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
Future Health Systems research in Bangladesh and Uganda is assessing how community empowerment strategies can affect service delivery and community capabilities. In Uganda, FHS partner, Makerere University School of Public Health, has partnered with Kibuku District in Eastern Uganda to develop and test a community and facility score card for maternal and newborn health service delivery. The feasibility study aims at identifying facilitators, barriers and factors that could influence implementation, institutionalization and scale-up of community and facility score cards in Uganda.
Delivering for Success at Scale - a two day conference from 7 to 8 February 2017 at the BRAC Auditorium, Mohakhali, Dhaka, Bangladesh - will build on the longstanding partnership between BRAC, ICDDR,B and the Institute of Development Studies to explore the role of knowledge in the conceptualisation, design, delivery and management of development programmes and policies.
Recent FHS Bangladesh Publications
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.
Thow AM, Karn S, Devkota MD, Rasheed S, Roy SK, Suleman Y, Hazir T, Patel A, Gaidhane A, Puri S, Godakandage S, Senarath U and Dibley MJ (2017) Opportunities for strengthening infant and young child feeding policies in South Asia: Insights from the SAIFRN policy analysis project, BMC Public Health, 17(Suppl 2):404 DOI: 10.1186/s12889-017-4336-2
South Asian countries experience some of the highest levels of child undernutrition in the world, strongly linked to poor infant and young child feeding (IYCF) practices. Strong and responsive policy support is essential for effective interventions to improve IYCF. This study aimed to identify opportunities for strengthening the policy environment in the region to better support appropriate infant and young child feeding.
Uddin S, Mahmood H, Senarath U, Zahiruddin Q, Karn S, Rasheed S and Dibley M (2017) Analysis of stakeholders networks of infant and young child nutrition programmes in Sri Lanka, India, Nepal, Bangladesh and Pakistan, BMC Public Health, 17(Suppl 2):405, DOI: 10.1186/s12889-017-4337-1
Effective public policies are needed to support appropriate infant and young child feeding (IYCF) to ensure adequate child growth and development, especially in low and middle income countries. The aim of this study was to: (i) capture stakeholder networks in relation to funding and technical support for IYCF policy across five countries in South Asia (i.e. Sri Lanka, India, Nepal, Bangladesh and Pakistan); and (ii) understand how stakeholder networks differed between countries, and identify common actors and their patterns in network engagement across the region.
Rasheed S, Roy SK, Das S, Chowdhury SN, Iqbal M, Akter SM, Jahan K, Uddin S and Thow AM (2017) Policy content and stakeholder network analysis for infant and young child feeding in Bangladesh, BMC Public Health, 17(Suppl 2):402, DOI: 10.1186/s12889-017-4338-0
Appropriate infant and young child feeding (IYCF) practices are essential for nutrition of infants and young children. Bangladesh has one of the highest levels of malnutrition globally along with sub-optimal IYCF practices. A supportive policy environment is essential to ensure that effective IYCF interventions are scaled up.
The objectives of our study were to assess the support for IYCF in the national policy environment through policy analysis and stakeholder analysis and in so doing identify opportunities to strengthen the policy environment.
Adams AM, Ahmed R, Mahbub Latif AHM, Rasheed S, Das SM, Hasib E, Farzana FD, Ferdous F, Ahmed S, Faruque ASG (2017) Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh, PLOS One, 12(4): e0174673, DOI: 10.1371/journal.pone.0174673
Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group. The authors explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.
Iqbal M, Chowdhury AH, Mahmood SS, Mia MN, Hanifi SMA and Bhuiya A (2017) Socioeconomic and programmatic determinants of renewal of membership in a voluntary micro health insurance scheme: evidence from Chakaria, Bangladesh, Global Health Action, Vol 10, Issue 1, DOI: 10.1080/16549716.2017.1287398
Out-of-pocket (OOP) healthcare expenditure is a major obstacle for achieving universal health coverage in low-income countries including Bangladesh. Sixty-three percent of the USD 27 annual per-capita healthcare expenditure in Bangladesh comes from individuals’ pockets. Although health insurance is a financial tool for reducing OOP, use of such tools in Bangladesh has been limited to some small-scale voluntary micro health insurance (MHI) schemes run by non-governmental organizations (NGO). The MHI, however, can orient people on health insurance concept and provide learning for product development, implementation, barriers to enrolment, membership renewal, and other operational challenges and solutions. Keeping this in mind, icddr,b in 2012 initiated a pilot MHI, Amader Shasthya, in Chakaria, Bangladesh. This paper explores the determinants of membership renewal in this scheme, which is a perpetual challenge for MHI.