Welcome to my Public Health World of Bangladesh!

Welcome! If you are interested about the health and health systems of Bangladesh, its problems and prospects, you have come to the right place! Be informed...

Monday, 7 May 2018

Leave no one behind, please!

The concept of ‘marginalization’ and ‘social exclusion’ is ‘highly depending on the historical and socio-economical context of a society.’ Briefly, ‘marginalizaion’ is ‘a process, originating from lack of awareness or negative attitudes of the larger society, by which certain population groups are denied access to resources and services essential for living a decent life’ and ‘social exclusion’ is ‘a process that involves the systematic denial of entitlements to resources and services...on the basis of  ethnicity, race, religion, sexual orientation, caste, descent, gender, age, disability, HIV status, migrant status or where they live.’

The underlying causes for marginalization and social exclusion include racism, extreme poverty, caste-based social system and associated stigma, migration (e.g., rural to urban migration, landing in pavements or slums), weak and  poorly-resourced and inefficient health systems failing to reach these populations, and lack of understanding and respect for human rights. Like the underlying causes, the process of margnalisation/social exclusion is also varied. The process involve structural barriers to education, employment, and land and other resources;  patriarchal attitude and norms of the society;  life-styles associated with extreme poverty and destitution; hazardous occupation for survival such as scavenging, ship-breaking, medical waste handling;  spatial remoteness; suffering from disease(s) with a social stigma e.g., TB, HIV/AIDS, Leprosy; having physical and/or mental disabilities; differing sexual orientation including sex trading; and  consequences of migration.

Existing policies failed to go more in-depth into the problem and identify the needs and priorities of these populations. The current Social Safety Net programme of the government, consolidating hitherto existing multiple, fragmented, and small-scale safety-net programmes into its social development activities, are not comprehensive and inclusive and fraught with abuse and misuse. The great proportion of the marginalized and socially excluded groups are deprived from the very basic/essential health care services from the formal system, giving rise to large ‘unmet health needs’.  The national databases, as well as some surveillance databases, do not collect and present disaggregated data beyond some common variables, and beyond sub-district. Thus, there is a large gap in data for taking evidence-based decision and policies and programmes to cover these populations, on the journey towards UHC by 2030!

To ensure that the true spirit of ‘inclusion’ underlying the SDGs are translated into effective actions, detailed information on different sections of the population is needed to understand ‘who are left behind’ in the context of a particular country including their needs and priorities for healthcare services. This study aimed to fill-in this knowledge gap in Bangladesh, to inform the relevant stakeholders at the policy and practice levels for designing an evidence-based and inclusive heath system towards UHC by 2030. Due to constraints in time and resources, a Rapid Review (RR) method was adopted ‘to provide actionable and relevant evidence in a timely and cost-effective manner.’

Thursday, 1 February 2018

Frugal innovation in healthcare

Providing ‘Good health at low Cost’, an imperative for UHC, is increasingly becoming a challenge due to rising cost of health care globally, especially in LMICs like Bangladesh where out-of=pocket expenditure for healthcare stands around 67% of the total health expenditure. This is mainly due to rise in life expectancy and associated rise in demand for care especially for chronic conditions over prolonged period of time, and expectations among population for the best available health care based on latest health technologies. In resource constraints LMICs like Bangladesh, ‘scarcity’ of HRH and non-HRH resources lead to search for alternatives and providing ‘inexpensive solutions for more people with fewer resources’. This idea that ‘more can be done for less for many more people,’ nicknamed ‘frugal innovations’, stands to benefit most the healthcare sector of the LMICs, and also, unsustainable growth in healthcare expenditure is forcing global healthcare systems to learn from these affordable technologies and models (‘reverse innovation’).

Some examples of such frugal innovations are: i) Reproductive Health Vouchers
Programme, Bangladesh (Maternal health programme which provides vouchers to pregnant women to cover transport to antenatal care, delivery and postnatal care and for purchasing medicines.); ii) GeriCare@North, Singapore (Telemedicine solution that involves a hospital-based specialist physician examining patients in
nursing homes with the assistance of a specially trained geriatric nurse on site); iii) ReMeDi: Medical Data Acquisition Unit, India (Provides Electronic Medical Records including; images, various health parameters as well as audio-video conferencing at very low bandwidth for remote healthcare delivery); iv) GlicOnLine, Brazil (Service to support the treatment of all types of diabetes by empowering patients to correctly follow treatment plans through digital alarm reminders and improved data collection through any Android mobile phone device or via the Internet); v) ReMeDi: Medical Data Acquisition Unit, India (Provides Electronic Medical Records including; images, various health parameters as well as audio-video conferencing at very low bandwidth for remote healthcare delivery); vi) i-calQ/Smartphone Thyroid Disease Management, multicountry (Turns an ordinary smartphone into a portable diagnostic laboratory combined with medical decision support algorithms to provide a comprehensive disease management solution) etc.

Sunday, 5 November 2017

Countdown on health and climate change: Report of the Lancet Commission

In a freshly released Lancet Commission Report (published online 30 Oct. 2017), monitoring data on health impacts of climate change in the past 25 years are presented for 40 indicators identified in the earlier Lancet Commission of 2015. Some of the key findings of the report include 1) climate change and increasing global warming are affecting the health of the population,  the vulnerable population in the LMICs are being affected disproportionately; 125 million more vulnerable people over the age of 65 years were exposed to heatwaves in 2016 than in 2000. This is effecting their earnings as data showed that Global labour capacity of rural dwellers such as farmers, has fallen by 5·3% from 2000 to 2016 due to rising temperatures and the inability to work when it's too hot. 2) most of the indicators tracked since the UN Framework Convention for Climate Change (UNFCCC) in 1992, the adaptation and mitigation efforts have been quite slow, with increase in carbon emissions and global temperature and only modest improvement in reduction of carbon emission from electricity generation occurred due to continued burning of Coals (while coal use increased globally since 1990, it appears to have peaked in 2013 and is now declining due to decision by a growing number of countries have committed to ensuring coal is completely phased out over the next decade); a particularly severe heat wave in the summer of 2003 resulted in more than 70 000 excess deaths across Western Europe; air pollution from a range of sources contributed to over 1·9 million premature deaths across southeast Asia in 2015 

Tuesday, 8 August 2017

The private retail drug shops market in Bangladesh is largely unregulated and unaccountable, giving rise to irrational use of drugs and high Out-of-pocket expenditure on health. These shops are served by salespersons with meagre or no formal training in dispensing.This facility-based cross-sectional study was undertaken to investigate how the drug shops currently operate vis-a-vis the regulatory regime including dispensing practices of the salespersons, for identifying key action points to develop an accredited model for Bangladesh.  About 90 rural and 21 urban retail drug shops from seven divisions were included in the survey. The salespersons were interviewed for relevant information, supplemented by qualitative data on perceptions of the catchment community as well as structured observation of client-provider interactions from a sub-sample. 

In 76% of the shops, the owner and the salesperson was the same person, and > 90% of these were located within 30 minutes walking distance from a public sector health facility. The licensing process was perceived to be was cumbersome, lengthy, and costly. Shop visits by drug inspectors were brief, wasn’t structured, and not problem solving. Only 9% shops maintained a stock register and 10% a drug sales record. Overall, 65% clients visited drug shops without a prescription. Forty-nine percent of the salespersons had no formal training in dispensing and learned the trade through apprenticeship with fellow drug retailers (42%), relatives (18%), and village doctors (16%) etc. The catchment population of the drug shops mostly did not bother about dispensing training, drug shop licensing and buying drugs without prescription. Observed client-dispenser interactions were found to concentrate mainly on financial transaction, unless, the client pro-actively sought advice regarding the use of the drug.