Innovation for universal health coverage in Bangladesh: a call to action

Quality of life and its predictors among patients with metastatic cancer in Bangladesh: the APPROACH survey

BACKGROUND

This study aimed to assess the health-related quality of life (HRQOL) (physical, functional, emotional, social, spiritual) and psychological (anxiety and depression) well-being and their associations with patient characteristics among patients with metastatic cancer in Bangladesh.

METHODS

A convenience sample of 386 Bangladeshi patients with stage IV solid cancers was recruited from a palliative care outpatient department and an inpatient palliative center. Dependent variables included the physical, functional, emotional, social, and overall scores of the Functional Assessment of Cancer Therapy-General (FACT-G) scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-SP) scale, the anxiety, depression, and overall scores of the Hospital Anxiety and Depression (HADS) scale. Linear regressions examined the association between dependent variables and patient characteristics.

RESULTS

A substantial proportion of Bangladeshi patients reported anxiety (59% of outpatients and 55% of inpatients) and depression (60% of outpatients and 73% of inpatients) symptoms. Generally, greater financial difficulty and symptom burden scores were associated with worse health outcomes. Older patients reported poorer functional and spiritual well-being but better anxiety scores. Females reported worse anxiety and depressive symptoms and physical well-being but better spiritual outcomes.

CONCLUSIONS

Additional efforts must be directed at improving the HRQOL of patients with metastatic cancer in Bangladesh. Furthermore, assistance should be made more accessible to vulnerable groups, including women, the elderly, and those with financial difficulty.

Study on the Impact of Government Health Expenditure Equity on Residents' Health Level in the Chengdu-Chongqing Economic Circle of China

BACKGROUND

When the global COVID-19 epidemic continues to spread, residents pay more attention to their health. This paper studies the relationship between the equity of government health expenditure and the health level of residents.

METHODS

The Theil index and a principal component analysis were used to measure the equity of government health expenditure and the health level of residents in the Chengdu-Chongqing economic circle. Then, an empirical study on the relationship between the equity of government health expenditure and the health level of residents in this region was conducted with the System GMM model.

RESULTS

1. The Theil index rose from 0.0115 in 2015 to 0.0231 in 2017 and gradually decreased to 0.0106 in 2020. 2. The overall health level of residents showed an upward trend, rising from 1.95 in 2015 to 2.33 in 2017, then remained high and fluctuated slightly. 3. There was a positive correlation between the Theil index and the health level of residents at a significance level of 1% (β = 0.903, p < 0.01).

CONCLUSIONS

1. The Theil index was close to 0, indicating that the equity of government health expenditure in the Chengdu-Chongqing economic circle was generally good. 2. The health level of residents in the Chengdu-Chongqing economic circle had improved compared to before. 3. The fairer the government's health expenditure, the higher the residents' health level.

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

BACKGROUND

Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.

METHODS AND FINDINGS

We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.

CONCLUSIONS

In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

General Demographics and Behavioral Patterns of Visitors Using a Self-help Website for Identification of and Intervention in Alcoholism and Common Mental Disorders in Suriname: Descriptive Study

Background

Digital health applications have been shown to be an accepted means to provide mental health information and advice in various high- and middle-income countries. Started in 2015, ehealth.sr was the first website to offer preventive information, self-tests, and unguided digital self-help for depression, anxiety symptoms, and problematic alcohol use in Suriname, an upper middle-income country in South America.

Objective

This study aimed to assess the general demographics and behavioral patterns of the visitors of ehealth.sr, as well as to evaluate different promotional channels to attract the target audience to the website.

Methods

Data collection for this study took place between August 2015 and December 2020. Conventional promotion channels such as newspaper and radio advertisements as well as social media advertisements were used to attract users to the website. The number of visits and activity on the website was registered using Google analytics and the website’s internal activity log.

Results

On average, about 115 unique visitors accessed the website per month. The average number of visits to the website increased notably when social media advertisement campaigns were conducted (266 per month in 2018) compared to when traditional advertisements campaigns through papers, radio, and television were used (34 per month in 2019). Of the 1908 new visitors, 1418 (74.32%) were female. On average, visitors accessed 2 (SD 0.3) pages of the website and a session lasted 2.6 (SD 0.9) minutes. The most popular pages for intervention on the website were those for the mood or anxiety screening (731/942, 77.6%) as opposed to those for alcohol screening (211/942, 22.4%). People aged <45 years (on average, 2.2 pages per session for 3.2 minutes) made more use of the website than people aged ≥45 years (on average, 1.7 pages per session for 2 minutes).

Conclusions

Promotion via social media led to more visitors to the website than newspaper or radio advertisements. Younger age groups and females visited the website more often. The pages on preventive information and brief self-tests were visited more frequently than the self-help modules. In general, user adherence to the website in terms of the average session duration and number of viewed pages per session is low and is a key point of concern for the successful implementation of digital mental health websites.

Exploring the possible sources of fiscal space for health in India: insights from political regimes

BACKGROUND

Rising healthcare costs and poor access to health services have become a significant concern for policy-makers; therefore, efforts must be made to generate fiscal space through alternative revenue measures in resource-poor economies. This study attempts to identify possible sources of fiscal space for health in India across political regimes.

METHODS

The study followed a descriptive approach to examine the political commitment towards health sector development by estimating the trend of growth in fiscal space indicators over the political regimes from 1998-1999 to 2021-2022 using a dummy variable regression model.

RESULTS

We found four possible sources of fiscal space for health, which include (1) raising domestic revenue mobilization, (2) generating alternative revenue collection mechanisms, (3) prioritizing health through expenditure management and (4) effective utilization of central transfer. Fiscal space measures such as goods and services tax reform, collection of health-specific tax, higher excise duty on tobacco products, cooking gas subsidies to poor people, tax administration reform and direct beneficiary transfer of health services could be alternative revenue mobilization channels for fiscal space for health.

CONCLUSION

The study reveals that the central government has a political commitment to generating revenue through various fiscal policy reforms. Health has been prioritized over the period, but there is less evidence of health-related political commitment for an increased share of health expenditure to total budgetary allocation. During the last 2 years, however, the health budget has been prioritized due to the COVID-19 pandemic crisis despite slower economic growth in India. This study will be a policy document for fiscal space analysis from a political-economic perspective, and the role of the ministry of finance can be assessed through administrative data and documents.

Implementing a digital human resources management tool in the government health sector in Bangladesh: a policy content analysis

INTRODUCTION

In Bangladesh, to address the challenges of ensuring adequate human resources for health (HRH), the government began implementing a digital tool for HRH management in 2017. However, evidence suggests institutionalizing such tools in low-and-middle-income countries is impeded by policy aspects like implementation strategy and poor regulatory framework. Therefore, we aimed to explore factors in the current policy landscape that might facilitate and challenge the implementation of the tool in Bangladesh.

METHODS

We conducted a review of policies related to ICT implementation and human resources management in the health sector in Bangladesh using qualitative content analysis method. Ten policies have been identified, and extensive reading was done to ascertain common themes and patterns. A document analysis matrix was developed to synthesize and help interpret the findings.

RESULTS

Regarding facilitators, strong upstream level commitments were reflected in the content of policies in terms of setting out specific objectives, targets, timelines, and budget allocation. However, the lack of explicit monitoring strategy and extent of stakeholders' engagement was not well-defined, ultimately creating chances for impeding downstream implementation. In addition, effective coordination among stakeholders and different HRH and ICT policies could be strengthened.

DISCUSSION

Findings support the current discourse that national commitment plays a vital role in the integration of ICTs in health services. However, well-defined monitoring strategy and inter-ministry and intra-ministry policy coordination are crucial.

Effects of integrated psychosocial stimulation (PS) and unconditional cash transfer (UCT) on children's development in rural Bangladesh: A cluster randomized controlled trial

BACKGROUND

There is evidence on benefits of psychosocial stimulation (PS) and cash transfer programmes in low- and middle-income countries on children's development. We integrated PS into an unconditional cash transfer (UCT) programme for poor Bangladeshi mothers to examine the effects on children's development.

METHODS

This cluster randomized controlled trial was conducted in rural Bangladesh from July 2017 to December 2018 in 33 clusters, with 11 clusters randomly assigned to each of the three arms, namely i) PS + UCT ii) UCT-only and iii) Comparison. We enrolled poor mothers and child (6-16 months) dyads eligible to receive maternity allowance by the Government of Bangladesh. Trained local women imparted training to mothers to provide psychosocial stimulation to their children for one year. Children's cognitive, language and motor development were measured with Bayley-III, behaviour with Wolke's ratings and maternal self-esteem with Rosenberg self-esteem scale. The analysis was intention-to-treat.

RESULTS

Of the 594 mother-child dyads, 40 (6·8%) were lost to follow-up. Compared to UCT-only, children in the PS + UCT had significant improvement in cognitive (B = 2.96, 95% CI: 0.46-5.47, Effect Size [ES] 0.24SD) and language (2.73, 0.39-5.00, ES 0.21SD) scores and were more responsive to examiner (0.30, 0.06-0.52, ES 0.27SD), while compared to comparison group, they had significantly higher cognitive (3.37, 1.27-6.19, ES 0.32SD), language (2.82, 0.53-5.10, ES 0.24SD) and motor (2.65, 0.24-5.06, ES 0.22SD) scores and were more responsive to examiner (0.30, 0.08-0.52, ES 0.26 SD). The mothers' self-esteem was significantly higher in PS + UCT (2.46, 0.94-3.98, ES 0.48 SD) and UCT-only (1.67, 0.02-3.20, ES 0.32 SD) compared to the comparison group.

CONCLUSION

PS integrated into an UCT programme benefited children's neurodevelopment and UCT improved mother's self-esteem. UCT programme may be an important platform for child stimulation programmes for rural poor populations.

The current state of mental healthcare in Bangladesh: part 1 - an updated country profile

Mental health is a significant factor for a sound and productive life; nevertheless, mental disorders do not often receive adequate research attention and are not addressed as a serious public health issue in countries such as Bangladesh. Part 1 of this two-part profile describes the current situation of mental health in Bangladesh in its wider sociocultural context, outlining existing policies and highlighting mental illness as a neglected healthcare problem in the country using a narrative synthesis method. The prevalence of mental disorders is very high and augmented in nature among different population groups in Bangladesh. A lack of public mental health facilities, scarcity of skilled mental health professionals, insufficient financial resource distribution, inadequately stewarded mental health policies and stigma contribute to making current mental healthcare significantly inadequate in Bangladesh. The country has few community care facilities for psychiatric patients. Furthermore, the current mental health expenditure by the Bangladeshi government is only 0.44% of the total health budget. Less than 0.11% of the population has access to free essential psychotropic medications.

Incentivising doctor attendance in rural Bangladesh: a latent class analysis of a discrete choice experiment

Objective

Doctor absenteeism is widespread in Bangladesh, and the perspectives of the actors involved are insufficiently understood. This paper sought to elicit preferences of doctors over aspects of jobs in rural areas in Bangladesh that can help to inform the development of packages of policy interventions that may persuade them to stay at their posts.

Methods

We conducted a discrete choice experiment with 308 doctors across four hospitals in Dhaka, Bangladesh. Four attributes of rural postings were included based on a literature review, qualitative research and a consensus-building workshop with policymakers and key health-system stakeholders: relationship with the community, security measures, attendance-based policies and incentive payments. Respondents’ choices were analysed with mixed multinomial logistic and latent class models and were used to simulate the likely uptake of jobs under different policy packages.

Results

All attributes significantly impacted doctor choices (p<0.01). Doctors strongly preferred jobs at rural facilities where there was a supportive relationship with the community (β=0.93), considered good attendance in education and training (0.77) or promotion decisions (0.67), with functional security (0.67) and higher incentive payments (0.5 per 10% increase of base salary). Jobs with disciplinary action for poor attendance were disliked by respondents (−0.63). Latent class analysis identified three groups of doctors who differed in their uptake of jobs. Scenario modelling identified intervention packages that differentially impacted doctor behaviour and combinations that could feasibly improve doctors’ attendance.

Conclusion

Bangladeshi doctors have strong but varied preferences over interventions to overcome absenteeism. We generated evidence suggesting that interventions considering the perspective of the doctors themselves could result in substantial reductions in absenteeism. Designing policy packages that take account of the different situations facing doctors could begin to improve their ability and motivation to be present at their job and generate sustainable solutions to absenteeism in rural Bangladesh.

Challenges and facilitators of implementation of an information communication and technology (ICT)-based human resources management tool in the government health sector in Bangladesh: protocol for an exploratory qualitative research study

INTRODUCTION

To improve human resources for health (HRH) management in Bangladesh, the directorate general of health services (DGHS) introduced a new information and communications technology (ICT) tool, named 'human resources information system (HRIS)', to process real-time HRH data of all facilities under the DGHS. However, synchronisation is a major concern since multiple authorities are involved in the implementation of the tool at different tiers of the health system. Introducing ICT tools in healthcare organisations has always proved challenging as evidence from low-income and middle-income countries suggests. The knowledge gap in terms of factors that support or constrain the successful implementation of the HRIS in Bangladesh will be investigated in this exploratory study to identify ways of engaging the key stakeholders in a better way for an effective use of the tool.

METHODS AND ANALYSIS

Desk review and qualitative data collection methods will be used to address the study objectives. Key informant interviews and in-depth interviews will be conducted to explore perspectives of policy-makers, programme managers, service providers and other stakeholders to understand the barriers to implementing HRIS in the context of Bangladesh. We plan to organise stakeholder consultation workshops to validate the qualitative study findings and to seek suggestions for ensuring a successful implementation of the HRIS. Framework analysis will be applied to analyse qualitative data, and an outline with the definitions of a priori codes guided by the policy engagement framework will be prepared. Besides, emerging themes will also be identified. A data display matrix will be prepared to summarise and interpret the findings for policy review.

ETHICS AND DISSEMINATION

The research review committee and the ethical review committee of icddr,b have approved the research protocol. Findings from the study will be communicated through national and international forums, conferences, policy briefs and peer-reviewed journal publications.

Digital Health and Inequalities in Access to Health Services in Bangladesh: Mixed Methods Study

Background

Globally, the rapid growth of technology and its use as a development solution has generated much interest in digital health. In line with global trends, Bangladesh is also integrating technology into its health system to address disparities. Strong political endorsement and uptake of digital platforms by the government has influenced the rapid proliferation of such initiatives in the country. This paper aims to examine the implications of digital health on access to health care in Bangladesh, considering who uses electronic devices to access health information and services and why.

Objective

This study aims to understand how access to health care and related information through electronic means (digital health) is affected by sociodemographic determinants (ie, age, gender, education, socioeconomic status, and personal and household ownership of mobile phones) in a semiurban community in Bangladesh.

Methods

A cross-sectional survey of 854 households (between October 2013 and February 2014) and 20 focus group discussions (between February 2017 and March 2017) were conducted to understand (1) who owns electronic devices; (2) who, among the owners, uses these to access health information and services and why; (3) the awareness of electronic sources of health information; and (4) the role of intermediaries (family members or peers who helped to look for health information using electronic devices).

Results

A total of 90.3% (771/854) of households (471/854, 55.2% of respondents) owned electronic devices, mostly mobile phones. Among these, 7.2% (34/471) used them to access health information or services. Middle-aged (35-54 years), female, less (or not) educated, and poorer people used these devices the least (α=.05, α is the level of significance). The lack of awareness, discomfort, differences with regular care-seeking habits, lack of understanding and skills, and proximity to a health facility were the main reasons for not using devices to access digital health.

Conclusions

Although influenced by sociodemographic traits, access to digital health is not merely related to device ownership and technical skill. Rather, it is a combination of general health literacy, phone ownership, material resources, and technical skill as well as social recognition of health needs and inequity. This study’s findings should serve as a basis for better integrating technology within the health system and ensuring equitable access to health care.

Prevention of social exclusion and role of antenatal care by BRAC community health workers in improving safe motherhood and neonatal care in urban slums of Bangladesh

The transformation of the BRAC MANOSHI programme from humanitarian to a social enterprise model, has made it increasingly urgent to enumerate the minimum number of door-to-door antenatal care (ANC) visits by community health workers (CHWs), for the purpose of effectively improving facility delivery. Thus prevent social exclusion of poor slum communities in Bangladesh with regard to safe motherhood and essential newborn care (ENC). This cross-sectional study was conducted, during March–July, 2015 in slums of Chittagong, Dhaka and Sylhet city corporations of Bangladesh. A census was conducted among 25,700 households covering 10 branch offices of MANOSHI to identify women with a delivery outcome in the preceding three years of the survey. A total of 1100 respondents were interviewed randomly through a structured questionnaire. These women were stratified into three categories-1, 2 & 3, consisting of 497, 205 and 398 women respectively. Women in category-1 did not receive any ANC checkup from the BRAC CHWs, while women in category-2 and category-3 received one to three and ≥four ANC checkups from BRAC CHWs respectively. Data was analysed using STATA Version 13 (Chicago Inc.). Findings revealed that women, who received ≥four ANC checkups from BRAC CHWs, are 25% more likely to avail facility delivery [adjusted Prevalence Ratio (aPR) 1.25; 95% confidence interval (CI) (1.01–1.54)] compared to the women who did not receive any ANC from BRAC CHWs. Women in category-2 [aPR3.64; 95% CI (1.76–7.54)] and in category-3 [aPR5.92; 95% CI (3.04–11.53)] respectively had four and six folds higher tendency to receive postnatal care (PNC) within 48 hours after delivery. Furthermore, facility delivery improved PNC assisted by medically trained providers (MTPs) within 48 hours after delivery and ENC in both categories 2 & 3. The evidence shows that at least four ANC visits of BRAC CHWs can increase institutional delivery, and which can further facilitate PNC and ENC visits. At present, the BRAC MANOSHI programme needs to implement feasible strategies to include pregnant women in the slums in receiving at least four ANC checkups by BRAC CHWs for ensuring safe motherhood and newborn care.

Impact evaluation of contracting primary health care services in urban Bangladesh

BACKGROUND

The Urban Primary Health Care Project (UPHCP) was implemented by the Government of Bangladesh in response to rapid urbanization and growing inequalities in access to and quality of primary health care. The goal of the project was to improve health status of the urban poor living in city corporations and municipalities through the provision of health care services by NGOs that are contracted through public-private partnership. The first phase of the project started in 1998 and the project is currently in its fourth phase covering more urban areas than the first three phases. This study evaluates the impact of the second phase project (UPHCP-II) on health outcomes, mainly child diarrhea, acute respiratory infection, antenatal and postnatal care, skilled birth attendance, breastfeeding prevalence, contraceptive prevalence, sexually transmitted infections, and HIV/AIDS awareness.

METHODS

The effect of the project was estimated through propensity score matching between project and non-project areas comparing baseline and endline surveys over a six-year period from 2006 to 2012. An innovation of this study is the recalibration of the sampling weights that allows the use of these two independent surveys in impact evaluation.

RESULTS

Over the six-year period, UPHCP-II improved the health status of the population in project areas compared to non-project areas. The study found significant improvement in health outcomes in terms of reduced diarrhea and acute respiratory infection in children, which explains the downward trend in child mortality rate. Moreover, the project also improved antenatal care and skilled birth attendance. Contraceptive prevalence and HIV/AIDS awareness and avoidance increased, and sexually transmitted infections decreased.

CONCLUSIONS

UPHCP-II was effective in achieving its health outcome targets, while previous studies show that it was efficient in the delivery of health care and clients were highly satisfied because health facilities were in close proximity, and doctors and staff were perceived as responsive in delivering high quality of care. The results of this study could help inform future design and implementation of urban health interventions that involve contracting primary health care service delivery in Bangladesh and other similar settings.

Harnessing instability as an opportunity for health system strengthening: A review of health system resilience

In recent years, resilience has emerged as a prominent topic in global health systems discourse as a result of the increasing variety and volume of sources of instability inflicting strain on systems. In line with this study's intent to bring together existing literature on health system resilience as a means to understand the process through which systems achieve resilience, a review of academic literature related to health system resilience was conducted. Emerging from this review is an operational model of resilience that builds on existing health systems frameworks. The model highlights health system resilience as a process through which leaders in all sectors need to be mobilized in order to harness instability as an opportunity for health system strengthening rather than a threat to the system's sustainability and integrity.

Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions

Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most of health indicators across social, economic, and demographic parameters. This study explores the existing health policy environment and current activities to further the progress towards Universal Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes: activities around UHC, implementation barriers, suggestions) was done using the manual coding technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health services for all, expansion of access to primary health care services (support by donors), and the piloting of health insurance which has been piloted in three sub districts. Political commitment for these areas is strong. However, there are barriers pertaining to the larger policy level which includes a rigid public financing structure dating from the colonial era. While others pertain to the health sector's implementation shortfalls including issues of human resources, political interference, monitoring, and supervision, most key informants discussed demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of empowerment. To overcome these, several policies have been recommended, e.g., redesigning the public finance structure, improving governance and regulatory mechanism, specifying code of conduct for service providers, introducing health-financing reform, and collaborating with different sectors. To address the implementation barriers, recommendations include improving service quality, strengthening overall health systems, improving health service management, and improving monitoring and supervision. Addressing demand-side barriers, such as patient education and community empowerment, is also needed. Research and advocacy are required to address crosscutting barriers such as the lack of common understanding of UHC.

Socioeconomic transition and its influence on body mass index (BMI) pattern in Bangladesh

RATIONALE, AIMS, AND OBJECTIVES

Bangladesh is an underdeveloped country that has recently joined the ranks of low-middle-income countries. This study aims to investigate how socioeconomic and developmental factors have influenced women towards a shift in their body mass index (BMI).

METHODS

The trend was analysed using data on ever-married women from 6 nationwide surveys covering the years 1996 to 2014, conducted by the Bangladesh Demographic and Health Survey (BDHS). To assess the relationship between the socioeconomic factors and BMI, binary regression models were fitted for 6 surveys and forest plots were applied to display the results.

RESULTS

Factors such as age, education, residence, economic status, and contraceptive use were found to have had an increasing influence on BMI over the years that were being analysed. Age and education for women were potential factors influencing BMI. Growing urbanization and economic inequality were found to have been substantial over time, and marital status and contraceptive use were influential whilst the employment status of women held no consequence.

CONCLUSIONS

Rapid urbanization allied with growing wealth inequality and dietary alteration seems to have forced a change in the capacity of women in Bangladesh to control their weight. Additional information is still needed on such factors as the amount of time that women are inactive and sitting down, for example, as well as their daily calorie intake in order to assemble all the pieces for addressing necessary health policy changes in Bangladesh. These factors will also help to indicate a shift of focus from rural malnutrition to urban obesity.

Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study

INTRODUCTION

Global actions to reduce antimicrobial resistance (AMR) include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers.The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation.

METHODS AND ANALYSIS

In-depth interviews will be conducted with (1) household members responsible for decision-making about illness and antibiotic use for family and livestock; (2) qualified and unqualified private and government healthcare providers in human and animal medicine and (3) stakeholders and policy-makers as key informants on the development and implementation of policy around AMR. Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis.A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behavioural change and the development of effective interventions to reduce the health risks of AMR.

ETHICS AND DISSEMINATION

Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh following review by the Research and Ethics Committees (PR-16100) and from Loughborough University (R17-P081). Information about the study will be provided in a participant information letter in Bangla (to be read verbally and given in writing to participants). A written informed consent form in Bangla will be obtained and participants will be informed of their right to withdraw from the study. Dissemination will take place through a 1 day dissemination workshop with key stakeholders in public health and policy, practitioners and scientists in Bangladesh, and through international conference presentations and peer-review publications. Anonymised transcripts of interviews will be made available through open access via institutional data repositories after an embargo period.

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

Costing essential services package provided by a non-governmental organization network in Bangladesh

The health profile of Bangladesh has improved remarkably, yet gaps in delivering quality health care remain. In response to the need for evidence to quantify resources for providing health services in Bangladesh, this study estimates unit costs of providing the essential services package (ESP) in the not-for-profit sector. This study used a stratified sampling approach to select 18 static clinics, which had fixed facilities, from 330 non-profit clinics under Smiling Sun network in Bangladesh. Costs were estimated from the providers' perspective, using both top-down and bottom-up methods, from July 2014 to June 2015. In total, there were 1115 observations (clients) for the 13 primary care services analysed. The estimated 2015 average costs per visit were: antenatal care ($7.03), postnatal care ($4.57), control of diarrheal diseases ($1.32), acute respiratory infection ($1.53), integrated management of child illness ($2.02), sexually transmitted infections ($4.70), reproductive tract infections ($3.56), tuberculosis ($41.65), limited curative care ($4.30), immunization ($2.23), family planning ($0.72), births by normal delivery ($29.45) and C-section ($114.83). Unit costs varied widely for each service, both between individual patients and among clinic level means. The coefficient of variation for the 13 services averaged 66%, implying potential inefficiencies. In addition, 32.9% of clients were not offered any lab test during the first antenatal visit. The unit cost of essential services differed by the type and location of clinics. Ultra clinics, on average, incurred 37% higher costs than vital (outpatient type) clinics, and urban clinics spent 40% more than rural clinics to deliver a unit of service. The study suggests that inefficiency and quality concerns exist in health service delivery in some facilities. Increasing the volume of clients through demand-side mechanisms and standardization of services would help address those concerns. Unit costs of services provide essential information for estimating resource needs for scaling up the ESPs.

Right to health and social justice in Bangladesh: ethical dilemmas and obligations of state and non-state actors to ensure health for urban poor

Background

The world is urbanizing rapidly; more than half the world’s population now lives in urban areas, leading to significant transition in lifestyles and social behaviours globally. While offering many advantages, urban environments also concentrate health risks and introduce health hazards for the poor. In Bangladesh, although many public policies are directed towards equity and protecting people’s rights, these are not comprehensively and inclusively applied in ways that prioritize the health rights of citizens. The country is thus facing many issues that raise moral and ethical concerns.

Methods

A narrative literature review was conducted between October 2016 and November 2017 on issues related to social justice, health, and human rights in urban Bangladesh. The key questions discussed here are: i) ethical dilemmas and inclusion of the urban poor to pursue social justice; and ii) the ethical obligations and moral responsibilities of the state and non-state sectors in serving Bangladesh’s urban poor. Using a Rawlsian theory of equality of opportunity to ensure social justice, we identified key health-related ethical issues in the country’s rapidly changing urban landscape, especially among the poor.

Results

We examined ethical dilemmas in Bangladesh’s health system through the rural–urban divide and the lack of coordination among implementing agencies. The unregulated profusion of the private sector and immoral practices of service providers result in high out-of-pocket expenditures for urban poor, leading to debt and further impoverishment. We also highlight policy and programmatic gaps, as well as entry points for safeguarding the right to health for Bangladeshi citizens.

Conclusions

The urban health system in Bangladesh needs a reform in which state and non-state actors should work together, understanding and acknowledging their moral responsibilities for improving the health of the urban poor by engaging multiple sectors. The social determinants of health should be taken into account when formulating policies and programs to achieve universal health coverage and ensure social justice for the urban poor in Bangladesh.

Health system innovations: adapting to rapid change

This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.

Relationship of sleep pattern and snoring with chronic disease: findings from a nationwide population-based survey

OBJECTIVES

To investigate the association of total sleep time and presence or absence of snoring with chronic disease among the Bangladeshi adult population.

DESIGN

Cross-sectional survey.

SETTING

Urban and rural Bangladesh.

PARTICIPANTS

A total of 12,338 men and women aged ≥35 years.

MEASUREMENTS

Total sleep time was considered as the total hours of sleep in 24 hours. Furthermore, sleep time was categorized into <7, 7-9, and >9 hours according to National Sleep Foundation (2015) guidelines. Self-reported snoring history was captured and corroborated with their respective sleep partner/spouse in more than 80% cases. Registered physician-diagnosed current and/or previous cases of hypertension, diabetes, coronary heart disease, cancer, stroke, chronic obstructive pulmonary disease, and any other chronic conditions were counted.

RESULTS

Overall prevalence of at least 1 chronic disease in our study population was around 18%: men (15.4%) and women (20.0%). Hypertension has the highest prevalence (overall: 12.7%, men: 12.2%, women: 15%) followed by diabetes (4.9%), coronary heart diseases (3.2%), stroke (1.8%), chronic obstructive pulmonary disease (0.9%), and cancer (any type: 0.1%). Sleep pattern and snoring are significantly associated with all individual chronic disease except cancer. Sociodemographic, behavioral, and lifestyle variables were adjusted, and inadequate total sleep time (<7 hours) and snoring (yes/no) showed significant association with chronic disease status (risk ratio = 1.11, 95% confidence interval 1.00-1.22 and risk ratio = 1.20, 95% confidence interval 1.11-1.29, respectively).

CONCLUSION

Inadequate sleep and snoring are independently associated with chronic disease in Bangladeshi adult population and perhaps elsewhere.

The influence of cost-per-DALY information in health prioritisation and desirable features for a registry: a survey of health policy experts in Vietnam, India and Bangladesh

Background

Economic evaluation has been implemented to inform policy in many areas, including coverage decisions, technology pricing, and the development of clinical practice guidelines. However, there are barriers to evidence-based policy in low- and middle-income countries (LMICs) that include limited stakeholder awareness, resources and data availability, as well as the lack of capacity to conduct country-specific economic evaluations. This study aims to survey health policy experts’ opinions on barriers to use of cost-effectiveness data in these settings and to obtain their advice on how to make a new cost-per-DALY database being developed by Tufts Medical Center more relevant to LMICs. It also identifies the factors influencing transferability.

Methods

In-depth interviews were conducted with 32 participants, including policymakers, technical advisors, and researchers in Health Ministries, universities and non-governmental organisations in Bangladesh, India (New Delhi, Tamil Nadu and Karnataka) and Vietnam.

Results

The survey revealed that, in all settings, the use of cost-effectiveness information in policy development is lacking, owing to limited knowledge among policymakers and inadequate human resources with health economics expertise in the government sector. Furthermore, researchers in universities do not have close connections with health authorities. In India and Vietnam, the demand for evidence to inform coverage decisions tends to increase as the countries are moving towards universal health coverage. The informants in all countries argue that cost-effectiveness data are useful for decision-makers; however, most of them do not perform data searches by themselves but rely on the information provided by the technical advisor counterparts. Most interviewees were familiar with using evidence from other countries and were also aware of the influences of contextual elements as a limitation of transferability. Finally, strategies to promote the newly developed database include training on basic economic evaluation for policymakers and researchers, and effective communication programs, with support from reputable global agencies.

Conclusions

Although cost-effectiveness information is recognised as essential in resource allocation, there are several impediments in the generation and use of such evidence to inform priority setting in LMICs. As such, the Cost-per-DALY database should be well-designed and introduced with appropriate promotion strategies so that it will be helpful in real-world policymaking.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0156-6) contains supplementary material, which is available to authorized users.

Recent Worldwide Developments in eHealth and mHealth to more Effectively Manage Cancer and other Chronic Diseases - A Systematic Review

OBJECTIVES

This paper is a systematic literature review intended to gain an understanding of the most original, excellent, stateof- the-art research in the application of eHealth (including mHealth) in the management of chronic diseases with a focus on cancer over the past two years.

METHOD

This review looks at peer-reviewed papers published between 2013 and 2015 and examines the background and trends in this area. It systematically searched peer-reviewed journals in databases PubMed, Proquest, Cochrane Library, Elsevier, Sage and the Institute of Electrical and Electronic Engineers (IEEE Digital Library) using a set of pre-defined keywords. It then employed an iterative process to filter out less relevant publications.

RESULTS

From an initial search return of 1,519,682 results returned, twenty nine of the most relevant peer reviewed articles were identified as most relevant.

CONCLUSIONS

Based on the results we conclude that innovative eHealth and its subset mHealth initiatives are rapidly emerging as an important means of managing cancer and other chronic diseases. The adoption is following different paths in the developed and developing worlds. Besides governance and regulatory issues, barriers still exist around information management, interoperability and integration. These include medical records available online information for clinicians and consumers on cancer and other chronic diseases, mobile app bundles that can help manage co-morbidities and the capacity of supporting communication technologies.

Evaluation of Maternal Health Service Indicators in Urban Slum of Bangladesh

Background

A continuous influx of poor people to urban slums poses a challenge to Bangladesh’s health system as it has failed to tackle maternal morbidity and mortality. BRAC is the largest non-governmental organisation in Bangladesh. BRAC has been working to reduce maternal, neonatal and under-five children morbidity and mortality of slum dwellers in cities. BRAC has been doing this work for a decade through a programme called MANOSHI. This programme provides door-to-door services to its beneficiaries through community health workers (CHWs) and normal delivery service through its delivery and maternity centres. BRAC started the ‘MANOSHI’ programme in Narayanganj City Corporation during 2011 to address maternal, neonatal and child health problems facing slum dwellers. We investigated the existing maternal health-service indicators in the slums of Narayanganj City Corporation and compared the findings with a non-intervention area.

Methods

This cross-sectional study was conducted during 2012, in 47 slums of Narayanganj City Corporation as intervention and 10 slums of Narsingdi Sadar Municipality as comparison area. A total of 1206 married women, aged 15–49 years, with a pregnancy outcome in the previous year were included for interview. Data on socio-demographic characteristics, reproductive and maternal health-care practices like use of contraceptive methods, antenatal care (ANC), delivery care, postnatal care (PNC) were collected through a structured questionnaire. The chi-square test, Student t test, Mann Whitney U-test, factor analysis and log-binominal test were performed by using STATA statistical software for analysing data.

Results

The activities of BRAC CHWs significantly improved four or more ANC (47% vs. 21%; p<0.000) and PNC (48% vs. 39%; p<0.01) coverage in the intervention slums compared to comparison slums. Still, about half of the deliveries in both areas were attended at home by unskilled birth attendants, of which a very few received PNC within 48 hours after delivery. The poorest and illiterate women received fewer maternal health services from medically trained providers (MTPs). The poorest had a lower likelihood of receiving services from MTPs during delivery complications.

Conclusion

The MANOSHI programme service coverage for delivery care and PNC-checkup for women who prefer home delivery needs to be improved. For sustainable improvement of maternal health outcomes in urban slums, the programme needs to facilitate access to services for poor and illiterate women.

A landscape analysis of universal health coverage for mothers and children in South Asia

The United Nations made universal health coverage (UHC) a key health goal in 2012 and it is one of the Sustainable Development Goals' targets. This analysis focuses on UHC for mothers and children in the 8 countries of South Asia. A high level overview of coverage of selected maternal, newborn and child health services, equity, quality of care and financial risk protection is presented. Common barriers countries face in achieving UHC are discussed and solutions explored. In countries of South Asia, except Bhutan and Maldives, between 42% and 67% of spending on health comes from out-of-pocket expenditure (OOPE) and government expenditure does not align with political aspirations. Even where reported coverage of services is good, quality of care is often low and the poorest fare worst. There are strong examples of ongoing successes in countries such as Bhutan, the Maldives and Sri Lanka. Related to this success are factors such as lower OOPE and higher spending on health. To make progress in achieving UHC, financial and non-financial barriers to accessing and receiving high-quality healthcare need to be reduced, the amount of investment in essential health services needs to be increased and allocation of resources must disproportionately benefit the poorest.

The importance of intersectoral factors in promoting equity-oriented universal health coverage: a multilevel analysis of social determinants affecting neonatal infant and under-five mortality in Bangladesh

INTRODUCTION

Health is multidimensional and affected by a wide range of factors, many of which are outside the health sector. To improve population health and reduce health inequality, it is important that we take into account the complex interactions among social, environmental, behavioural, and biological factors and design our health interventions accordingly.

OBJECTIVES

This study examines mortality differentials in children of different age groups by key social determinants of health (SDH) including parental education and employment, mother's level of autonomy, age, asset index, living arrangements (utilities), and other geographical contextual factors (area of residence, road conditions).

DESIGN

We used data from the two rounds of Bangladesh Health and Demographic Survey, a nationally representative sample survey of the population residing in Bangladesh. Multilevel logistic models were used to study the impact of SDH on child mortality.

RESULTS

The study found that the mother's age, the education of both parents, the mother's autonomy to take decisions about matters linked to the health of her child, the household socio-economic conditions, the geographical region of residence, and the condition of the roads were significantly associated with higher risks of neonatal, infant, and under-five mortality in Bangladesh.

CONCLUSION

The study findings suggest there are complex relationships among different SDH. Thus larger intersectoral actions will be needed to reduce disparities in child health and mortality and achieve meaningful progress towards equity-oriented universal health coverage.

Social and economic determinants of pediatric health inequalities: the model of chronic kidney disease

Purpose of this review is to deal with priorities and strategies to significantly tackle inequalities in the management of pediatric diseases in low-middle-income countries. This issue has become a focal point of epidemiological and public health, with special reference to chronic nontransmissible diseases. We will provide our readership with an essential overview of the cultural, institutional, and political events, which have occurred over the last 20 y and which have produced the current general framework for epidemiology and public health. Then the most recent epidemiological data will be evaluated, in order to quantify the interaction between the medical components of the disease profiles and their socioeconomic determinants. Finally, a focus will be added on models of pediatric chronic kidney diseases, which are in our opinion amongst the most sensitive markers of the interplay between health and society. Collaborative, pediatrician-initiated, multicentre projects in these fields should be given priority in calls for grants supported by public agencies. The involvement of a critical mass of those working in the "fringes" of pediatric care is a final, essential mean by which significant results can be produced under the sole responsibility and research interest of centers of excellence.

Overview of a multi-stakeholder dialogue around Shared Services for Health: the Digital Health Opportunity in Bangladesh

BACKGROUND

National level policymaking and implementation includes multiple stakeholders with varied interests and priorities. Multi-stakeholder dialogues (MSDs) can facilitate consensus building through collective identification of challenges, recognition of shared goals and interests, and creation of solution pathways. This can shape joint planning and implementation for long-term efficiency in health and other sectors. Scaling up the effective use of information and communication technologies (ICTs) requires cohesive strategic planning towards a shared goal. In Bangladesh, the government and partners convened an MSD in March 2015 to increase stakeholder engagement in policymaking and implementation of a national ICT or electronic or mobile health (eHealth or mHealth) strategy, which seeks to incorporate ICTs into the national health system, aligning with the Digital Bangladesh Vision 2021.

METHODS

Relevant stakeholders were identified and key priorities and challenges were mapped through key informant interviews. An MSD was conducted with key stakeholders in Dhaka, Bangladesh. The MSD included presentations, group option generation, agreement and prioritization of barriers to scaling up ICTs.

RESULTS

The MSD approach to building consensus on key priorities highlights the value of dialogue and collaboration with relevant stakeholders to encourage country ownership of nationwide efforts such as ICT scale-up. This MSD showed the dynamic context in which stakeholders operate, including those from academia, donors and foundations, healthcare professionals, associations, multilateral organizations, non-governmental organizations, partner countries and the private sector. Through this MSD, participants improved understanding of each other's contributions and interests, identified existing relationships, and agreed on policy and implementation gaps that needed to be filled. Collaboration among stakeholders in ICT efforts and research can promote a cohesive approach to scaling up, as well as improve policymaking by integrating interests and feedback of different key cross sectoral actors.

CONCLUSION

MSDs can align stakeholders to identify challenges and solution pathways, and lead to coordinated action and accountability for resources and results. In addition, the MSD template and approach has been useful to guide ICT scale up in Bangladesh and could be replicated in other contexts to facilitate multi-constituency, multi-sector collaboration.

Trends and inequities in use of maternal health care services in Bangladesh, 1991-2011

Background and Methods

Monitoring use-inequity is important to measure progress in efforts to address health-inequities. Using data from six Bangladesh Demographic and Health Surveys (BDHS), we examine trends, inequities and socio-demographic determinants of use of maternal health care services in Bangladesh between 1991 and 2011.

Findings

Access to maternal health care services has improved in the last two decades. The adjusted yearly trend was 9.0% (8.6%-9.5%) for any antenatal care (ANC), 11.9% (11.1%-12.7%) for institutional delivery, and 18.9% (17.3%-20.5%) for C-section delivery which is above the WHO recommended rate of 5-15%. Use-inequity was significant for all three indicators but is reducing over time. Between 1991-1994 and 2007-2011 the rich:poor ratio reduced from 3.65 to 1.65 for ANC and from 15.80 to 6.77 for institutional delivery. Between 1995-1998 and 2007-2011, the concentration index reduced from 0.27 (0.25-0.29) to 0.15 (0.14-0.16) for ANC, and from 0.65 (0.60-0.71) to 0.39 (0.37-0.41) for institutional delivery during that period. For use of c-section, the rich:poor ratio reduced from 18.17 to 13.39 and the concentration index from 0.66 (0.57-0.75) to 0.47 (0.45-0.49). In terms of rich:poor differences, there was equity-gain for ANC but not for facility delivery or C-section delivery. All socio-demographic variables were significant predictors of use; of them, maternal education was the most powerful. In addition, the contribution of for-profit private sector is increasingly growing in maternal health.

Conclusion

Both access and equity are improving in maternal health. We recommend strengthening ongoing health and non-health interventions for the poor. Use-inequity should be monitored using multiple indicators which are incorporated into routine health information systems. Rising C-section rate is alarming and indication of C-sections should be monitored both in private and public sector facilities.

Assessing willingness to pay for health care quality improvements

BACKGROUND

Contingent valuation (CV) is used to estimate the willingness to pay (WTP) of consumers for specific attributes to improve the quality of health care they received in three hospitals in Bangladesh.

METHODS

Random sample of 252 patients were interviewed to measure their willingness to pay for seven specified improvements in the quality of delivered medical care. Partial tobit regression and corresponding marginal effects analysis were used to analyze the data and obtain WTP estimates.

RESULTS

Patients are willing to pay more if their satisfaction with three attributes of care are increased. These are: a closer doctor-patient relationship, increased drug availability and increased chances of recovery. The doctor patient relationship is considered most important by patients and exhibited the highest willingness to pay.

CONCLUSIONS

This study provides important information to policy makers about the monetary valuation of patients for improvements in certain attributes of health care in Bangladesh.

Cause-specific mortality and socioeconomic status in Chakaria, Bangladesh

Background

Bangladesh has achieved remarkable gains in health indicators during the last four decades despite low levels of economic development. However, the persistence of inequities remains disturbing. This success was also accompanied by health and demographic transitions, which in turn brings new challenges for a nation that has yet to come to terms with pre-transition health challenges. It is therefore important to understand the causes of death and their relationship with socioeconomic status (SES).

Objective

The paper aims to assess the causes of death by SES based on surveillance data from a rural area of Bangladesh, in order to understand the situation and inform policy makers and programme leaders.

Design

We analysed population-based mortality data collected from the Chakaria Health and Demographic Surveillance System in Bangladesh. The causes of death were determined by using a Bayesian-based programme for interpreting verbal autopsy findings (InterVA-4). The data included 1,391 deaths in 217,167 person-years of observation between 2010 and 2012. The wealth index constructed using household assets was used to assess the SES, and disease burdens were compared among the wealth quintiles.

Results

Analysing cause of death (CoD) revealed that non-communicable diseases (NCDs) were the leading causes of deaths (37%), followed by communicable diseases (CDs) (22%), perinatal and neonatal conditions (11%), and injury and accidents (6%); the cause of remaining 24% of deaths could not be determined. Age-specific mortality showed premature birth, respiratory infections, and drowning were the dominant causes of death for childhood mortality (0–14 years), which was inversely associated with SES (p<0.04). For adult and the elderly (15 years and older), NCDs were the leading cause of death (51%), followed by CDs (23%). For adult and the elderly, NCDs concentrated among the population from higher SES groups (p<0.005), and CDs among the lower SES groups (p<0.001).

Conclusions

Epidemiologic transition is taking place with a shift from the dominance of CDs to NCDs. SES inequity in mortality still persists – the poor suffer from CDs in all age groups, whereas those better off suffer more from NCDs than CDs. Policy makers thus need to consider the social distribution of diseases before developing any public health action targeted towards reducing mortality and the extent of disease burden in an equitable manner.

Monitoring and evaluating progress towards Universal Health Coverage in Bangladesh

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary

Reducing the health effect of natural hazards in Bangladesh

Bangladesh, with a population of 151 million people, is a country that is particularly prone to natural disasters: 26% of the population are affected by cyclones and 70% live in flood-prone regions. Mortality and morbidity from these events have fallen substantially in the past 50 years, partly because of improvements in disaster management. Thousands of cyclone shelters have been built and government and civil society have mobilised strategies to provide early warning and respond quickly. Increasingly, flood and cyclone interventions have leveraged community resilience, and general activities for poverty reduction have integrated disaster management. Furthermore, overall population health has improved greatly on the basis of successful public health activities, which has helped to mitigate the effect of natural disasters. Challenges to the maintenance and reduction of the effect of cyclones and floods include rapid urbanisation and the growing effect of global warming. Although the effects of earthquakes are unknown, some efforts to prepare for this type of event are underway.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Harnessing pluralism for better health in Bangladesh

How do we explain the paradox that Bangladesh has made remarkable progress in health and human development, yet its achievements have taken place within a health system that is frequently characterised as weak, in terms of inadequate physical and human infrastructure and logistics, and low performing? We argue that the development of a highly pluralistic health system environment, defined by the participation of a multiplicity of different stakeholders and agents and by ad hoc, diffused forms of management has contributed to these outcomes by creating conditions for rapid change. We use a combination of data from official sources, research studies, case studies of specific innovations, and in-depth knowledge from our own long-term engagement with health sector issues in Bangladesh to lay out a conceptual framework for understanding pluralism and its outcomes. Although we argue that pluralism has had positive effects in terms of stimulating change and innovation, we also note its association with poor health systems governance and regulation, resulting in endemic problems such as overuse and misuse of drugs. Pluralism therefore requires active management that acknowledges and works with its polycentric nature. We identify four key areas where this management is needed: participatory governance, accountability and regulation, information systems, and capacity development. This approach challenges some mainstream frameworks for managing health systems, such as the building blocks approach of the WHO Health Systems Framework. However, as pluralism increasingly defines the nature and the challenge of 21st century health systems, the experience of Bangladesh is relevant to many countries across the world.

The Bangladesh paradox: exceptional health achievement despite economic poverty

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.