Eliciting the voices of health service users at the grassroots

 

The health system is the societal response to the determinants of health. The effectiveness of a health system depends on the availability, accessibility, affordability and acceptability of services in a form that the people can understand, accept and utilise according to their felt needs. The health system in Bangladesh, with extensive infrastructure in both public and private sectors, is highly pluralistic. The formal health system relies heavily on the government/ public sector for financing and setting overall policies and service delivery mechanisms. The private sector services are too expensive, especially for the poor, and out-of-pocket expenditure for getting healthcare services is very high. Quality of Care (QoC) in both the public and private sectors is poor. Improving health system responsiveness by involving various community actors and applying a bottom-up social accountability approach is crucial. The latter refers to a broad range of actions and mechanisms that citizens, communities and civil society organisations can use to hold public officials and public servants accountable. Social accountability implies the engagement of civic organisations to express demand for public services and extract accountability from local service providers to improve service quality.

Bangladesh Health Watch (BHW), established in 2006, is a multi-stakeholder civil society initiative dedicated to improving the health system in Bangladesh through evidence-based advocacy and appropriate actions for change. Towards this end, BHW has formed eight Regional Forums (RFs) based in eight districts in eight divisions. The RFs comprise different types of stakeholders, including non-government organisatios (NGOs), civil society organisation (CSO) activists/members, youth leaders and citizens of a region based in a district/sub-district/union headquarters. Each RF is hosted by a local NGO/CSO, including a health rights forum of active and informed citizens motivated to improve the quality of health services at the local level.

The idea of forming these Forums is to give voice to the people, especially from hard-to-reach and remote and rural areas, regarding their felt needs for health care services and form citizen’s platform at the grassroots. Besides giving voices to the people, these regional forums also intend to help local providers/health systems try to respond, solve the problems within their jurisdiction, and take the issues beyond their jurisdiction. In the beginning, formative research is planned to explore, document and evaluate the process of formation and functional dynamics of the RFs, including its strategic interaction with the host organisations and the community.

Formative research is ‘exploratory and is usually done at the early phase of the project to guide the entire process of programme development.’ The is an approach that help organisations to learn from their implementation experience[1]. To begin with, the formative research will adopt a process documentation study design to document the initial dynamics of the RF formation, host organization selection and identifying the roles and responsibilities, including critical observation of the RF activities and its evaluation for future learning. The process will be inductive to explore the interface between RF and the people it works with. This will help RFs to respond to context-specific requirements.

The information gained from the formative research will enable the regional forums to customise its field operations to ‘capture’ the voice of the people (on health and allied issues) in the local context and take these forward to relevant authorities for soluble actions. We will use the ‘Ecological Model’[2] of formative research, which focuses on information gathering at specific levels (e.g., community, organisation and individual levels) that may be amenable to change by particular interventions.

 

We will adopt a participatory approach in implementing this formative research. The study team will visit programme sites to understand the intervention modality and the strengths and challenges of the approaches. The data collection will take place from Sept. - Dec 2022 continuously. Data will be collected by study team members and trained volunteers. Data will be collected on RF core activities e.g. organisational activities (e.g. coordination meeting with Health Right Forum and Youth Forums); awareness building/campaign-based activities; advocacy and networking activities (e.g., multi-stakeholders meetings, public hearings, communication with external partners); capacity building activities (e.g., training for forum members, volunteers, journalists, workshop with stakeholders).  Data will be collected from the following four sites: Barguna (Barisal) from the central region; Khagrachhari (Chittagong) from the hill tracts region with indigenous community; Sunamganj (Sylhet) from the haor region; and Kurigram (Rangpur) from the high level of poverty area.

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[1] Amita S. Process documentation research. PLA Notes CD-ROM 1988–2001.

[2] Newes-Adeyi G, Helitzer DL, Caulfield LE, Bronner Y: Theory and practice: applying the ecological model to formative research for a WIC training progra in New York State. Health Educ Research 2000, 15:283-291.