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. 

Adolescent health/sexual and reproductive health scenario in Bangladesh and recipe for action

There have been attempts at developing programmes and interventions to address key    challenges related to a lack of adolescent-friendly health services, limited access to age-appropriate counselling services, promotion of a healthy lifestyle, and menstrual management facilities at the school, both in the government and non-state sectors for quite some time. These programmes have mostly been on a small scale, localised and fragmented. A study has been done to fill in this knowledge gap by conducting a situation analysis on AH/SRH and identifying past and present programmes that have been highly effective and impactful.

The study adopted multiple methods for collecting data: i) a Scoping review of relevant  documents to get a ‘snap shot’ of the current situation; ii) a Qualitative study including Key Informant Interviews (KIIs) with stakeholders at district and central levels, In-depth Interviews (IDIs) with programme participants, and Focus Group Discussions (FGDs) with members of the beneficiary community; iii) Observational case studies based on field visits to selected programme sites, and iv) feedback from a deliberative workshop with the stakeholders to share and discuss findings.

Data were collected from 11 purposively selected sub-districts (of eight districts, one district per division) during Jan. – Mar. 2022. The sub-districts were selected based upon programme concentration and discussion with DGHS/DGFP of MoHFW, MoE, and MoWCA. A total of 39 IDIs, 34 KIIs, 9 FGDs, and 18 case observations were done. Finally, a stakeholder deliberative dialogue with key stakeholders at the central level was organised on 30^th May 2022 at BRAC Centre Inn Dhaka.

Here are some glimpses from the findings:

·         In the study, 28 Adolescent SRH programmes were reviewed by the study team. Findings reveal that BRAC was a pioneer in implementing programmes for adolescent girls since the ‘90s as part of its women empowerment mission, e.g., BRAC Adolescent Development Programme (1993) and APON (1998). This was followed by UNICEF at the beginning of the millennium (Kishori Abhijan, 2001) and then the government (Adolescent-friendly Health Corners, DGHS/MoHFW, 2011).

·         An attempt was made to identify some impactful (and scalable) AH/SRH programmes based on the scoping review and perspectives of the programme implementers and beneficiaries. For example, child marriage interventions improved awareness about the problems of early marriage, including the legal age of marriage for girls and its rationale. Some interventions positively affected unmarried girls’ preference for marriage at 20 years of age or later and increased their confidence in negotiating with their parents to delay marriage.

·         Menstrual hygiene management programmes helped to improve relevant knowledge and use of health products and services as intended by the programmes. Findings show that additional focus on male family members, especially fathers, was helpful to improve the utilisation of MHM products.

·         Some Nutrition programmes successfully improved nutrition practices and shifted gender dynamics at household and community levels, beside improving knowledge of nutrition and its practical implications in everyday life. Some

·         Programmes focusing on gender-based violence achieved reasonable awareness of the participants around domestic and intimate-partner violence, harassment, rape and acid throwing etc.

·         Findings show that in-school girls developed better gender-equitable attitudes than their out-of-school peers. Some programmes achieved a higher percentage of married adolescents using modern contraceptive methods.

·         Educational interventions enhanced access to AH/SRH knowledge and helped lower the barrier for adolescents to access information, counselling, and sexual and reproductive health services.

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A Trauma Registry (TR) and Trauma System Improvement Project (TSIP) for Bangladesh

 

The trauma registry has been an invaluable tool for informing the design of quality trauma care system, including planned resource allocation and injury surveillance over time. However, its implementation in lower middle in-come countries (LMICs) like Bangladesh faces many barriers and challenges. To test the feasibility of implementation of a trauma registry (TR) and trauma system improvement programme (TSIP) in Bangladesh, a pilot study was conducted in four public sector hospitals in districts with a high incidence of Road-traffic accidents (RTAs) (Bogra, Comilla, Jhenaidah and Tangail). Following the World Health Organisation (WHO) guidelines, the TR and TSIP were designed, contextualised and implemented simultaneously in the above hospitals from Oct. 2021– Feb. 2022. 

A few key findings ae summarised below:

·         Approximately 56 per cent of patients missed the golden hour (first 60 minutes of the occurrence of the accident/crush) of hospital arrival. In 44 per cent of RTAs, the time difference between the occurrence of road traffic injury (RTI) and screening by a health care provider was ≤60 minutes.

·         RTI victims with a household income of less than 15000 had a higher rate (15%) of late arrival at hospital ER, i.e., ≥ 3 hours.

·         80% of the RTA victims were males but females were admitted in the in-patient wards at a higher proportion (70%); the lower extremities (68%) of the body endured the most injuries and the most common injury being  abrasion (72%).

·         Motorists sustained a high proportion of lower extremity (76%), cut/open wound injuries (44%), and abrasion (76%) type injuries.

·         Eighty-one per cent of the cases were attended by nurses, followed by support staff (17%) and physicians (1%) when the patient arrived at the emergency room.

·         In 76% of cases, the vital signs were neither observed nor recorded. The practice of Glasgow Coma Scale (GCS) scoring of the road traffic accident (RTA) victims is low  (14%). Almost all patients receive non-operative management (95%) upon admission to a healthcare facility.

·         Clinical investigations were not requested or documented for more than half of the patients (53%); radiology/X-ray (37%) and CT scan (11%) were requested at a higher proportion compared to other investigations.

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