Reproductive Health Services for Garment Factory Workers in Bangladesh

 

Over the last decade there has been a rapid increase in the number of garment factories in Bangladesh in response to foreign demand for cheap labour and materials. The factories employ around 1.5 million workers, of whom the vast majority are young women of reproductive age. Many of these women are suffering from chronic ill health. Marie Stopes Clinic Society (MSCS) works closely with the factory owners to address the needs of some of these women by providing health services on site. As the owners pay a monthly insurance premium on behalf of each worker, the services are provided free of charge and are almost completely self-funding.

 

Research has shown that over 40% of the female workers in the factories suffer from chronic diseases such as gastro-intestinal and sexually transmitted diseases (STDs), reproductive tract infections (RTIs), menstrual and blood pressure problems, anaemia and family planning related illnesses. The abortion rate among garment workers is also high, with about 18% of married workers interviewed having experienced at least one abortion usually in unhygienic and inappropriate situations.

 

The high rate of illness has had two major outcomes. Firstly, there is widespread suffering of physical disability and chronic fatigue. Secondly, there has been a knock-on impact on earnings as a result of lower productivity and absenteeism. It is estimated that each worker loses approximately two days salary per month due to illness and fatigue. The loss of earnings is exacerbated by the worker having to seek external, often private, medical assistance which could cost up to 9% of their monthly wage. Chronic ill-health has meant that many employees have to give up working at the factory and figures show that the majority of garment workers last less than three years in the industry.

 

Factory Health Insurance Scheme

 

In response to this situation of a poor, largely female workforce almost entirely of reproductive age (the average age is 20), MSCS implemented a Factory Health Insurance Scheme in 1997. The aim of the scheme is to provide free, quality reproductive and general health services to workers on-site, financed through monthly health insurance payments made by the factory owners.

 

The Factory Health Insurance Scheme currently operates in 172 factories covered by five Marie Stopes Centres. Each Marie Stopes Centre acts as a focal point for the Factory Health Insurance Scheme that operates within its vicinity, with factory satellite teams using the Centre clinic as a base. Factory sessions provided by the satellite teams last three hours, with two factories visited by each team every day, six days a week. The team comprises a doctor and a paramedic/counsellor. All staff undergo induction and ongoing training and are subject to regular performance appraisals.

 

Various criteria are used in the selection of factories for the Health Insurance Scheme. For the scheme to be financially viable there needs to be a minimum number of workers per factory, of whom some 75% must be women of reproductive age. Existing health service provision by the government, private and non-government organisations is also researched to establish unmet needs. Location of the factories in relation to the Marie Stopes Centre (for referrals and support services) and with each other also have a bearing on selection.

 

Health Scheme Services

 

The scheme provides reproductive services, general health checks, ante-natal care, STI treatments, treatment for minor infections and immunisations. Educational sessions and other IEC activities also take place at the factory, usually in the workers’ lunch hour. These take the form of slide show/audio story lines on reproductive and general health issues such as ante and post-natal health, oral contraceptives, condom usage, STIs and HIV/AIDS, nutrition and personal hygiene.

 

A factory manager is responsible for arranging workers’ visits the satellite health service, with the number of clients limited to around 30-40 per session to ensure each receives adequate time for consultation and/or treatment. Recent results from the MSCS scheme indicate that approximately 60% of clients require general health services and 40% reproductive health services.

 

Clients are invited to attend the Marie Stopes Centre for free services that are not provided by the Satellite team, such as IUD and tubal ligation. For any services not provided by MSCS, referral systems are established with other health centres.

 

Factory Owner Co-operation

 

The scheme is only possible with the full co-operation of the factory owners, who contribute to the costs of the project, thus ensuring a high degree of sustainability is reached. The owners pay a monthly contribution on behalf of each worker. This amount is very small but high enough to cover costs and requires the careful linking of the number of visits by the satellite team to the number of workers. Too many satellite teams per worker would be too expensive; too few would impact on the quality of services provided.

 

Some of the main difficulties for the scheme are caused by the non-clinical, and often cramped and chaotic, environment in which the services are provided. This can make it quite a challenge to ensure the best possible quality of service and MSCS ensures that the best possible conditions are agreed beforehand with the factory owner.

 

MSCS follows various monitoring processes to maintain high standards. Counselling, client relations, infection prevention and cleanliness are audited regularly, while staff and client feedback is sought. Monthly meetings are also held between factory management/owners and Marie Stopes Centre managers to review the service and discuss any issues or suggestions.

 

Despite the efficient and economic systems put in place at MSCS for satellite service provision, the Factory Health Insurance Scheme represents a considerable financial outlay for the factory owner. However, owners are aware that this is offset by other financial benefits:

 

·         Over 90% of Bangladesh’s garment products are for export, mainly to European and North American buyers who are under increasing pressure from consumer groups, NGOs and civil society to apply more ethical standards to their modes of production. As a result of this pressure, international buyers have developed ethical codes of conduct to which factory owners must comply. The adoption of the Factory Health Insurance Scheme puts the factory owner in a far stronger position to be awarded international contracts.

 

·         There is a clear link between the poor health of workers and poor productivity levels in a factory environment. Studies have estimated that a medium sized factory of about 500 workers loses 237 man-days per month due to workers illness and an additional huge work-hour loss through decreased effectiveness of workers suffering from ill-health. Where the Factory Health Insurance Scheme has been adopted, there has been a marked improvement in productivity and job satisfaction among workers as a result of improved health. Absenteeism has also decreased as workers’ health has improved and the availability of medical services on site has reduced the need for workers to take time off to visit often quite distant clinics. Another advantage is a lower rate of turnover of workers as job satisfaction and motivation increases, which translates into lower training costs and higher productivity levels.

 

Conclusion

 

The Factory Health Insurance Scheme has proved a very successful way of involving the commercial sector through local factory owners in the financing of health care. This is this increasingly relevant, given the increasing global pressure on international buyers and factory owners to provide health services to their workers. It also offers an efficient and effective way of meeting the general health needs over 55,000 of the poorest and most under-served women.

 

The ‘buy-in’ by local factory owners is the key element of the project, as this has made the scheme virtually self-sustaining. It is this factor that has made similar commercial sector partnership projects a high priority among Marie Stopes International activities in other countries. Similar schemes are already being piloted in Latin America and private sector participation in the social marketing of condoms is also taking place in Nepal.

 

This article first appeared in Sexual Health Exchange 2001/4: www.kit.nl/exchange

 

Bayard Roberts, Assistant Programme Manager, Marie Stopes International, 153-157 Cleveland Street, London W1T 6QW, United Kingdom; Tel: +44-20-7574 7368; Fax: +44-20-7574 7417; e-mail: bayard.roberts@stopes.org.uk