Friendship Floating Hospitals: Healthcare for the Riverine People of Bangladesh

Abstract

Bangladesh is a land of rivers, with the settlements near the river banks, coastal areas, and char island areas typically being zones of great poverty. Providing basic healthcare services to these people is a considerable challenge. In this situation, the Friendship Floating Hospitals emerged, offering a line of floating hospitals—the Lifebuoy Friendship Hospital, Emirates Friendship Hospital, and Rongdhonu Friendship Hospital. Providing full-fledged hospitals inside a ship, these ships sail to the threshold of the riverine people of Bangladesh and dock nearby to help people access their basic right to decent health. This article explores the unique health services provided by the Friendship team, utilizing an approach, “the 4As” (affordability, availability, acceptability, and awareness), to assess health service delivery for the riverine people of Bangladesh.

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Blossier: The Achilles’ Heel of the Brazilian Economy 175
Copyright © 2019 SAGE Publications www.sagepublications.com
(Los Angeles, London, New Delhi, Singapore, Washington DC and Melbourne)
Vol 35(1): 175–194. DOI: 10.1177/0169796X19826763
Friendship Floating Hospitals: Healthcare for
the Riverine People of Bangladesh
Jashim Uddin Ahmed
North South University
Maliha Rahanaz
InterResearch, Dhaka
Rubaiyat-i-Siddique
InterResearch, Dhaka
ABSTRACT
Bangladesh is a land of rivers, with the settlements near the river banks, coastal
areas, and char island areas typically being zones of great poverty. Providing basic
healthcare services to these people is a considerable challenge. In this situation, the
Friendship Floating Hospitals emerged, offering a line of floating hospitals—the
Lifebuoy Friendship Hospital, Emirates Friendship Hospital, and Rongdhonu
Friendship Hospital. Providing full-fledged hospitals inside a ship, these ships
sail to the threshold of the riverine people of Bangladesh and dock nearby to help
people access their basic right to decent health. This article explores the unique
health services provided by the Friendship team, utilizing an approach, “the 4As”
(affordability, availability, acceptability, and awareness), to assess health service
delivery for the riverine people of Bangladesh.
Keywords: Bangladesh, Friendship hospitals, healthcare, poverty, floating
hospitals, char
The notion of human right builds on our shared humanity. These rights are
not derived from the citizenship of any country, or the membership of any
nation, but are presumed to be claims or entitlements of every human being.
They differ, therefore, from constitutionally created rights guaranteed for
specific people.
—Amartya Sen, The Idea of Justice (2011, pp. 143–144)

176 Journal of Developing Societies 35, 1 (2019): 175–194
Introduction
Bangladesh is a country located in the north-eastern part of South Asia,
covering an area of 147,570 square kilometers (57,000 square miles).
Bangladesh is almost entirely surrounded by India except for a short
south-eastern frontier with Myanmar and a southern coastline on the
Bay of Bengal. Bangladesh has a population of about 159.45 million (July
2018 estimate), the eighth most populous country in the world. Population
density, at 1,212 people per square kilometer (1,146 per square mile), is
very high, presenting a challenging situation for any developing coun-
try (Streatfield & Karar, 2008). With a growth rate of 1.34 percent per
annum, 1.8–2.0 million people are being added to the total population
every year (Nabi, 2012).
Since independence in 1971, the Bangladesh healthcare system cannot
claim to have made any significant progress. Public, private, and non-
government organization (NGO), the three types of healthcare services
available in the country, are inadequate and conditions are worst in the
remote parts of the country.
Public healthcare services generally come in the form of medical
college hospitals, postgraduate hospitals, specialized hospitals, district
hospitals, maternal and child welfare centers, Upazila (sub-district) health
complexes, and community clinics (Talukder, 2011). This system is set
within a complex context of political divisions and sub-divisions: the entire
territory of Bangladesh is divided into eight divisions and 64 districts.
Additionally, the country is further divided into 488 Upazilas which are
the lowest administrative units of the central government.
The Government of Bangladesh (GoB) has set a three-tier healthcare
service structure. At least in its design, the system includes household
level services for the rural population, community-level institutional
services, and Upazila level health services. The Ministry of Health and
Family Welfare (MoHFW) has two separate wings: health services and
family planning. The wings have vertically integrated programs which
provide primary healthcare services at district, Upazila, and village levels
(Ahmed, Shimul, Sen, & Khan, 2015).
Socio-economic differences and geographical inequities in access to
curative and rehabilitative services are quite apparent across Bangladesh,
as doctors and health resources continue to be concentrated in urban
areas, focusing their attention on the needs of wealthier individuals
(Adams et al., 2014). Private hospitals are equipped with modern facili-
ties and expensive equipment, while NGOs and the government usually

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 177
are the only ones to provide healthcare to rural areas. Most rural people
are not able to access the healthcare institutions concentrated in urban
zones, and could not usually afford the costly private services even if they
could travel to the cities seeking care (Talukder, 2011). There is consid-
erable fragmentation of service, with a separately developed specialized
array of health personnel, training institutions, health facilities, support-
ing services, and information systems (Vaughan, Karim, & Buse, 2000).
The public system is administered under the Department of Health and
Family Planning of the MoHFW (Adams et al., 2014), while the private
sector healthcare is administered by local entrepreneurs, an array of dif-
ferent NGOs, and international organizations. The private sector mainly
focuses on curative care.
This article aims to highlight the service activities of the three float-
ing hospitals that have sought to address riverine people’s healthcare
issues, utilizing Anderson and Billou (2007) “4As” model (affordability,
availability, acceptability, and awareness) of service delivery issues. The
article opens with a description of the disadvantaged situation of the
riverine people in Bangladesh followed by a discussion of the issues these
individuals face in accessing healthcare. Following this is treatment of
the creation of Friendship NGO and their current staff and operational
areas, coupled with an assessment of the impact of the three floating
hospitals (Lifebuoy, Emirates, and Rongdhonu). It will be argued here
that the dedicated operations of Friendship and its floating hospitals has
brought about positive impacts for the underprivileged riverine people
of the country, providing a model of success that could be applied in
other settings.
Riverine People in Bangladesh
Bangladesh is a low flat land built upon alluvial soil that has washed down
over the ages. The most significant feature of the land is the extensive
network rivers that are of primary importance to the socio-economic life
of the nation (Bose, 2013; National Institute of Population Research and
Training [NIPORT], Mitra and Associates, & ICF International, 2013).
Compared to other countries in the region, the landmass that constitutes
Bangladesh is fairly new (Chowdhury et al., 2013). Bangladesh is a great
delta, formed by the deposits of the three mighty Himalayan rivers, the
Ganges, the Brahmaputra, and the Meghna (NIPORT et al., 2013). There
are about 405 rivers in Bangladesh of which 57 are transboundary rivers

178 Journal of Developing Societies 35, 1 (2019): 175–194
(as shown in Figure 1). Out of the 57 transboundary rivers, 54 are com-
mon with India and the remaining three border with Myanmar.
The life and livelihood of the millions of people of Bangladesh have
revolved around these rivers. Bangladesh is highly vulnerable to flooding
Figure 1.
Map of Bangladesh
Source: http://www.maps-of-the-world.net/maps-of-asia/maps-of-bangladesh/

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 179
and riverbank erosion. The major rivers of South Asia, specifically
the Ganges–Padma, Jamuna–Brahmaputra, and the Meghna, drain a
1,559,400 square kilometers basin area (600,000 square miles), of which
7.5 percent is located in Bangladesh. Although the total length of
the bank-line of these major rivers does not exceed 2,000 kilometers
(1,200 miles), the interwoven complex system of the tributaries has
more than 150,000 kilometers (93,000 miles) of the total river bank-line
(Zaman, 1991).
Bangladesh is a home to numerous chars, the floating river beds that
rise in the middle of rivers. Ordinary people residing in the chars maintain
communication with mainland areas through small boats (kheyas). The
kheyas are the only year-round mode of transport and communication
for the char people.
It is estimated that there are approximately 6 million people that live
in chars in Bangladesh. Among these people, a significant number of
inhabitants are settled in southeastern coastal char areas. The absence
of infrastructure in the chars adds to the problems of accessing basic
services for the people who make these floating islands their homes
(Islam & Hossain, 2014; Mahamud, 2011). Their situation leaves these
people isolated from the main national development initiatives. These
multiple factors had led to an overall deprivation of adequate healthcare
services to these underprivileged people living in these remote areas of
Bangladesh (Islam & Hossain, 2014).
Healthcare for Riverine People
Bangladesh faces substantial barriers to adequately meet its healthcare
needs, particularly to rural people. The rural population constitutes 64.20
percent of the country’s entire population and the majority of these people
cannot afford basic healthcare needs (CIA Factbook, 2018). These regions
suffer the nation’s highest mortality and morbidity rates compared with
the national averages (Khan, 2010).
Bangladesh is after all a very poor nation, home to six million of the
world’s bottom billion people who live below the poverty line. The nation
has never offered anything resembling a dependable healthcare deliv-
ery mechanism, and those that suffer the most are the poverty-stricken
people (Khan, 2010). People residing in the char areas are at the pit of
poverty and, worse still, are geographically detached from any viable and
dependable healthcare service delivery. Lack of adequate resources and
inefficient allocation and utilization of healthcare resources throughout

180 Journal of Developing Societies 35, 1 (2019): 175–194
the country can be attributed to the inability of the GoB to address the
healthcare needs of these people.
Health problems in the riverine areas include maternal and child
mortality, outbreaks of infectious diseases, untreated cases of common
ailments, orthopedic problems, and cases needing reconstructive surgical
interventions. Additionally, riverine infections and diseases are common
in these areas, and the unavailability of treatment often leads to prolong-
ing and deepening the impact of these afflictions (Khan, 2010).
Access to Healthcare
The WHO Constitution (1946) envisages “…the highest attainable stan-
dard of health as a fundamental right of every human being.” Access to
healthcare should be regarded as a basic societal right (Culyer, 1995),
but as a practical matter people in developing countries tend to have
less access to healthcare services than their developed counterparts.
The situation is graver with poorer communities within the develop-
ing countries, as the poor have even less access to healthcare services.
Although a lack of financial resources or information can create barriers
to accessing services, there is a direct causal relationship between poverty
and inability to access to healthcare services (Peters et al., 2008).
As the Alma-Ata Declaration of 1978 made plain, access is the first
step toward ensuring “essential healthcare based on practical, scien-
tifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community
through their full participation and at a cost that the community and
country can afford to maintain at every stage of their development in
the spirit of self-reliance and self-determination” (Declaration of Alma-
Ata, 1978; Declaration: VI). In context of the riverine people and their
right to affordable medical care within their vicinity, floating hospitals
present then a viable option to bring them modern healthcare. Floating
hospitals are of considerable significance to these people, offering
accessibility to healthcare that would not otherwise be available (Alam,
Chongsuvivatwong, Mahmud, & Gupta, 2013). The concept of acces-
sibility also requires the elimination of significant barriers to obtaining
needed healthcare services. That is, even when services are available,
people may not know how to access them. The 4As model of service
delivery (as shown in Figure 2) provides a useful way of thinking about the
issues involved.

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 181
Affordability
Owing to the low average income in many developing countries, cash-flow
can be a significant problem in attaining proper healthcare, especially
when these services are expensive, beyond the reach of impoverished
families (Anderson & Billou, 2007). However, there is generally a
strong correlation between quality of service received and price paid
for receiving it, and compromising with quality increases the likelihood
of unsafe care. At the extreme, financial barriers can even block people
from accessing care at all (Morshed & Islam, 2015). Consequently, lack
of healthcare affordability results in poorer health for riverine people;
too often this means their complete exclusion from the healthcare sys-
tem. While in recent years in Bangladesh the per capita income over has
risen to US$1,466, this progress has not been diffused among the entire
population. For the wealthier families, private facilities provide world
class treatment, but for most people in Bangladesh, and most of the char
people, decent healthcare is still a dream.
Availability
Bangladesh has a long way to go in terms of providing quality medical
facilities for the vast majority of people. Medical facilities should be in
close proximity of its recipients (Peters et al., 2008), with rural areas suf-
fering the most in terms of availability of medical facilities. The worst off
Figure 2.
The 4As Model in Healthcare
Source: Adapted from Anderson and Billou (2007).

182 Journal of Developing Societies 35, 1 (2019): 175–194
are the riverine people. But it is not just a matter of access, for timing is
critical too. The remoteness from the city centers limit the char dwellers’
access to properly timed healthcare. Availability of transport, physical
distance from existing facilities, as well as the need to reach a facility
undoubtedly influence the health seeking behavior and health services
utilization (Peters et al.,2008; Shaikh & Hatcher, 2004).
Given the distance separating patients from the nearest health facility,
some NGOs have come forward to address this need, making in some
noteworthy cases important contributions in improving the lives of the
rural people, for example, bringing paramedical services to their doorsteps
through community health workers (El Arifeen et al., 2013). The services
provided by the NGO healthcare workers include health and nutrition
education, family planning, immunization, and basic curative facilities.
In some of these initiatives health professionals offer door-to-door
visits and raise awareness on health issues through lectures; discussions
of symptoms of various diseases and the utility of home remedies; advice
on medicines for treating common illness; and other related outreach
activities. The NGO health workers service is commendable, for through
their work in awareness creation, common diseases like diarrhea, fevers
from various causes, malaria, and other afflictions are prevented or more
effectively controlled. In the char areas, the NGOs work mainly through
paramedics, Shasthya shebikas (female health workers), and trained
traditional birth attendants (TBAs) (Raza, Bhattacharjee, & Das, 2011).
The health worker position creates a respectable and socially acceptable
work opportunity for female members of the rural areas who are trained
by the NGOs to provide much needed services. The array of NGO pro-
gram represent a good start, even as these services offered are in no way
meeting local needs for adequate care.
Acceptability and Awareness
For primary healthcare to reach the greatest number of homes, it must
be in line with the prevailing local cultural norms (Declaration of Alma-
Ata, 1978). However, there has been relatively little research on how
poor people living in developing countries understand and make use
of modern medical approaches that might conflict with local values
and custom (Peters et al., 2008). Some people avoid the medical atten-
tion they are entitled to if modern medicine raises cultural concerns.
However, the active role of NGOs in Bangladesh in providing healthcare
in impoverished rural areas has begun to build a strong sense of inclusion

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 183
and mutual understanding, working to allow people in these districts to
better understand their rights to modern medical care. As a result, more
people are making use of these services. The trouble is that while the care
provided by the NGOs health workers is admirable, they can only offer
a partial solution. The poor people of the riverine zones have medical
needs beyond common colds and diarrhea. In cases of serious illness, they
need to be able to seek advanced and often costly medical intervention
(The World Bank, 2005).
The Creation of the Friendship Program
It all started in 1994, when Yves Marre, a French sailor, navigated a
retired oil barge from France to Bangladesh to have it converted into a
floating hospital to provide healthcare services to those who had limited
or no access to healthcare. After countless failed attempts to convince
various local and international NGOs in Bangladesh of the possibility of
converting the barge into a sustainable healthcare delivery model, Yves
Marre and Runa Khan took it upon themselves to realize their dream,
and that is when their organization, Friendship, began.
Currently, Runa Khan is the Executive Director of Friendship, while
Yves Marre plays the role of an advisor. Prior to the launching of the
Friendship program, Runa and Yves operated the Contic River Cruise
Company, which offered river excursions on traditional boats along the
prime rivers of Bangladesh. Apart from Runa and Yves, Friendship has
four other founding members: Md Mohsen Rashid, Behrouze Ispahani,
Ayesha Ispahani, and Ahmed Iliyas. With the help of corporate fund-
ing from Unilever Bangladesh, an organization that believed in the
Friendship vision, they were able to start their work in the chars of north-
ern Bangladesh. From this modest beginning, Friendship currently works
in the most remote and vulnerable areas of the country, with activities in
22 Upazilas over 12 districts in Bangladesh.
Friendship’s approach has always been to create and develop an
exemplary organization with proven sustainable social, health, and
environmental initiatives for the poorest of the poor. The goal is to
help to create “a world where people, especially the hard to reach and
unaddressed, will have equal opportunity to live with dignity and hope”
(Friendship, 2016). The interventions of Friendship are based on compas-
sion, empathy, in-depth knowledge, and grassroots experience, facilitated
by modern technology.

184 Journal of Developing Societies 35, 1 (2019): 175–194
Friendship currently employs over 1,600 people who work from the
Dhaka Head office and 14 regional offices. These employees staff the
three hospital ships and are also deployed in the adjacent communities.
The organization supports, supervises, and coordinates 525 Friendship
Community Medic-Aides (FCM), 60 Friendship Community Governance
Aides (FCGA), and also offers paralegal services. These employees are
supported by the efforts of an annual average of 30 teams of medical
volunteers and interns working in the most remote and neediest regions
of Bangladesh (Friendship, 2016).
More than just healthcare, the Friendship program also addresses the
underlying issues of poverty. The Friendship teams work to establish
links to allow the ultra-poor improved access financial resources, using
models of risk sharing, leasing and mortgaging of capital goods, cash
advances, resolving of debts owed to middlemen, training, and insurance
against natural shocks. Friendship’s Sustainable Economic Development
(SED) program has helped 5,700 poor farmers and fishermen financially.
The program has also given over 1,000 solar home systems (SHS) to the
poorest of households. Likewise, training is offered in various vocational
skills, including weaving, dyeing, and tailoring.
Friendship works to create wider international awareness of their
programs through various online platforms that function to help gen-
erate financial support. The official website states the funding target
of § € 650,000 in 2017 (this level of support would equal roughly
§ € 12 per patient for the Friendship program). Armed with these
resources, Friendship coordinates with Bangladesh political and public
health authorities, maintaining continuous liaison on leading govern-
ment programs, including especially Bangladesh’s Extended Program
for Immunization, Family Planning, Cervical Cancer prevention and
treatment.
The head office of Friendship works largely in a coordinative and sup-
portive capacity. It oversees the activities of the regional offices, moni-
tors progress in the field, prepares reports on field activities, coordinates
external relations, and supervises the finances and general administra-
tive activities of the Friendship initiatives. Friendship has a number of
regional offices which supports Friendship district level offices in both
the northern and southern regions of the country (www.friendship-bd.
org). Friendship’s key working areas comprise some of the most remote
and inaccessible chars and riverbank areas of Gaibandha and Kurigram
districts, situated in northern Bangladesh, as well as areas in the south

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 185
that include Bagerhat, Barguna, Patuakhali, and Satkhira districts. Taking
a holistic development approach, the Friendship organization imple-
ments intensive program activities with an aim to improve the overall
socio-economic condition of the marginalized and vulnerable populace
of these areas. Friendship started working in southern Bangladesh after
Cyclone Sidr hit on November 15, 2007, greatly impacting people in the
12 districts of the region. Since that time Friendship has also operated in
Bogra, Jamalpur, Sirajganj, Tangail, Pabna, and Pirojpur districts during
disasters and emergency situations.
Floating Hospitals
Floating hospitals are one of several services offered by the Friendship
program, aimed at reducing the critical gap in segmented, highly expen-
sive, and complex healthcare systems of the riverine regions. These hos-
pitals have succeeded in delivering state-of-the-art healthcare (as shown
in Figure 3) to regions where clean water, electricity, medical facilities,
and personnel are limited or nonexistent. Across the world, more than
75 percent of the population lives within 161 kilometers (100 miles) of a
port city; floating hospitals provide a solution for many people who could
not otherwise access required healthcare (Ahmed et al., 2015).
Under the Friendship umbrella the three floating hospitals, Lifebuoy
Friendship Hospital (LFH), Emirates Friendship Hospital (EFH), and
Rongdhonu Friendship Hospital (RFH), welcome a constant flow of
volunteer doctors—local and foreign—who come to provide primary
and secondary healthcare services (as shown in Figure 3), especially
surgical procedures. Friendship hosts on an average 90 medical teams
and interns (local and foreign) at any given time. The floating hospitals
are fully functioning and up-to-date, providing care to 175 people per
day per ship. Overall, the Friendship programs serve about 3 million
patients annually.
The Friendship field members on the ground ensure that all Friendship
planned activities, such as conducting satellite clinics, are being carried
out. These healthcare professionals coordinate then with the vessels, each
of which offers resident doctors, medical assistants, paramedics, nurses, a
pathologist, a radiologist, a dental technician, an eye technician, midwife,
ship master and crew, along with the support staff on each Friendship
ship. The LFH and EFH normally dock at chars in the northern part of
Bangladesh. However, the design of the RFH does not permit it to dock

186 Journal of Developing Societies 35, 1 (2019): 175–194
along the river banks. Therefore, the RFH moors a bit removed from
the river banks and small boats are used to bring the patients on board.
Lifebuoy Friendship Hospital
The absence of medical resources and healthcare in isolated river areas
has influenced many multinational organizations to come forward and
offer assistance to the char or riverine people as a part of their social
responsibility outreach initiatives. One such multinational organiza-
tion is Unilever. Working with Friendship, Unilever Bangladesh paid
for the complete transformation of a French oil-barge into a comfort-
able residential boat with proper amenities for medical procedures to
serve remote riverine people. Conversion work on the vessel began
Figure 3.
The Floating Hospitals Services
Source: The authors.

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 187
in November 2000 with support from Unilever Bangladesh, Canadian
International Development Agency (CIDA), and other donors. The
floating hospital opened its doors in December 2001. Launched in 2001,
the 38-meter-long, 5-meter wide Lifebuoy Friendship Hospital floats up
and down the char regions of Bangladesh with a full team of medical
experts and a well-stocked dispensary. After re-servicing from 2010 to
2012, the Lifebuoy re-commenced its journeys up and down the rivers of
Bangladesh, continuing to serve people whose access to healthcare would
otherwise remain severely limited. The LFH is today a double-decked
shallow draft barge, at the center of Friendship’s healthcare services. The
ship is automated by hospital management system software developed
specially by the Friendship team. Units serve in a wide array of areas,
including anti-natal and post-natal care, gynecology, pediatrics, family
planning, and obstetrics as well as treating many other area afflictions.
There is a dispensary on-board to distribute free medicine to the patients
upon consultation. The LFH provides regular on-board primary and
secondary healthcare services. It also organizes specialized health camps
every month to provide advanced secondary healthcare, where prominent
local and international doctors volunteer their time to perform medical
surgeries and consultations at the floating hospital. The LFH also offers
emergency healthcare in case of natural calamities such as floods and
cyclones. By mid-2017 the total number of patients treated at Friendship’s
LFH had reached 756,955, a considerable achievement.
Emirates Friendship Hospital
The Emirates Friendship Hospital (EFH), funded by a grant from
Emirates Airlines, began service on November 22, 2008. The vessel
was built under the supervision of Friendship advisor, Yves Marre, the
first steel multi-hull ship to operate in Bangladesh. Equipped with the
most modern medical facilities, the EFH has conducted operations on
over 3,000 patients, with the total number of patients treated rising by
mid-2017 to over half a million people. Both primary and secondary
healthcare facilities are provided to the patients, monthly check-ups
are carried out in health camps, and critical surgeries are performed
by international and domestic surgeons who volunteer their time and
expertise free of charge. The specialty of this hospital lies in its ability to
travel up and down the river Brahmaputra, where tiny villages and farms
are dotted along expansive flood plains. The native people around those
areas heretofore receive scant healthcare attention, delaying visits to the

188 Journal of Developing Societies 35, 1 (2019): 175–194
hospitals in the cities, and thus causing treatable diseases to evolve into
life-threatening ones.
The EFH is fully equipped with a specialized pediatric chamber and
women’s healthcare unit. The hospital also offers anti-natal care, post-
natal care, gynecology, family planning, and obstetrics. The EFH is fitted
with surgical theaters, a dispensary, and a laboratory with a fulltime staff,
and equipped with chambers for doctors, primary healthcare facilities,
two operating theaters, two eight-bed wards, pediatric and gynecology
units, a dental room, a pathological laboratory, an X-ray room, and an
ophthalmic room. Moreover, the dispensary on board delivers medicines
at free of cost to patients. The deck of the ship can accommodate 30–40
patients in emergency wards with 24-hour staff supporting typically eight
visiting doctors. In addition to regular medical procedures, ad hoc surgical
camps for specialist treatment such as orthopedics and cleft palate treat-
ment, sponsored by generous donations from Emirates Skyward Miles,
are organized. Teams of volunteer surgeons are flown in to board the
EFH to perform the procedures. As Tim Clark, President of Emirates
Airline, noted, “this is the Emirates Airline Foundation’s flagship project
in Bangladesh and we hope to be able to do a lot more in the years to come
with the kind support of Friendship customers who donate generously
onboard” (The Emirates Airline Foundation, 2017).
Rongdhonu Friendship Hospital
Cyclone Sidrin in 2007 brought severe human devastation to south-
ern Bangladesh, and in response Runa Khan, Executive Director of
Friendship, took immediate action to address the complete lack of
infrastructure and access to basic healthcare in the impacted region. The
Friendship organization, led by Yves Marre, joined with the help of their
friends at Greenpeace International, identified and applied for acquisi-
tion of the Greenpeace International ship Rainbow Warrior II, which
Greenpeace had decided to decommission. In April 2011, after complet-
ing the formalities required to take ownership of the retired Greenpeace
ship, Friendship acquired Rainbow Warrior II. On November 14, 2012,
Friendship’s newest and third floating hospital, Rongdhonu (RFH), for-
merly Rainbow Warrior II, was launched at TM Ghat at the Chattogram
port. RFH first reached the coastal island of Kutubdia, District of Cox’s
Bazaar on January19, 2013. By mid-2017 the RFH had added to its itiner-
ary Hatiya Island (an island in the northern Bay of Bengal, Bangladesh,
at the mouth of the Meghna river), reaching an additional of 198,487

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 189
people. The Friendship program soon added a specialized health camp
(Paediatric Surgery Camp), developed with the help of HumaniTerra
International (HTI), France, which worked alongside with RFH
medical staff.
Rongdhonu has been arranged in such a way that it allows for
the providing of an especially wide array of medical treatments. The
Friendship teams run satellite clinics in the riverine areas to provide
primary healthcare services. A shuttle boat, docked at the river’s edge,
is available at all times to transport referral patients from shore to the
floating hospital. A makeshift waiting room and dispensary (dismantled
when the ship moves on) are also set up to treat patients as the await their
arrival at the Rongdhonu. The RFH is prepared to go almost any coastal
area in the region, and does so if special need arises.
The Rongdhonu floating hospital was built upon the proven and effec-
tive systems and principles learned throughout the 10-year working his-
tory of the LFH and EFH. The RFH is equipped with facilities to assist
with eye care, dental care, pediatric care, women’s healthcare, recovery
wards, and many other basic primary and secondary healthcare needs.
Onboard doctors, most commonly volunteers from the US and Europe,
carry out 15 different types of surgeries to treat common local issues.
Cataract surgery is a Rongdhonu specialty, restoring vision to those who
were blind or nearly so. To those receiving this care, to their loved ones
and families, the work of Friendship is a godsend.
Discussion
Bangladesh has certainly grown economically in some sectors in the post-
independence era (since 1971), with significant foreign direct investments
from multinational companies, a rise in exports, some improvements
in education and the extension of the nation’s physical infrastructure.
However, these economic opportunities and advances have been con-
centrated to the urban areas. If the rural side of Bangladesh is taken into
consideration, it offers rather a very different story to tell. Economic
and social progress in Bangladesh has been very uneven. While proper
healthcare in terms of availability, affordability, accessibility, and aware-
ness (as shown in Figure 4) should be provided for every individual as a
basic right, it was indeed not until the Friendship initiative that world-class
treatment and medical facilities reached beyond those fortune few who
could afford the expensive charges (Morshed & Islam, 2015).

190 Journal of Developing Societies 35, 1 (2019): 175–194
NGOs in Bangladesh have successfully begun the work of engaging
voluntary workers to focus under-served areas (Kaplan & Porter, 2011).
But the Friendship initiative stands out as a program that has been most
effectively providing both primary and secondary healthcare to the
most neglected areas. Friendship not only provides healthcare facilities
for free or nominal token charges, but also distributes over-the-counter
medicines for free.
The success of the Friendship hospitals has depended upon the generos-
ity of the multinational corporations (MNCs) Unilever and Emirates, as
well as the support of global organization like Greenpeace. The disadvan-
taged communities have well quickly accepted the services provided by
Friendship, in part because Friendship developed a bottom-up approach
rooted at the community level. In the last 15 years Friendship has worked
with the aim of entitling the same healthcare treatment and support as
those living in urban areas, be it the most basic treatment to the most
delicate and demanding surgeries. The Friendship teams have successfully
undertaken education campaigns on critical local health issues, creating
better health awareness among communities by setting up training centers,
family planning institutions, and maternal care centers. Riverine people
are continuously encouraged to be alert for symptoms and to reach out
to Friendship for care.
Overall the, the floating hospitals are an innovative approach that
has proven effectiveness in overcoming the geographical inaccessibility
Figure 4.
Mobilized Healthcare Services
Source: The authors.

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 191
(Alam et al., 2013). The initiative has helped to save hundreds of lives
in the many communities they serve. Docking at the most secluded of
riverine areas to provide both primary and secondary healthcare, this
venture has realized its goal of allowing the remote inhabitants in the
midst of massive water bodies of Bangladesh to get access to healthcare,
something unknown to them previously.
Conclusions
The char areas of the river embankments of Bangladesh are regions of
great socio-economic vulnerability and repeated natural calamities (Luo,
2014; Wilde, 2000). The need for an area-specific program in coastal
Bangladesh was recognized in a number of earlier initiatives and the poli-
cies and programs of different government agencies (Mahamud, 2011).
However, it took the exemplary action of the Friendship team to bring
to these riverine people modern medical care (Porter & Lee, 2015). As
Porter and Lee (2015) and Anderson and Billou (2007) have correctly
noted, healthcare resources should be readily available, widely acceptable,
people should be aware of the services, and, most importantly, it should
be affordable. Friendship, together with a team of dedicated personnel,
doctors, and caregivers, has gone beyond the prevalent mainstream prac-
tice to bring basic healthcare services in accordance with the 4As to the
disadvantaged riverine populace of Bangladesh. The Friendship program
provides a stunning model of success worthy of emulation.
DECLARATION OF CONFLICTING INTERESTS
The author(s) declared no potential conflicts of interest with respect to the
research, authorship and/or publication of this article.
FUNDING
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The authors gratefully acknowledge
the aid of InterResearch, Bangladesh, to fund the study.
REFERENCES
Adams, A. M., Ahmed, T., El Arifeen, S., Evans, T.G., Huda, T., & Reichenbach,
L. (2014). Innovation for universal health coverage in Bangladesh: A call to
action. The Lancet, 382(9910), 2104–2111.

192 Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed, J. U., Shimul, M. A. S., Sen, P., & Khan, N. N. (2015). Jibon Tari: A
floating hospital to serve distressed humanity. Business Perspectives and
Research, 3(2), 146–160.
Alam, M. F., Chongsuvivatwong, V., Mahmud, H., & Gupta, P. S. (2013).
Comparison of accessibility among vision-impaired patients visiting mobile
and stationary hospitals in rural Bangladesh. Journal of Health, Population
and Nutrition, 31(2), 223–230.
Anderson, J., & Billou, N. (2007). Serving the world’s poor: Innovation at the
base of the economic pyramid. Journal of Business Strategy, 28(2), 14–21.
Bose, S. (2013). Sea-level rise and population displacement in Bangladesh: Impact
on India. Maritime Affairs: Journal of the National Maritime Foundation of
India, 9(2), 62–81.
Chowdhury, A. M. R., Bhuiya, A., Chowdhury, M. E., Rasheed, S.,
Hussain, Z., & Chen, L. C. (2013). The Bangladesh paradox: Exceptional
health achievement despite economic poverty. The Lancet, 382(9906),
1734–1745.
CIA Factbook. (2018). The world factbook. Washington, DC. CIA Facts File.
Culyer, A. J. (1995). Need: The idea won’t do—But we still need it. Social Science
and Medicine, 40(6), 727–730.
Declaration of Alma-Ata—WHO. (1978). Declaration of Alma-Ata. Retrieved
from www.who.int/publications/almaata_declaration_en.pdf
El Arifeen, S., Christou, A., Reichenbach, L., Osman, F. A., Azad, K., Islam,
K. S., … Peters, D. H. (2013). Community-based approaches and partnerships:
Innovations in health-service delivery in Bangladesh. The Lancet, 382(9909),
2012–2026.
Friendship. (2016). Friendship strategy 2016-2018. Retrieved from http://www.
friendship-bd.org/
Islam, M. R., & Hossain, D. (2014). Island Char Resources Mobilization (ICRM):
Changes of livelihoods of vulnerable people in Bangladesh. Social Indicators
Research, 117(3), 1033–1054.
Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in healthcare.
Harvard Business Review, 89(9), 46–52.
Khan, R. (2010). Friendship’s 3-tier healthcare system: An innovative approach
to delivering healthcare to geographically and socially remote areas. Social
Space, 114–119. Retrieved from: https://ink.library.smu.edu.sg/lien_research/46
Luo, J. (2014). Integrating the huff model and floating catchment area methods
to analyze spatial access to healthcare services. Transactions in GIS, 18(3),
436–448.

Journal of Developing Societies 35, 1 (2019): 175–194
Ahmed et al.: Friendship Floating Hospitals 193
Mahamud, M. S. (2011). Intervention of char development and settlement project:
Does it make a difference in people’s livelihood at Boyer Char in Bangladesh
(Masters dissertation). MPPG Program, NSU.
Morshed, M., & Islam, S. (2015, June 12). Healthcare: For profit or people?
(The) Daily Sun (Weekend Magazine-Moring Tea), 5(26), 6–11. Retrieved
from: http://www.daily-sun.com/magazine/details/50101/Health-Care:-For-
Profit-or-People/2015-06-12
Nabi, A. K. M. N. (2012, July). Population challenges for Bangladesh. (The)
Daily Star (Monthly Publication), Forum, 6(7). Retrieved from: http://archive.
thedailystar.net/forum/2012/July/population.htm
National Institute of Population Research and Training (NIPORT), Mitra and
Associates, and ICF International. (2013). Bangladesh demographic and health
survey 2011. Dhaka, Bangladesh and Calverton, MD: NIPORT, Mitra and
Associates, and ICF International.
Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R., & Hafizur, R. M.
(2008). Poverty and access to healthcare in developing countries. Annals of
the New York Academy of Sciences, 1136(1), 161–171.
Porter, M. E., & Lee, T. H. (2015). Why strategy matters now. New England
Journal of Medicine, 372(18), 1681–1684.
Raza, W., Bhattacharjee, A., & Das, N. C. (2011). Impact of char development
and settlement project on improving the livelihood of char dwellers (Working
Paper No.17). Dhaka: Research & Evaluation Division, BRAC.
Shaikh, B. T., & Hatcher, J. (2004). Barriers to family planning service use among
the urban poor in Pakistan. Asia-Pacific Population Journal, 19(2), 5–26.
Streatfield, P. K., & Karar, Z. A. (2008). Population challenges for Bangladesh
in the coming decades. Journal of Health, Population and Nutrition, 26(3),
261–272.
Talukder, M. M. H. (2011). On patient-physician relationships: A Bangladesh
perspective. Asian Bioethics Review, 3(2), 65–84.
The Emirates Airline Foundation. (2017). Retrieved from http.www.emirates
airlinefoundation.org/english/projects/friendship-hospital.aspx
The World Bank. (2005). The economics and governance of non-governmental
organizations (NGOs) in Bangladesh. The World Bank, Poverty Reduction
and Economic Management Sector Unit South Asia Region. Retrived from:
http://documents.worldbank.org/curated/en/105291468207267279/pdf/382910
BD0NGOre10also03586101PUBLIC1.pdf
Vaughan, J. P., Karim, E., & Buse, K. (2000). Healthcare systems in transition
III. Bangladesh, Part I. An overview of the healthcare system in Bangladesh.
Journal of Public Health Medicine, 22(1), 5–9.

194 Journal of Developing Societies 35, 1 (2019): 175–194
Wilde, K. (2000). Out of the periphery: Development of coastal chars in
Southeastern Bangladesh. Dhaka: The University Press Limited.
Zaman, M. Q. (1991). Social structure and process in char land settlement in the
Brahmaputra-Jamuna floodplain. Man, 26(4), 673–690.
Jashim Uddin Ahmed, PhD, is a Professor and Chairman of the
Department of Management, School of Business & Economics, at North
South University, Bangladesh. Dr. Ahmed is the founder of InterResearch,
a leading research organization in Bangladesh. He received his PhD in
Management Sciences from the University of Manchester Institute of
Science and Technology (UMIST, currently known as The University of
Manchester), in the UK. He earned master’s degrees both in Marketing
and Management from the University of Northumbria, UK. He also
studied at the University of Reading and the University of Lincolnshire
and Humberside (currently known as University of Lincoln), UK. His
research interests lie broadly within the intersections of social inno-
vation, strategic management, and contemporary issues in business.
He has published over 100 research articles and case studies in lead-
ing journals. An expert on Asian and Emerging Markets business case
writing, Prof. Ahmed can be reached at jashim.ahmed@northsouth.edu,
or at jashimahmed@hotmail.com.
Maliha Rahanaz completed her master’s degree from the University of
Nottingham, UK. She has research interest in the areas of development
studies, non-governmental organizations, and social innovation. Currently
she is a Research Associate with InterResearch, Dhaka, Bangladesh. She
can be reached at maliha.rahanaz@gmail.com.
Rubaiyat-i-Siddique completed her master’s degree from the University
College London (UCL), UK. She is a development practitioner and has
been working in the development arena of Bangladesh for a decade.
Currently she is a Research Associate with InterResearch, Dhaka,
Bangladesh. She can be reached at rubaiyat.i.siddique@gmail.com.