The inadequacies of the formal healthcare sector in Bangladesh has resulted in a widespread increase in informal providers as an alternative source of care providing basic and essential outpatient health services to millions of poor people in the rural areas. Close proximity to clients, availability to the community day and night, sympathetic behavior, well established relations within the community, and flexible payment methods have made the village doctors a popular source of care.
Findings from our initial studies confirmed that the village doctors (VDs) provide care of questionable quality with considerable over-prescription of drugs, including the prescription of drugs that are mostly inappropriate and potentially harmful. Regardless, the widespread existence of VDs and their significance as an integral contributor of healthcare within rural communities in Bangladesh necessitates an effective regulatory arrangement that improves and ensures a minimum standard in the quality of services provided.
FHS Phase 1
In the first phase, FHS Bangladesh established the ShasthyaSena intervention, which employed a combination of three strategies to improve healthcare services in rural Chakaria, Bangladesh. All of the 157 village doctors (VDs) practicing in the intervention areas were invited to participate in a free training in managing common illnesses such as pneumonia, diarrhea, hepatitis, malaria, tuberculosis, viral fever, and various complications related to labor and delivery. A small booklet with information on what to do and what not to do for eleven common illnesses was distributed as a source of future reference. As members of the SS network, qualified village doctors were awarded crests containing the SS logo. A memorandum of understanding outlining the responsibilities and objectives of SS was signed between each joining member and the network.
The study has shown that training and branding has acceptability among village doctors although their behaviour has had no drastic changes due to the lack of financial incentives. The ShasthyaSena intervention has also resulted in a change in the attitude of the government toward informal healthcare providers.
FHS Phase 2
In Phase 2, FHS Bangladesh is pursuing branding and social franchising mechanisms and marrying them to new technologies such as telemedicine and the “health box”. This will show and guide the informal healthcare providers how to treat and manage many common illnesses through the use of computer-based diagnostic algorithms. These components together will create a brand with serious content that is attractive to village doctors and even more attractive to customers through improvements in the quality of care. The intervention will further link village doctors with formal healthcare providers for more complicated illnesses. While over-the-counter drugs can be dispensed by the village doctors themselves, dispensing prescription drugs will be guided by linking them with qualified physicians. Dispensing of medicines will be part of the profit made by village doctors and will provide them with a financial incentive. All the above activities will be ensured and supervised by the project. If acceptability and efficacy of the intervention can be shown, a stronger case can be made that shows that using informal healthcare providers will be profitable in a country that has a huge shortfall in the health workforce.
FHS Partners in Bangladesh
News and announcements from FHS Bangladesh
A “learning-by-doing” approach, using tools and techniques that are inclusive, participatory, and flexible, can help engagement and learning in different contexts to improve the delivery of health services.
This DC Health Systems Board event will bring together researchers and practitioners to share their experiences of engaging and working alongside service providers, beneficiaries, officials, and other local stakeholders through implementation research, and to discuss tools that can support such processes.
FHS is pleased to announce the publication of a new BMC Health Research Policy and Systems supplement , titled Engaging Stakeholders in Implementation Research: tools, approaches, and lessons learned from application.
Implementation research and the engagement of stakeholders in such research have become increasingly prominent in finding ways to design, conduct, expand and sustain effective and equitable health policies, programmes and related interventions.
The articles in this supplement examine some of the tools and approaches used to facilitate stakeholder engagement in implementation research, and describe learning from the experience of the Future Health Systems (FHS) Research Programme Consortium.
Recent FHS Bangladesh Publications
Hanifi SMA, Das S, and Rahman M (2018) Bangladeshi neonates miss the potential benefits of early BCG vaccination, International Journal of Epidemiology, Volume 47, Issue 1, Pp 348–349, DOI: 10.1093/ije/dyx223
Bangladesh is a high-TB-burden country. It is recommended, for TB-endemic areas, that BCG be given to neonates at the first possible opportunity of their life. Several observational studies and lately a few randomized trials show that BCG offers ‘heterologous protective effects’ beyond its target disease tuberculosis. A recent review by WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) on non-specific effects of BCG vaccine shows that vaccination at birth reduces neonatal mortality by 48% (18–67%), which is mainly due to the prevention of neonatal sepsis and respiratory infections. In Bangladesh, neonatal mortality is high (28 per 1000 live births) (and accounts for about two-thirds of all under-five deaths), mainly due to infections, birth asphyxia, respiratory infection and prematurity.
Chowdhury AH, Hanifi SMA, Mia MN and Bhuiya A (2017) Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years, International Journal for Equity in Health (2017) 16:197, DOI: 10.1186/s12939-017-0693-9
Socioeconomic inequality in health and mortality remains a disturbing reality across nations including Bangladesh. Inequality drew renewed attention globally. Bangladesh though made impressive progress in health, it makes an interesting case for learning. This paper examined the trends and changing pattern of socioeconomic inequalities in under-five mortality in rural Bangladesh. It also examined whether mother’s education had any effect in reducing socioeconomic inequalities.
Khatun F, Heywood AE, Hanifi SM, Rahman MS, Ray PK, Liaw ST and Bhuiya A (2017) Gender differentials in readiness and use of mHealth services in a rural area of Bangladesh, BMC health services research, 17:573, DOI: 10.1186/s12913-017-2523-6
Traditional gender roles result in women lagging behind men in the use of modern technologies, especially in developing countries. Although there is rapid uptake of mobile phone use in Bangladesh, investigation of gender differences in the ownership, access and use of mobile phones in general and mHealth in particular has been limited. This paper presents gender differentials in the ownership of mobile phones and knowledge of available mHealth services in a rural area of Bangladesh.
Paina L, Wilkinson A, Tetui M, Ekirapa-Kiracho E, Barman D, Ahmed T, Mahmood SS, Bloom G, Knezovich J, George A and Bennett S (2017) Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda, Health Research Policy and Systems, 15(Suppl 2):109, DOI: 10.1186/s12961-017-0272-y
The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.
Bennett S, Mahmood SS, Edward A, Tetui M and Ekirapa-Kiracho E (2017) Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda, Health Research Policy and Systems, 15(Suppl 2):108, DOI: 10.1186/s12961-017-0270-0
Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.
Bloom G, Berdou E, Standing H, Guo Z and Labrique A (2017) ICTs and the challenge of health system transition in low and middle-income countries, Globalization and Health, 13:56, doi: 10.1186/s12992-017-0276-y
The aim of this paper is to contribute to debates about how governments and other stakeholders can influence the application of ICTs to increase access to safe, effective and affordable treatment of common illnesses, especially by the poor. First, it argues that the health sector is best conceptualized as a ‘knowledge economy’. This supports a broadened view of health service provision that includes formal and informal arrangements for the provision of medical advice and drugs. This is particularly important in countries with a pluralistic health system, with relatively underdeveloped institutional arrangements. It then argues that reframing the health sector as a knowledge economy allows us to circumvent the blind spots associated with donor-driven ICT-interventions and consider more broadly the forces that are driving e-health innovations. It draws on small case studies in Bangladesh and China to illustrate new types of organization and new kinds of relationship between organizations that are emerging. It argues that several factors have impeded the rapid diffusion of ICT innovations at scale including: the limited capacity of innovations to meet health service needs, the time it takes to build new kinds of partnership between public and private actors and participants in the health and communications sectors and the lack of a supportive regulatory environment. It emphasises the need to understand the political economy of the digital health knowledge economy and the new regulatory challenges likely to emerge. It concludes that governments will need to play a more active role to facilitate the diffusion of beneficial ICT innovations at scale and ensure that the overall pattern of health system development meets the needs of the population, including the poor.