Over the last decade, the number of garment factories in Bangladesh has increased rapidly in response to foreign demand for cheap labour and materials. The factories employ around 1.5 million workers, most of them young women of reproductive age. Many of these women suffer from chronic ill health. Marie Stopes Clinic Society (MSCS) works closely with the factory owners to address these women's needs 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 factory workers suffer from chronic diseases such as gastrointestinal and sexually transmitted infections (STIs), reproductive tract infections (RTIs), menstrual and blood pressure problems, anaemia and problems related to family planning. The abortion rate among garment workers is also high, with about 18% of interviewed married workers having experienced at least one abortion, usually in unhygienic and unsafe situations.

The high rate of illness has had two major outcomes. First is widespread suffering of physical disability and chronic fatigue and second is the knock-on impact on earnings as a result of lower productivity and absenteeism. 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 that could cost up to 9% of his/her monthly wage. Chronic ill health has meant that many employees have had to give up factory work; statistics show that most 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 years), MSCS implemented a Factory Health Insurance Scheme in 1997, aimed at providing free, quality reproductive and general health services to workers on-site, financed through monthly health insurance payments made by factory owners. The Scheme currently operates on-site in 172 factories covered by five Marie Stopes Centres. Each Centre acts as a focal point for the Scheme 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 members undergo an introduction and ongoing training and are subject to regular performance appraisals.

Various criteria are used to select factories for the Health Insurance Scheme. For the scheme to be financially viable, each factory must have a minimum number of workers, of whom some 75% must be women of reproductive age. Existing health services provided by government, private and non-governmental organisations are investigated to determine unmet needs. The location of the factories in relation to the nearest Marie Stopes Centre (for referrals and support services) and with each other also has a bearing on selection.

Health scheme services

The scheme provides reproductive health services, general health checks, antenatal care, STI treatment, treatment for minor infections and immunisations. Educational sessions and other IEC activities also take place at the factory, usually during the workers' lunch hour. These take the form of slide shows/audio stories 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 to the satellite health service, with the number of clients limited to around 30-40 per session, to ensure that each receives adequate time for consultation and/or treatment. 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 intrauterine devices and tubal ligation. For any services not provided by MSCS, referral systems are established with other health centres.

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

Factory owner cooperation

The scheme is only possible and sustainable with the full cooperation of the factory owners. 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 have an impact on the quality of services provided. 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. Owners are aware, however, 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 with 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.
• The workers' poor health is clearly linked to poor productivity levels in the factories. Studies have estimated that a medium-sized factory of about 500 workers loses 237 workdays per month due to illness and an additional work-hour loss through the decreased effectiveness of workers suffering from ill health. Factories that have adopted the Factory Health Insurance Scheme have shown a marked improvement in productivity and job satisfaction among workers as a result of improved health. Absenteeism has also decreased, and medical services on site have reduced the time workers take off to visit often quite distant clinics. Another advantage is a lower rate of turnover of workers as job satisfaction and motivation increase, which translates into lower training costs and higher productivity levels.

Conclusion

The Factory Health Insurance Scheme has proved successful in involving the commercial sector by motivating local factory owners to finance health care. This is 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 of over 55,000 of the poorest and most under-served women in Bangladesh.

The "buy-in" by local factory owners is key, as this has made the scheme virtually self-sustaining. Establishing similar commercial sector partnership projects is now a high priority for Marie Stopes' 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.