Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared?

In the South Asian region, delivering non-communicable disease (NCD) prevention and control services through existing primary health-care (PHC) facilities is urgently required yet currently challenging. As the first point of contact with the health-care system, PHC offers an ideal window for prevention and continuity of care over the life course, yet the implementation of PHC, to address NCDs is insufficient. This review considers evidence from five South Asian countries to derive policy-relevant recommendations for designing integrated PHC systems that include NCD care. Findings reveal high political commitment but poor multisectoral engagement and health systems preparedness for tackling chronic diseases at the PHC level. There is a shortage of skilled human resources, requisite infrastructure, essential NCD medicines and technologies, and dedicated financing. Although innovations supporting integrated interventions exist, such as innovations focusing on community-centric approaches, scaling up remains problematic. To deliver NCD services sustainably, governments must aim for for increased financing and a redesign of PHC service. (abstract).

1.                Ahmed SM et al. Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared? Lancet Glob Health 2024;12: e1706–19. Published Online August 20, 2024.  https://doi.org/10.1016/2214-109X(24)00118-9

Just Transitions to mitigate antimicrobial resistance

 

Antimicrobial resistance (AMR) is among the most significant global health concerns of our time. In 2019, 1.27 million deaths were attributed to resistant bacterial infections, and by 2050, it is predicted AMR will cost upwards of $100USD trillion, accounting for 10 million deaths worldwide.  Antimicrobial resistance transcends borders, affecting communities in every region of the world. Poor and marginalized populations are among the most impacted by AMR, yet global discourse on policies and solutions often overlooks the challenges faced in these settings. Containing the spread of AMR, and avoiding a future where antimicrobials no longer work and common infections become potentially lethal, will require urgent and system-wide change. 

Just Transitions for AMR brings together social science and humanities researchers from diverse backgrounds and differentially affected regions to discuss what a just and equitable transition will mean for containing and mitigating AMR. The Just Transitions for AMR programme will explore how it could be adapted and used in the context of AMR.  The Just Transitions framework represents a different way of approaching systemic change, placing importance on effective social dialogue as a way to minimize challenges and maximize social and economic opportunities .

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.

An innovative approach to tackle ‘absenteeism’ of doctors in Bangladesh

In Bangladesh, healthcare service delivery remains significantly challenged by staff shortages, maldistribution of workforce, and absenteeism, especially of doctors. The health system has an extensive infrastructure in urban and rural areas, but the dynamic intersection of the pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for ‘corruption,’ especially in remote rural areas. Although data are scarce, it has been estimated that 40% of doctors are absent from their posts at any one time, and when a facility is staffed by a single doctor, as is often the case in rural areas with underserved communities, absenteeism can be as high as 74%. The Bangladesh government is well aware of the problems posed by absenteeism within the health system and have enacted several regulatory approaches, such as compulsory rural service after graduation and introducing biometric fingerprint in all sub-district and district-level government hospitals, to retain doctors at rural postings. 

Despite these initiatives, publicly available health systems data suggests that absenteeism among doctors continues to be a very significant problem across the country. The failure of these policies is driven in large part by a reliance on universal top-down approach for action (accountability and transparency mechanisms) and not paying attention to the structural drivers of absenteeism. 

From SOAS Anti-Corruption Evidence consortium Bangladesh health study platform, a study was designed to understand these drivers among junior doctors in rural health facilities in Bangladesh for potential policy interventions. The approach adopted by the SOAS-ACE Consortium is to design sector-specific anti-corruption strategies that enable the enforcement of the rule of law supported by players affected by those rules; this makes the enforcement of anti-corruption strategies more feasible. ACE suggested four broad strategies (aligning incentives, designing for different, building coalitions, and resolving rights) to develop this ‘horizontal’ support for successful anti-corruption outcomes.