what will happen if they marry andleave the slum, most echoed this person’s view:‘It is true that we will get married one day,but the knowledge we have gained will not getmarried off. Wherever we go and live, we willuse the knowledge gathered from this projectand thus serve people. Even if the project isclosed, we will continue our service; nobodycan stop us from continuing our effort.’Nevertheless, the project continues to rely on external resources. its overall budget for thefirst year was approximately £5,000. Accordingto many project staff, the patients to whom they are providing treatment and services arebecoming dependent upon them. they fear thatthe beneficiaries will be left helpless if the projectis closed. Community participation in the projectis also still quite limited, but just one year in, itwould be premature to make judgements on itsfuture viability. Conclusionsthere are enormous challenges in running a slum-based community palliative care project of thistype, characterised by a highly mobile population,informal power structures and high levels ofuncertainty. Yet it is apparent from the evaluationthat the project has achieved considerable successwithin a year. the clients are highly satisfied withthe services they have received and appear to havebenefited physically, socially, psychologically andspiritually – reflecting the component parts of theproject. the community volunteers who werechased away by slum dwellers at the beginning ofthe project are now made welcome in people’shouses. the objectives of palliative care are nowknown and appreciated by the community.Globally, there are very few examples ofcommunity oriented end-of-life care in resource-poor settings such as this. it is widely argued thatperhaps the most refined version of the model isthe Neighbourhood Networks in Palliative Care(NNPC) in Kerala, india.5,6 the NNPC is anattempt to facilitate a sustainable, community-ledservice capable of providing palliative care to allthose in need, with limited resources. Given thefact that almost all the available palliative careservices in Bangladesh have taken institution-based approaches following Western models, thiscommunity-based initiative in the slum may havemuch to teach us ■Declaration of interestthe authors declare that there is no conflict of interest.Acknowledgmentsthe authors would like to thank Worldwide hospice palliative care alliance(Whpca) and the Wellcome trust (grant number 103319/Z/13/Z) for fundingthe evaluation of the project.References1. World health assembly (Wha). Strengthening of palliative care as acomponent of comprehensive care through the life course. sixty-seventh Worldassembly, agenda item 15.5. World health organization, 2014.http://apps.who.int/gb/ebwha/pdf_files/Wha67/a67_r19-en.pdf2. lynch t, connor s, clark d. mapping levels of palliative care development: aglobal update. J Pain Symptom Manage 2013; 45: 1094–1106.3. national institute of population research and training (niport). NationalSituation Analysis of Palliative Care in Bangladesh, 2013. dhaka: ministry ofhealth and Family Welfare, 2013.4. Bangladesh Bureau of statistics (BBs). Population and housing consensus2011. dhaka: BBs, 2011.5. Kumar s, palmed d. india: a regional community-based palliative care model.J Pain Symptom Manage 2007; 33: 623–627.6. sallnow l, Kumar s, numpeli m. home-based palliative care in Kerala, india:the neighbourhood network in palliative care. Prog Palliat Care 2010; 18:14–17.| www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)160service developmentS Bangladesh has approximately 600,000incurable patients at any point of time. Atpresent, it has only six capital city Dhaka-based comprehensive palliative careprogrammes, which altogether served <1,500 patients in 2013.S In 2007, Bangabandhu Sheikh Mujib MedicalUniversity – the country’s only medicaluniversity – recognised palliative care as oneof its key services and established the Centrefor Palliative Care (CPC). In 2015, the CPCinitiated a pilot project to extend the reach ofpalliative care services for older people andtheir families in two urban slums in Dhaka.S A mixed methods evaluation of the projectafter one year reveals that it created highlypositive impacts on the lives of thebeneficiaries and the wider community.S Nevertheless, the sustainability of the projectremains in doubt while it continues to dependon external resources.S In a country in which almost all the availablepalliative care services have taken institution-based approaches, following Western models,this community-based initiative in Bangladeshhas much to commend it and could serve as apublic health model for palliative care in otherresource-poor settings.KeypointsCopyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk

Palliative care for slum population: a case from Bangladesh

Enlighten: Publications

  
 
 
 
 
Zaman, S., Ahmed, N., Ur Rashid, M. and Jahan, F. (2017) Palliative care for slum 
population: a case from Bangladesh. European Journal of Palliative Care, 24(4), pp. 156-
160. 
 
   
This document is held under copyright by Hayward Group Ltd, publisher of 
the European Journal of Palliative Care. It may be downloaded for single academic use 
only. Reproduction for any other purpose is not allowed. For further information, please 
contact the journal by clicking here. 
 
 
http://eprints.gla.ac.uk/144475/  
     
 
 
 
 
 
 
Deposited on: 15 September 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enlighten – Research publications by members of the University of Glasgow 
http://eprints.gla.ac.uk 
| www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)156
service development
S
Palliative 
care for slum
populations: 
A case from 
Bangladesh
S as is the case in other developing countries, 
palliative care remains a major unmet need in
Bangladesh. Shahaduz Zaman, Nezamuddin Ahmed,
Mamun Ur Rashid and Ferdous Jahan present a project
undertaken to provide community-based palliative care
to people living in two slum towns in Bangladesh.
S Inhabitants of 
Korail Slum living
under an open sky in
March 2017. The slum
has experienced 
two major fires – in 
March this year and
December 2016 – 
each of which
destroyed several
hundred shanties.
raKiB hasan/alamy
Copyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
he World Health Assembly has
recommended that countries
integrate evidence-based, cost-effective
and equitable palliative care services in
the continuum of care, across all levels,
with emphasis on primary, community
and home-based care.1 Bangladesh is in
Stage 3a on the world palliative care
developmental map, which means that
some isolated palliative care services and
training provision exist here.2 However, a
recent situation analysis revealed that
although Bangladesh has approximately
600,000 incurable patients at any point in
time, at present it has only six capital city
Dhaka-based comprehensive palliative
care programmes, which altogether
served fewer than 1,500 patients in 2013.3
The same study found that 75% of cancer
patients experienced pain, and more than
90% of health professionals did not have
any training in pain management or
palliative care.
in 2007, Bangabandhu Sheikh Mujib Medical
University (BSMMU) in Dhaka, which is the only
medical university in the country, recognised
palliative care as one of its key objectives and
began to provide some rudimentary services. 
A Centre for Palliative Care (CPC) was formally
established in 2011. this was a most remarkable
breakthrough among the few palliative care
initiatives in Bangladesh. in 2011, 15 inpatient
beds were created in the centre. in 2015, the CPC
initiated a pilot project to extend its activities into
two urban slums in Dhaka, the Agargaon and
Korail slums, in collaboration with the Worldwide
Hospice Palliative Care Alliance (WHPCA). 
Goals of the slum palliative 
care project
Of Bangladesh’s population of 160 million, it is
estimated that 2.23 million people – many of
them elderly – are currently living in over 9,000
slums.4 Slum life is characterised by cramped
conditions, lack of access to clean water, poor
drainage, flooding, infections, exploitation and
extreme poverty. the pilot project initiated by
BSMMU mainly focused on the provision of
palliative care to elderly people in the Agargaon
and Korail slums. it was jointly funded by
BSMMU and the WHPCA, with additional
contributions from the rotary Club of
Metropolitan Dhaka and the Afzalunnessa
Foundation. it was taken forward through a
community-driven, public health approach, 
with the following specific goals:
● to undertake a situation and needs analysis of
older people, and their caregivers, who require
palliative care and assess the current care
provision by family, community members and
relevant organisations.
● to identify and forge partnerships with
community health workers, grassroot networks
for health and older people, and other relevant
organisations working in the two urban slums.
● to undertake a sensitisation programme to
increase understanding and awareness of
palliative care in the slums, including
developing an activist group of older people.
● to print 200 copies of the Palliative Care
toolkit in Bengali – the toolkit was originally
produced in English by Help the Hospices 
(now Hospice UK) in 2008.
● to train six to eight Palliative Care Assistants
(PCAs) from the communities to provide care
and refer for further medical care, using the
Palliative Care toolkit.
● to establish a homecare outreach palliative care
service in the two slums, comprising nursing
staff and trained assistants.
● to provide treatment and support to 100
palliative care patients and their
caregivers/family members.
● to demonstrate an effective model of palliative
care for older people in an urban slum, through
the production of a final evaluation report.
At the beginning of the pilot project, CPC
Bangladesh conducted a rapid situation analysis
www.ejpc.eu.com |European Journal of Palliative Care | 2017; 24(4) 157
service development
&
Shahaduz Zaman
phd research Fellow
(global intervention
at the End of life
project)1
Nezamuddin
Ahmed md Fcps mBBs
professor of
palliative medicine 2
Mamun Ur Rashid
mss Executive
director3
Ferdous Jahan phd
professor of public
adminstration 4
1 school of
interdisciplinary
studies, dumfries
campus, university of
glasgow, dumfries,
scotland
2 centre for palliative
care, Bangabandhu
sheikh mujib medical
university, dhaka,
Bangladesh
3 development
research initiative,
dhaka, Bangladesh
4 department 
of public
administration,
university of dhaka,
dhaka, Bangladesh
T
Table 1. Support and care provided by the project
Category Services and support provided Frequency
health support • regular follow-up • medicine supply • Emergency health service
• routine check-up
regular basis
care support • Wound care, helping in shower, nail cutting, hair cutting, home cleaning etc.
• counselling to shocked/bereaved family members
Based on necessity
Food support • rice (5 kg) • peas (2 kg) • sugar (1 kg) • salt (1 kg) • Edible oil (1 kg) monthly
Festival support new clothes, blankets, special food during festival time
additional support Exercise machines, cataract operation and other medical services Based on necessity
Copyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
to select programme beneficiaries and develop an
operation strategy. Activities began by meeting
with teachers and committee members of two
schools in the slums to discuss the objectives of
the project. During the meetings, support was
sought for introductions to the slum dwellers,
and experiences of working in the slums were
shared. the feasibility of the project activities was
also discussed and feedback obtained. Following
the meetings, a two-day sensitisation programme
was organised with people in the two slums,
targeting the parents of the students. the PCA
recruits underwent a thorough training
programme on palliative care, following a
structured curriculum: six weeks of classroom
teaching, followed by six weeks in the hospital
ward and then 12 weeks spent mostly on home
visits in the slum under supervision.
Support and care 
provided by the project
Eight young women were trained as ‘vanguards’,
and took on the role of PCAs. these female
volunteers in the community were trained to
provide home-based palliative care, including
physical, social, psychological and spiritual care,
to their patients. table 1 (see page 157)  shows the
support and care provided by the PCAs to the
patients. Various medical services, including
emergency health services, were provided by
nurses and doctors.
Evaluation of the project
An independent evaluation of the project was
carried out one year after inception by a local
research organisation called Development
research initiative (dri) under the supervision of
Shahaduz Zaman, a research fellow at the
University of Glasgow. the evaluation study was
carried out using various qualitative techniques,
including in-depth interviews with project
beneficiaries, key informant interviews with
project managers and community leaders, and
focus group discussions with PCAs,
complemented by demographic, medical and
service-related quantitative data reviewing
secondary sources. Qualitative data were analysed
manually using framework approach. the
evaluation had three dimensions: the
management of the project; the effects of the
project on the beneficiary’s life; and sustainability.
A total of 106 patients and their families
benefited from the project during the first six
months. the majority (62.3%) were female; the
| www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)158
service development
S One of the 
pilot project’s eight
Palliative Care
Assistants attends
to the palliative care
needs of an elderly
woman in Korail
Slum, with her
colleagues from 
the Centre for
Palliative Care.
cEntrE For palliativE
carE/BangaBandhu
shEiKh muJiB mEdical
univErsity
Copyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
average age was 66.8 years (female patients) and
71.9 (male). Eighty per cent of the beneficiaries
were illiterate, with an average income of US$180
per month. the patients received essential
medicines, various forms of care and food
assistance. the beneficiaries were selected
through a rapid Situation Analysis by consulting
with community-based organisations in the slum
and involving local adolescents. Selecting
appropriate beneficiaries was challenging in the
beginning. the evaluation showed that, initially,
the project did not follow strict criteria for
selecting beneficiaries. As time progressed, the
project personnel endeavoured to correct their
own mistakes and became more effective in
targeting their resources. However, in the 
context of extreme poverty, and a complete lack
of health services, it became very difficult for the
project to determine the inclusion criteria for the
palliative care beneficiary – this is something that
demands a discussion in the broader palliative
care community.
in the beginning, the people within the
community were uncooperative. in addition, 
due to the absence of previous relevant experience,
the project personnel had to proceed through a
‘learning by doing’ approach. initially, the PCAs
experienced some resistance to their work in the
community, but they are now largely accepted and
play a pivotal role in the project. the beneficiaries
hold the services PCAs provide to them in high
regard. the beneficiaries were found to be highly
satisfied with the medical, social and food support
provided to them by the project. As one elderly
male patient said of himself and his wife: 
‘Both of us are old now and there is no one 
to look after us. We take care of each other,
but when both of us get sick, then there is 
no one left to take care of us in this shanty.
Girls [PCAs] from the office visit our home
regularly and look after us. They spend a
good time with us, talk to us freely and we
share our thoughts with each other. They 
are like family to us.’
the study revealed that almost all the
beneficiaries found that their self-confidence 
and self-esteem increased after joining this
project. During one discussion, a female
beneficiary observed:
‘I have confidence now … nothing will
happen if my son or daughter do not look
www.ejpc.eu.com |European Journal of Palliative Care | 2017; 24(4) 159
service development
S Today, Korail Slum,
Dhaka’s largest, seen
here across Banani
Lake, is estimated to
have in the region of
40,000 residents;
most of them live in
shanties constructed
from bamboo frames
with corrugated tin
walls and roofs.
palash Khan/alamy
Copyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk
after me … I have the confidence that these
people from the office are beside me … they
will surely support me if anything happens.’
the project also has changed some
community perceptions. For example, one
shopkeeper remarked:
‘The rice and peas for project beneficiaries
are bought from my shop. I don’t take 
profit from them because they are doing 
a good job.’
Questions remain, however, about whether 
the project is sustainable. the PCAs are the key
movers of the project and much depends on them.
When asked what will happen if they marry and
leave the slum, most echoed this person’s view:
‘It is true that we will get married one day,
but the knowledge we have gained will not get
married off. Wherever we go and live, we will
use the knowledge gathered from this project
and thus serve people. Even if the project is
closed, we will continue our service; nobody
can stop us from continuing our effort.’
Nevertheless, the project continues to rely 
on external resources. its overall budget for the
first year was approximately £5,000. According
to many project staff, the patients to whom 
they are providing treatment and services are
becoming dependent upon them. they fear that
the beneficiaries will be left helpless if the project
is closed. Community participation in the project
is also still quite limited, but just one year in, it
would be premature to make judgements on its
future viability. 
Conclusions
there are enormous challenges in running a slum-
based community palliative care project of this
type, characterised by a highly mobile population,
informal power structures and high levels of
uncertainty. Yet it is apparent from the evaluation
that the project has achieved considerable success
within a year. the clients are highly satisfied with
the services they have received and appear to have
benefited physically, socially, psychologically and
spiritually – reflecting the component parts of the
project. the community volunteers who were
chased away by slum dwellers at the beginning of
the project are now made welcome in people’s
houses. the objectives of palliative care are now
known and appreciated by the community.
Globally, there are very few examples of
community oriented end-of-life care in resource-
poor settings such as this. it is widely argued that
perhaps the most refined version of the model is
the Neighbourhood Networks in Palliative Care
(NNPC) in Kerala, india.5,6 the NNPC is an
attempt to facilitate a sustainable, community-led
service capable of providing palliative care to all
those in need, with limited resources. Given the
fact that almost all the available palliative care
services in Bangladesh have taken institution-
based approaches following Western models, this
community-based initiative in the slum may have
much to teach us ■
Declaration of interest
the authors declare that there is no conflict of interest.
Acknowledgments
the authors would like to thank Worldwide hospice palliative care alliance
(Whpca) and the Wellcome trust (grant number 103319/Z/13/Z) for funding
the evaluation of the project.
References
1. World health assembly (Wha). Strengthening of palliative care as a
component of comprehensive care through the life course. sixty-seventh World
assembly, agenda item 15.5. World health organization, 2014.
http://apps.who.int/gb/ebwha/pdf_files/Wha67/a67_r19-en.pdf
2. lynch t, connor s, clark d. mapping levels of palliative care development: a
global update. J Pain Symptom Manage 2013; 45: 1094–1106.
3. national institute of population research and training (niport). National
Situation Analysis of Palliative Care in Bangladesh, 2013. dhaka: ministry of
health and Family Welfare, 2013.
4. Bangladesh Bureau of statistics (BBs). Population and housing consensus
2011. dhaka: BBs, 2011.
5. Kumar s, palmed d. india: a regional community-based palliative care model.
J Pain Symptom Manage 2007; 33: 623–627.
6. sallnow l, Kumar s, numpeli m. home-based palliative care in Kerala, india:
the neighbourhood network in palliative care. Prog Palliat Care 2010; 18:
14–17.
| www.ejpc.eu.com European Journal of Palliative Care | 2017; 24(4)160
service development
S Bangladesh has approximately 600,000
incurable patients at any point of time. At
present, it has only six capital city Dhaka-
based comprehensive palliative care
programmes, which altogether served 
<1,500 patients in 2013.
S In 2007, Bangabandhu Sheikh Mujib Medical
University – the country’s only medical
university – recognised palliative care as one
of its key services and established the Centre
for Palliative Care (CPC). In 2015, the CPC
initiated a pilot project to extend the reach of
palliative care services for older people and
their families in two urban slums in Dhaka.
S A mixed methods evaluation of the project
after one year reveals that it created highly
positive impacts on the lives of the
beneficiaries and the wider community.
S Nevertheless, the sustainability of the project
remains in doubt while it continues to depend
on external resources.
S In a country in which almost all the available
palliative care services have taken institution-
based approaches, following Western models,
this community-based initiative in Bangladesh
has much to commend it and could serve as a
public health model for palliative care in other
resource-poor settings.
Key
points
Copyright © Hayward Medical Communications 2017. All rights reserved. No unauthorised reproduction or distribution. For reprints or permissions, contact edit@hayward.co.uk


https://eprints.gla.ac.uk/144475/7/144475.pdf

Palliative care for slum population: a case from Bangladesh

Abstract

Similar works

Full text

Available Versions

Enlighten

Enlighten: Publications