'Connecting the dots' for generating a momentum for Universal Health Coverage in Bangladesh: findings from a cross-sectional descriptive study.
ABSTRACT: OBJECTIVE:This study was conducted to explore how and whether, the strategic grants made by the Rockefeller Foundation (RF) in different sectors of health systems in the inception phase were able to 'connect the dots' for 'generating a momentum for Universal Health Coverage (UHC)' in the country. DESIGN:Cross-sectional descriptive study, using document review and qualitative methods. SETTING:Bangladesh, 17 UHC-related projects funded by the RF Transforming Health Systems (THS) initiative during 2010-2013. DATA:Available reports of the completed and on-going UHC projects, policy documents of the government relevant to UHC, key-informant interviews and feedback from grant recipients and relevant stakeholders in the policy and practice. OUTCOME MEASURES:Key policy initiatives undertaken for implementing UHC activities by the government post grants disbursement. RESULTS:The RF THS grants simultaneously targeted and connected the academia, the public and non-profit development sectors and news media for awareness-building and advocacy on UHC, develop relevant policies and capacity for implementation including evidence generation. This strategy helped relevant stakeholders to come together to discuss and debate the core concepts, scopes and modalities of UHC in an attempt to reach a consensus. Additionally, experiences gained from implementation of the pilot projects helped in identifying possible entry points for initiating UHC activities in a low resource setting like Bangladesh. CONCLUSIONS:During early years of UHC-related activities in Bangladesh, strategic investments of the RF THS initiative played a catalytic role in sensitising and mobilising different constituencies for concerted activities and undertaking necessary first steps. Learnings from this strategy may be of help to countries under similar conditions of 'low resource, apparent commitment, but poor governance,' on their journey towards UHC.
Project description: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.
Project description:<h4>Introduction</h4>Elimination of kala-azar is planned for South Asia requiring good surveillance along with other strategies. We assessed surveillance in Gaffargaon upazila (a subdistrict of 13 unions) of Mymensingh district, Bangladesh highly endemic for kala-azar.<h4>Methods</h4>In 4703 randomly sampled households, within nine randomly sampled villages, drawn from three randomly sampled unions, we actively searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila health complex (UHC). We investigated factors associated with the medical recording by interviewing the cases and their families. We also did a general observation of UHC recording systems and interviewed health staff responsible for the monthly reports of kala-azar cases.<h4>Results</h4>Our active case finding detected 58 cases, but 29 were not recorded in the Gaffargaon UHC. Thus, only 50% (95% CI: 37%-63%) of kala-azar cases were reported via the government passive surveillance system. Interviews with health staff based in the study UHC revealed the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and considerable complexity in the recording system. After adjusting for kala-azar treatment drug, recording was found more likely for those aged 18 years or more, males, receiving supply and administration of drug at the UHC, and more recent treatment.<h4>Discussion</h4>Fifty percent of kala-azar cases occurring in one highly endemic area of Bangladesh were recorded in registers that were the source for monthly reports to the national surveillance system. Recording was influenced by patient, treatment, staff and system factors. Our findings have policy implications for the national surveillance system. Future studies involving larger samples and including interviews with health authorities at more central level and surveillance experts at the national level will generate more precise and representative evidence on the performance of kala-azar surveillance in Bangladesh.
Project description:BACKGROUND: Bangladesh is a malaria hypo-endemic country sharing borders with India and Myanmar. Artemisinin combination therapy (ACT) remains successful in Bangladesh. An increase of artemisinin-resistant malaria parasites on the Thai-Cambodia and Thai-Myanmar borders is worrisome. K13 propeller gene (PF3D7_1343700 or PF13_0238) mutations have been linked to both in vitro artemisinin resistance and in vivo slow parasite clearance rates. This group undertook to evaluate if mutations seen in Cambodia have emerged in Bangladesh where ACT use is now standard for a decade. METHODS: Samples were obtained from Plasmodium falciparum-infected malaria patients from Upazila health complexes (UHC) between 2009 and 2013 in seven endemic districts of Bangladesh. These districts included Khagrachari (Matiranga UHC), Rangamati (Rajasthali UHC), Cox's Bazar (Ramu and Ukhia UHC), Bandarban (Lama UHC), Mymensingh (Haluaghat UHC), Netrokona (Durgapur and Kalmakanda UHC), and Moulvibazar (Sreemangal and Kamalganj UHC). RESULTS: Out of 296 microscopically positive P. falciparum samples, 271 (91.6%) were confirmed as mono-infections by both real-time PCR and nested PCR. The K13 propeller gene from 253 (93.4%) samples was sequenced bi-directionally. One non-synonymous mutation (A578S) was found in Bangladeshi clinical isolates. The A578S mutation was confirmed and lies adjacent to the C580Y mutation, the major mutation causing delayed parasite clearance in Cambodia. Based on computational modeling A578S should have a significant effect on tertiary structure of the protein. CONCLUSION: The data suggest that P. falciparum in Bangladesh remains free of the C580Y mutation linked to delayed parasite clearance. However, the mutation A578S is present and based on structural analysis could affect K13 gene function. Further in vivo clinical studies are required to validate the effect of this mutation.
Project description:BACKGROUND: There has been limited research on the impact of research funding for small, institutional grants. The IWK Health Centre, a children and women's hospital in Maritime Canada, provides small amounts (up to $15,000) of research funding for staff and trainees at all levels of experience through its Research Operating Grants. These grants are rigorously peer-reviewed. To evaluate the impact of these grants, an assessment was completed of several different areas of impact. FINDINGS: An online questionnaire was sent to 64 Principal Investigators and Co-Investigators from Research Operating Grants awarded from 2004 to 2006. The questionnaire was designed to assess five areas of potential impact: (1) research, (2) policy, (3) practice, (4) society and (5) personal. Research impact reported by participants included publications (72%), presentations (82%) and knowledge transfer beyond the traditional formats (51%). Practice impact was reported by 67% of participants, policy impact by 15% and societal impact by 18%. All participants reported personal impact. CONCLUSIONS: Small research grants yield similar impacts to relatively large research grants. Regardless of the total amount of research funds awarded, rigorously peer-reviewed research projects have the potential for significant impact at the level of knowledge transfer and changes in clinical practice and policy. Additional findings in the present research indicate that small awards have the potential to have significant impact on the individual grant holder across a variety of capacity building variables. These personal impacts are particularly noteworthy in the context of developing the research programs of novice researchers.
Project description:INTRODUCTION:In 2011, WHO, the European Union and Luxembourg entered into a collaborative agreement to support policy dialogue for health planning and financing; these were acknowledged as core areas in need of targeted support in countries' quest towards universal health coverage (UHC). Entitled 'Universal Health Coverage Partnership', this intervention is intended to strengthen countries' capacity to develop, negotiate, implement, monitor and evaluate robust and integrated national health policies oriented towards UHC. It is a complex intervention involving a multitude of actors working on a significant number of remarkably diverse activities in different countries. METHODS AND ANALYSIS:The researchers will conduct a realist evaluation to answer the following question: How, in what contexts, and triggering what mechanisms, does the Partnership support policy dialogue for health planning and financing towards UHC? A qualitative multiple case study will be undertaken in Togo, Liberia, Democratic Republic of Congo, Cape Verde, Burkina Faso and Niger. Three steps will be implemented: (1) formulating context-mechanism-outcome explanatory propositions to guide data collection, based on expert knowledge and theoretical literature; (2) collecting empirical data through semistructured interviews with key informants and observations of key events, and analysing data; (3) specifying the intervention theory. ETHICS AND DISSEMINATION:The primary target audiences are WHO and its partner countries; international and national stakeholders involved in or supporting policy dialogues in the health sector, especially in low-income countries; and researchers with interest in UHC, policy dialogue, evaluation research and/or realist evaluation.
Project description:<h4>Introduction</h4>Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of institutions and initiatives promoting the uptake of implementation research in Africa, their role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). This review aims to extensively identify and characterise the nature, facilitators and barriers to the use of implementation research for assessing or evaluating UHC-related interventions or programmes in Africa.<h4>Methods and analysis</h4>This scoping review will be developed based on the methodological framework proposed by Arksey and O'Malley and enhanced by the Joanna Briggs Institute. It will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search of the following electronic databases will be conducted: Medline (via PubMed), Scopus and the Cochrane Library. Relevant grey literature and reference lists will also be searched. All publications describing the application of implementation research in the context of UHC will be considered for inclusion. Findings will be narratively synthesised and analysed using a predefined conceptual framework. Where applicable, quantitative evidence will be aggregated using summary statistics. There will be consultation of stakeholders, including UHC-oriented health professionals, programme managers, implementation researchers and policy-makers; to provide methodological, conceptual and practical insights.<h4>Ethics and dissemination</h4>The data used in this review will be sourced from publicly available literature; hence, this study will not require ethical approval. Findings and recommendations will be disseminated to reach a diverse audience, including UHC advocates, implementation researchers and key health system stakeholders within the African region. Additionally, findings will be disseminated through an open-access publication in a relevant peer-reviewed journal.
Project description:Many nations use ecological compensation policies to address negative impacts of development projects and achieve No Net Loss (NNL) of biodiversity and ecosystem services. Yet, failures are widely reported. We use spatial simulation models to quantify potential net impacts of alternative compensation policies on biodiversity (indicated by native vegetation) and two ecosystem services (carbon storage, sediment retention) across four case studies (in Australia, Brazil, Indonesia, Mozambique). No policy achieves NNL of biodiversity in any case study. Two factors limit their potential success: the land available for compensation (existing vegetation to protect or cleared land to restore), and expected counterfactual biodiversity losses (unregulated vegetation clearing). Compensation also fails to slow regional biodiversity declines because policies regulate only a subset of sectors, and expanding policy scope requires more land than is available for compensation activities. Avoidance of impacts remains essential in achieving NNL goals, particularly once opportunities for compensation are exhausted.
Project description:BACKGROUND:Equity seems inherent to the pursuance of universal health coverage (UHC), but it is not a natural consequence of it. We explore how the multidimensional concept of equity has been approached in key global UHC policy documents, as well as in country-level UHC policies. METHODS:We analysed a purposeful sample of UHC reports and policy documents both at global level and in two Western African countries (Benin and Senegal). We manually searched each document for its use and discussion of equity and related terms. The content was summarised and thematically analysed, in order to comprehend how these concepts were understood in the documents. We distinguished between the level at which inequity takes place and the origin or types of inequities. RESULTS:Most of the documents analysed do not define equity in the first place, and speak about "health inequities" in the broad sense, without mentioning the dimension or type of inequity considered. Some dimensions of equity are ambiguous - especially coverage and financing. Many documents assimilate equity to an overall objective or guiding principle closely associated to UHC. The concept of equity is also often linked to other concepts and values (social justice, inclusion, solidarity, human rights - but also to efficiency and sustainability). Regarding the levels of equity most often considered, access (availability, coverage, provision) is the most often quoted dimension, followed by financial protection. Regarding the types of equity considered, those most referred to are socio-economic, geographic, and gender-based disparities. In Benin and Senegal, geographic inequities are mostly pinpointed by UHC policy documents, but concrete interventions mostly target the poor. Overall, the UHC policy of both countries are quite similar in terms of their approach to equity. CONCLUSIONS:While equity is widely referred to in global and country-specific UHC policy documents, its multiple dimensions results in a rather rhetorical utilisation of the concept. Whereas equity covers various levels and types, many global UHC documents fail to define it properly and to comprehend the breadth of the concept. Consequently, perhaps, country-specific policy documents also use equity as a rhetoric principle, without sufficient consideration for concrete ways for implementation.
Project description:BACKGROUND:Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework. METHODS:A series of in-depth key informant interviews were conducted at national and county level (n?=?13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour. RESULTS:Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection. CONCLUSIONS:This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.
Project description:Background & Objective: Poor people, in general, get poor quality of health services. The situation is very much worsening for the poor who live in the remote areas in the coastal belt of Bangladesh as health care facilities and services are often less complete, farther away, and therefore most costly to reach than in urban hospitals and physician. Ensure of better health service for the poor, it is essential to examine the effectiveness of Universal Health Coverage (UHC). This study sets its objectives to evaluate the health service for the poor in the coastal area of Bangladesh and develop an approach of management strategy. Methods: This study followed a two-stage cluster sampling technique and carried out a household survey through the open-ended questionnaire. In addition, the study applied the logistic regression model to generate empirically supported assessments. Results: Result from the disparity rate ratio (DRR) revealed that there is a big health care disparity of different income groups like poor and rich. Furthermore, results from the model demonstrated that Medicaid, Medicare, Social Health Insurance, Telemedicine and Capitation under the provision Universal Health Coverage (UHC) are statistically significant compared to reduce the health care disparity. Conclusion: UHC becomes a critical issue for improved and quality health care system for all the groups especially, the poor in coastal Bangladesh. This study showed that Medicaid, Medicare and Social Health Insurance and Capitation perform well to provide better health care facilities for all.