After USAID left: How Surjer Hashi learned to survive without donors

Women receive care at a Surjer Hashi satellite clinic, reflecting its shift toward self-sustaining services. Photo: Courtesy

In November 2023, the end of funding from the United States Agency for International Development (USAID) put NGOs in Bangladesh to a tough test. Surjer Hashi Network, one of the country's largest private primary healthcare providers, was among those expected to shut down. However, it reinvented itself.

For decades, donor-funded development projects in Bangladesh have followed a familiar cycle: generous grants, broad service coverage, and an eventual wind-down once funding dries up. Surjer Hashi appeared headed for the same fate. At the time of the USAID exit, the network operated 134 clinics with nearly 3,400 staff and had long depended on external financing.

What followed, however, was not closure but transformation—internally described in four words: "From Burning to Earning."

From donor dependency to commercial discipline 

Founded in 1997 as a donor-backed initiative under the name "Sabuj Chhata," Surjer Hashi initially focused on maternal health and family planning. At its peak, the network reportedly operated nearly 399 clinics nationwide. 

International intermediaries such as Chemonics International and Cambridge Economic Policy Associates coordinated funding and programme management, while local NGOs ran operations on the ground. Contracts typically ran for four to five years before rebidding. 

That model fostered service expansion but not financial independence. 

"Earlier, the focus was on the number of people we serve. Now the question is: how do we sustain ourselves?" Abdul Kader Bhuiya, senior clinic manager at Surjer Hashi Network, told The Business Standard.

The leadership concluded that waiting for another donor cycle was no longer viable. Revenue generation had to replace grant dependency.

The shift required difficult decisions. Staff were rationalised. High-rent facilities were relocated to smaller premises. Five-room clinics were downsized into three-room operations. Daily revenue-expense projections were introduced, an unfamiliar discipline in a donor-driven environment. 

The government provided transitional support following the donor exit, initially around Tk5 crore and later Tk15 crore, to ensure continuity of essential services. But the long-term model had to stand on its own. 

Clinics were reorganised into three categories: basic outpatient centres; basic centres offering normal vaginal delivery (NVD); and advanced facilities with caesarean section capability.

The decline in funding

According to data from Surjer Hashi Network, the organisation received about Tk58 crore from the USAID in the 2018-2019 fiscal year, when it operated 369 clinics, accounting for 64% of its total funding.

In 2019-2020, USAID support rose to around Tk113 crore, representing 61% of the total. In 2020-2021, when the number of clinics declined to 134, the network received about Tk47 crore from USAID, or 46% of its funding. This was followed by about Tk52 crore in 2021-2022, accounting for 49%.

In the 2022-2023 fiscal year, USAID contributed approximately Tk39 crore, representing 50% of the total funding, while the government provided Tk5 crore. In 2023-2024, USAID funding fell further to about Tk15 crore, accounting for 18% of the total, although government support increased to Tk15 crore.

However, in the 2024-2025 fiscal year, the organisations received no funding from USAID, and the number of clinics dropped to 60.

A mindset shift 

According to Yusuf Abdul Noor, deputy general manager (Revenue and Clinic Operations, Business Development), the real transformation was cultural. 

"Earlier, we were burning donor funds. Now our focus is on earning," he said. "This mindset shift was the biggest challenge." 

A dedicated revenue team with commercial backgrounds was formed. Across 134 clinics, thousands of staff – from cleaners to doctors – participated in repeated meetings and training sessions focused on cost recovery, patient engagement, and service bundling.

The strategy moved beyond cost-cutting toward revenue expansion.

"Surjer Hashi is not a privately owned company; it was once a donor-based project. When funding stops, such projects usually shut down. But we have shown that with the right strategy and transparency, primary healthcare can survive under a social enterprise model." … Shaila Parveen, CEO, Surjer Hashi Network

Service quality was improved. Specialist consultants were brought in. Operating hours were extended, with some centres running 24/7. Commercial pharmacy services were launched. Laboratories were expanded. Healthcare workers began proactive door-to-door outreach. 

Advanced centres now host between 20 and 25 specialist consultants. Gynaecologists, physicians, dentists, ophthalmologists, urologists, paediatricians, neurologists and cardiologists use clinic facilities to see patients. Many of those patients subsequently undergo diagnostic tests at in-house laboratories and purchase medicines from the clinic pharmacy – forming a core pillar of the revenue model. 

Investments have included CBC machines, hormone analysers, Vitamin D testing equipment, and ultrasound upgrades. Laboratories now offer 21 types of tests, including dengue screening, VIA tests, and ECG services. 

Plans are underway to introduce physiotherapy, speech, and developmental therapy for children, as well as mental health and non-communicable disease services. 

Yusuf says the network has also emerged as one of the leading private-sector vaccine providers, particularly in cervical cancer prevention. Outside the government's school-based programme, Surjer Hashi offers counselling and HPV vaccination for women aged 20-49, sourcing vaccines from local manufacturers.

The numbers behind the turnaround

When CEO Shaila Parveen joined on 8 December 2020, clinic-level cost recovery stood at just 40%. The remaining operational costs were covered by donor funds.

By 2022, cost recovery had surpassed 70%. Today, the network reports average cost recovery of 90-93% at the clinic level and about 92% across the network.

"Thirty clinics are now generating surplus. The surplus is not huge, but they are covering their costs and contributing to the network," she said.

Photo: Courtesy

Over several years, the organisation invested approximately Tk35-40 crore in equipment upgrades, laboratory expansion, and human resource development - reversing nearly 15 years of underinvestment.

"Surjer Hashi is not a privately owned company; it was once a donor-based project. When funding stops, such projects usually shut down. But we have shown that with the right strategy and transparency, primary healthcare can survive under a social enterprise model," Parveen said.

However, structural vulnerabilities remain. All clinics operate from rented premises, creating long-term uncertainty.

"We have faced incidents where clinics were taken over, or rental agreements were not renewed. The absence of our own infrastructure remains a major limitation," she added.

The long-term vision includes establishing a specialised maternal and child health hospital in Dhaka, potentially financed through low-interest loans or social enterprise funding mechanisms.

Restructuring the footprint

The donor exit forced a reduction in scale. From 134 clinics, the network now directly operates around 62 facilities. 

To avoid abrupt service disruptions and job losses, roughly 60-80 clinics were handed over to local committees along with equipment worth Tk4-10 lakh per facility. While not all are fully operational, many continue to provide services under community management. Surjer Hashi offers technical, IT, and clinical quality support free of charge.

The restructuring reduced overhead while preserving community access – a delicate balancing act between sustainability and social responsibility.

Community trust as capital 

At the grassroots level, outreach has become central to the model. 

Anwara Begum, who has worked with Surjer Hashi for nearly 30 years, begins her day at 6am, visiting households in areas such as Aftabnagar and Rampura. She identifies pregnant women, counsels them on antenatal care, and guides families through delivery and child vaccination. 

"Many women are working, so I meet them before they leave for the office," she said.

At one clinic, most patients were seeking antenatal services. For Tk320, they can consult an in-house physician. A normal delivery costs around Tk6,000. Caesarean packages range from approximately Tk20,000 for ward services to Tk27,000 for cabin facilities. Government EPI vaccinations are provided free, with a Tk220 service charge. 

Word-of-mouth referrals now serve as a critical driver of sustainability. 

"We keep patients under observation for three to four days in normal delivery cases to build confidence. Referrals increase from satisfied families," Yusuf said.

Patients echo that sentiment. Many cite affordability compared to private hospitals and an emphasis on attempting normal delivery before resorting to surgical intervention.

A test case for Bangladesh 

Surjer Hashi's journey challenges a long-standing assumption in Bangladesh's development sector: that donor-funded healthcare cannot survive without grants. 

However, it is also true that the transformation has not been without sacrifice — fewer clinics, leaner operations, and continued infrastructure risks. Yet the network's near-complete cost recovery suggests that a hybrid social enterprise model in primary healthcare may be viable.