Synergy or fragmentation of service delivery at the grassroots? The case of UHC, HP and GHS agenda

•        The concept of UHC was introduced in the country around 2010/2011. During that period, the non-state actors in Bangladesh played a key role in advancing the UHC agenda when the concept was relatively new in the country, especially in the public sector. In this early stage, support from the Rockefeller Foundation in the form of strategic grants to different institutions and individuals in the public and non-state sectors was crucial to initiate relevant activities. The PM of the country made global commitment for UHC for Bangladesh at the 64^th WHA in May 2011. It further gained momentum when the UNGA passed the historical resolution on UHC in 2012 and endorsed it for its member countries.
•          On the other hand, the concept of health promotion (HP) dates back to the early ‘80s when Health for All was launched by WHO at Alma Ata in 1978. It constituted an integral part of the PHC package of preventive and promotive health care services in the form of Essential health care where health education on different aspects of health and nutrition was given due importance.
•       Compared to these two, the Health security concept is quite recent in Bangladesh.  The Global Health Security Agenda, complying with frameworks and strategies of IHR (2005), was launched in February 2014  and Bangladesh developed a GHS roadmap in 2015. A Joint External Evaluation (JEE) done in 2016 found Bangladesh to have scored poorly (1=no capacity) in areas such as laboratory quality, emergency response operations, linking public health and security authorities, and chemical events. Anecdotal evidence points to improvement in some sectors since 2016 such as laboratory quality, AMR and selected disease surveillance, field epidemiology training etc.  
•           The outbreak of avian influenza in Bangladesh in 2007 exposed the vulnerability of the country to transmission of infection from animals and environment. In 2008, stakeholders in the human, animal and environmental sectors came together to promote the concept of ‘One Health’ in Bangladesh [88]. As a consequence of this movement, the GoB came up with the ‘National One Health Strategy’ in 2012. In 2016, a One Health Secretariat was established at the IEDCR with staff from three ministries (human health, animal health and environment) and support from the development partners [90].

Thus, the concepts do not have a hierarchical but sequential introduction in Bangladesh and thus differs in priority and activity. As of now, UHC (+HP especially for preventing NCDs) is prioritised by both the government and the non-state sectors.

How does Bangladesh foster synergy among the three agendas (Examples)?

There is no ‘fostering’ done pro-actively by the Government. The synergies (and also the fragmentations) that exist, have naturally evolved.

Synergies:

·         This is first and foremost is to acknowledge that the activities around UHC+HP and GHS are all concerned with strengthening the health systems and developing ‘resilience,’ and  take place under one ministry i.e., the Ministry of Health and Family Welfare (MoHFW) and all policies are (supposed to be) tailored from one single planning wing of the MoHFW. However, the three elements of the triangle have different focal agencies responsible for delivering relevant services e.g., HP on prevention and behavioural changes (Bureau of Health Education), UHC on delivering quality services equitably (DGHS and DGFP), and GHS on epidemic preparedness and response (IEDCR). There are some synergies between HP and UHC in certain areas (e.g., prevention of NCDs), but not GHS which is implemented by IEDCR through, again, the frontline health workforce at PHC levels who are under the jurisdiction of DGHS. However, we see a lack of coordination when it comes to planning actions or its implementation at the frontlines.

Fragmentations:

·         However, we see a lack of coordination when it comes to planning actions or its implementation at the frontlines. Besides, there are three different agencies (within MoHFW) to take care of these (as mentioned above), and anecdotal evidence exists about lack of communication among them for consolidated action on a particular issue. Of note, the existing PHC infrastructure is at the core of taking these activities practically to the frontlines.

·         
h   There is no dearth of policies and strategies with implications for the health sector and the three elements of the triangle. However, there is lack of coordination, both intra-ministerial (different agencies of the MoHFW) and inter-ministerial (MoHFW and the other ministries providing some health services).

 What are the main hindrances to achieve synergies in Bangladesh (Examples)?

The triangulation of findings from the document analysis, interviews and stakeholder meeting again and again showed that there is hardly any coordination of the activities of UHC+HP and GHS which could hamper achieving synergy in these three areas. This is summarized below:

1. a) The three elements have different agenda, focal agency, and roles and responsibilities with little attempt to coordinate and consolidate activities from top to bottom by the ministry, though, all implementing agencies are housed within the same ministry. Although the policy analysis of the 4^th health sector plan revealed partial alignment between UHC and GHS (for example, in terms of early notifications of epidemic outbreaks from the field), in practice, a coordination hardly exist as revealed in the KIIs and stakeholders meeting. GHS comprises of many other activities that have more relevance to UHC but not addressed in the policies or practices.
2. b)  Lack of conceptual clarity about UHC and GHS was quite obvious from the interviews and discussion, pointing to their compartmentalized mentality and sticking to their respective ‘comfort zone’.  Only those working in IEDCR have some good knowledge in the GHS area. Because of this situation, majority perceived GHS and UHC to have different focus, roles and responsibilities with less opportunities for synergy, which appears to be an important barrier.

1. c) The responsible agencies implementing UHC and GHS were found to have less coordination and communication with the MoHFW. Not only the different agencies but overall less coordinating efforts between public and private sectors was found to be problematic, especially when there are donors involved that have their own interests resulting in duplication and overlapping work and inefficient use of resources.

1. d)   Health promotion that is common for both UHC and GHS, and therefore could act as a synergistic medium, was found to be rather focused on behavior change at individual level.

From the perspective of health system strengthening, leadership and governance were found to be a crucial area to bring about synergy. It reinforces the other components of the health system and acts as a focal point to strengthen health security, and therefore better integration with UHC.   

(Notes for a forthcoming Case study on interlinking the three concepts

for integrated service delivery by the frontline healthcare providers)