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
Last Thursday, FHS partner icddr,b in collaboration with brac and The Lancet launched a six-part special investigation into the health landscape in Bangladesh. The series explores how a country with low spending on health care, a weak health system, and widespread poverty has managed to make some exceptional health gains over the last two decades -- for example in the survival of infants and children under five years of age, life expectancy, immunisation coverage, and tuberculosis control.
Recent FHS Bangladesh Publications
In Future Health Systems, we focused on communities as active service delivery participants across a wide variety of contexts. In this brief, we reflect on the process of unlocking community capabilities, the key actors involved, and the productive tensions within community partnerships forged to build more responsive, resilient and equitable health systems.
Mirelman AJ, Rose S, Khan JAM, Ahmed S, Peters DH, Niessen LW, Trujillo AJ (2016) The relationship between non-communicable disease occurrence and poverty—evidence from demographic surveillance in Matlab, Bangladesh, Health Policy and Planning. 2016, 1-8, doi: 10.1093/heapol/czv134
In low-income countries, a growing proportion of the disease burden is attributable to non- communicable diseases (NCDs). There is little knowledge, however, of their impact on wealth, human capital, economic growth or household poverty. This article estimates the risk of being poor after an NCD death in the rural, low-income area of Matlab, Bangladesh.
Khan JAM, Trujillo AJ, Ahmed S, Siddiquee AT, Alam N, Mirelman AJ, Koehlmoos TP, Niessen LW and Peters DH (2015) Distribution of chronic disease mortality and deterioration in household socioeconomic status in rural Bangladesh - an analysis over a 24 year period, International Journal of Epidemiology, 44 (6), 1917-1926, doi: 10.1093/ije/dyv197
Little is known about long-term changes linking chronic diseases and poverty in low-income countries such as Bangladesh. This study examines how chronic disease mortality rates change across socioeconomic groups over time in Bangladesh, and whether such mortality is associated with households falling into poverty.
Khatuna F, Heywood AE, Ray PK, SMA Hanifi, Bhuiya A, Liaw ST (2015) Determinants of readiness to adopt mHealth in a rural community of Bangladesh, International Journal of Medical Informatics, Volume 84, Issue 10, Pages 847–856, http://dx.doi.org/10.1016/j.ijmedinf.2015.06.008
Evidence in favour of mHealth for healthcare delivery in settings where trained health workforce is limited or unavailable is accumulating. With rapid growth in access to mobile phones and an acute shortage of health workforce in Bangladesh, mHealth initiatives are increasing with more than 20 current initiatives in place. “Readiness” is a crucial prerequisite to the successful implementation of telehealth programs. However, systematic assessment of the community readiness for mHealth-based services in the country is lacking. This article reports on a recent study describing the influence of community readiness for mHealth of a rural Bangladesh community.
Khan NUZ, Rasheed S, Sharmin T, Ahmed T, Mahmood SS, Khatun F, Hanifi SMA, Hoque S, Iqbal M and Bhuiya A (2015) Experience of using mHealth to link village doctors with physicians: lessons from Chakaria, Bangladesh, BMC Medical Informatics and Decision Making, 15:62, doi:10.1186/s12911-015-0188-9
Bangladesh is facing serious shortage of trained health professionals. In the pluralistic healthcare system of Bangladesh, formal health care providers constitute only 5 % of the total workforce; the rest are informal health care providers. Information Communication Technologies (ICTs) are increasingly seen as a powerful tool for linking the community with formal healthcare providers. This study assesses an intervention that linked village doctors (a cadre of informal health care providers practising modern medicine) to formal doctors through call centres from the perspective of the village doctors who participated in the intervention.
This paper presents a conceptual approach for discussing health information seeking among poor households in Africa and Asia. This approach is part of a larger research endeavor aimed at understanding how health systems are adapting; with possibilities and constraints emerging. These health systems can be found in a context of the changing relationships between states, markets and civil society in low and middle income countries. The paper starts from an understanding of the health sector as a “health knowledge economy”, organized to provide people with access to knowledge and advice. The use of the term “health knowledge economy” draws attention to the ways the health sector is part of a broader knowledge economy changing the way individuals and households obtain and use specialist information. The paper integrates an actor centric approach with the theory of planned behavior. It seeks to identify the actors engaged in the health knowledge economy as a precursor to longer term studies on the uptake of innovations integrating health services with mobile phones, commonly designated as mHealth, contributing to an understanding of the potential vulnerabilities of poor people, and highlighting possible dangers if providers of health information and advice are strongly influenced by interest groups.