A homegrown model of sustainable primary healthcare

The United States Agency for International Development (USAID) established Surjer Hashi (SH), meaning Smiling Sun clinics, the agency's flagship health service delivery project in Bangladesh in 1997. Designed to complement the government of Bangladesh's efforts, USAID's investment signified important healthcare shifts, including: USAID health funding ramped up to 40% in 1997; and service delivery out of static facilities instead of door-to-door.

Smiling Sun (SH) grew into the world's largest non-government primary healthcare network, serving almost 17% of Bangladesh's population at its height in 2014–15. The SH network complemented the government's service delivery, strengthened partner NGOs, trained thousands of health workers, and provided about 50 million annual service contacts during 2012–2017.

Smiling Sun clinics also functioned as a conduit for global research, health-sector innovations, and international best practices. SH's many knowledge products informed national policies, guidelines, protocols, and job aids.

Smiling Sun first invested extensively in NGOs' technical and managerial ability to help them move from donor dependence without compromising service delivery. Eventually, it became evident that USAID financing was the only thing holding the NGO network together.

In hindsight, all-out dependence on donor funds likely puts a damper on NGOs' progress towards financial self-sufficiency. There was little cognisance of the phenomenal expansion of public health infrastructure. For every SH facility, 33 community clinics had been established (in 2023, this ratio was 1:100).

By 2005, the use of private medical care in Bangladesh was the highest among neighbouring countries and higher than the average of 45 other developing countries. SH clinics refused or failed to recognise themselves as actors in an increasingly competitive market; consequently, the network's revenues covered just 17% of costs.

USAID projects continued to promote network-wide local ownership and leadership. However, NGOs did not appear to continue crucial services without USAID support. SH's healthcare presence decreased in rural satellite clinics and among the rural poor between 2012 and 2017. This was due to the poor's expanding purchasing power and desire for higher-level providers, specialists, new diagnostics, etc.

AUHC began in 2017 and will finish this year, marking USAID's final technical and financial support for the health network. AUHC had to create a business to run clinics without donor money.

Creating a healthcare social enterprise was new. Managing 369 health clinics with a 38% cost recovery was considerably harder. Additionally, many clinics provided low-margin basic services with deteriorated infrastructure and equipment.

AUHC developed a new operating model, which included setting up structures, people, and processes to manage the network, which came to be called the Surjer Hashi Network (SHN).

AUHC transferred clinic ownership, assets, and staff to the not-for-profit, limited enterprise. Simultaneously, AUHC's business incubator focused on designing a sustainable business model. As a 'social' enterprise, SHN had to strike a balance between ensuring inclusive healthcare and being financially sustainable.

AUHC upgraded buildings, built human resource capacity, and launched promotional activities after optimising the network to 134 clinics. New services were added to meet changing A rigorous quality improvement approach developed 'QI collaboratives' in crucial services, including antenatal care and delivery. SHN uses data to improve quality continuously. An e-learning portal hosts AUHC's many knowledge products, including clinical protocols and operations manuals.

Today, service revenue covers 80% of SHN costs, putting it on track for financial sustainability. The clinics serve over three million individuals in 54 districts. Despite developments over the past five years, Surjer Hashi clinics remain family-oriented and sympathetic. With its long-term collaboration with the government to provide important services, the SHN will remain a trusted, affordable healthcare provider for millions of Bangladeshis.

The Surjer Hashi Network, a homegrown sustainable healthcare model, may inspire public and private stakeholders to rethink private actors' role in universal health coverage.

The writer is the Chief of Party, USAID's Advancing Universal Health Coverage (AUHC) Activity.