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L4 uhc-ju

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L4 uhc-ju

  1. 1. Under JPG Teaching Fellowship Permission from JPGSPH CoE-UHC
  2. 2. Health service coverage in Bangladesh: prospects and challenges for achieving UHC Md. Jasim Uddin, Ph.D Scientist Centre for Equity and Health Systems icddr,b 2
  3. 3. Outlines - Brief overview on Bangladesh health systems - Prospects and strengths of Bangladesh health service coverage systems - Challenges that are being faced Bangladesh in achieving UHC - Sharing of successful interventions that were undertaken to overcome the challenges (EPI studies in urban slums and rural hard-to-reach areas; study on street dwellers) 3
  4. 4. Three dimensions of UHC 4
  5. 5. Brief overview on Bangladesh health systems 5
  6. 6. Bangladesh Health Systems • Bangladesh has developed a comprehensive health service delivery infrastructure with a vast network of primary health care facilities from grassroots to higher levels • Distribution of public health services follows uniform patterns of administrative tires: national to ward (community) levels • Ministry of Health and Family Welfare (MOHFW) established “Health, Population and Nutrition Service Delivery Programme (HPNSDP)” 6
  7. 7. Bangladesh Health Systems • The MOHFW delivers services through two separate executing authorities under HPNSDP: – Directorate General of Health Services (DGHS) – Directorate General of Family Planning (DGFP) • Essential service delivery (ESD)/PHC services provides at ward level through community health staff appointed by MOHFW • Non-government organizations (NGOs) also play important role in providing services 7
  8. 8. Bangladesh Health Systems Ministry of Health and Family Welfare Director General (Health) Director General (FP) Div. 7 Divisional Director (Health) Divisional Director (FP) Dist. 64 Civil Surgeon (CS) Deputy Director (DD-FP) Upa. 483 Upazila Health & Family Planning Officer (UHFPO) Family Planning Officer (FPO) Union 4501 Medical Officer/Paramedics Paramedics/Field supervisors Ward 40,509 Field staff (HA, AHI, HI) Field staff (FWA, FPI, FWV) 8
  9. 9. Type of health facilities under the DGHS in different administrative tiers National Divisional District Upazila Union Ward •Public Health Institute •Medical College & Hospital with Nursing Institute (in some) •District Hospital with Nursing institute •Upazila Health Complex •Rural Health Centre (in some) •Community Clinic •Postgraduate Medical Institute & Hospital with Nursing Institute •Specialized Health Centre •General Hospital with Nursing Institute (in some) • Infectious Disease Hospital •Institute of health Technology •General Hospital with Nursing Institute (in some) •Medical College & Hospital with Nursing Institute (in some) •Chest Clinic (in some) •Leprosy Hospital (in some) •Medical Assistant’s Training School •TB Clinic (in some) •Union sub-centre (in some) •Union Health & Family Planning Welfare Centre (in some)
  10. 10. Health systems (Urban) Ministry of Local Government, Rural Development & Co-operatives Mayor Dhaka City Corporation, North Mayor Dhaka City Corporation, North Chief Executive Officer Chief Executive Officer Chief Health Officer Chief Health Officer Deputy Chief Health Officer Deputy Chief Health Officer Health Officer Health Officer Assistant Health Officer (Zonal level) Assistant Health Officer (Zonal level) EPI Supervisors Sanitary Inspectors Mosquito Supervisors Vaccinators Sample collectors Spray men/Crews Birth & Death Register Assistants EPI Supervisors Sanitary Inspectors Mosquito Supervisors Vaccinators Sample collectors Spray men/Crews Note: NGO activities are being monitored by UPHCP in collaboration with City Corporation (HQ and Zone offices) Birth & Death Register Assistants
  11. 11. Health service coverage-prospects in Bangladesh 11
  12. 12. Health service coverage-prospects in Bangladesh • Bangladesh has made tremendous progress in health and population sector programme. In some cases, we have made more impressive gains than most of our neighbors. • We now live longer – the average life expectancy increased from 40 years in 1960 to 67.2 years in 2009 • The infant mortality rate (number of infants aged 12 months or less dying per 1,000 live births) in Bangladesh declined dramatically – from 145 in 1970 to 39 in 2009 • Under-5 mortality rate (children aged 5 years or less dying per 1,000 live births) declined from 239 in 1970 to 50 in 2009 12
  13. 13. Health Service Coverage-prospects in Bangladesh • Total fertility rate (number of children born to women aged between 15 and 49 years) declined from 6.3 during 1971-75 to 2.15 by 2009 and now it is 2.3 in 2011 • Contraceptive prevalence rate also registered impressive growth – from 7% (percentage of married couples using modern methods of contraception) in 1975 to 61% in 2011 • The National immunization coverage remained <2% till 1985, now it is 79% 13
  14. 14. Challenges in achieving UHC 14
  15. 15. Challenges in achieving UHC Inequitable services in different regions: • Although Bangladesh has established a comprehensive physical infrastructure to deliver health and family planning services, but the impact of extensive health service network has been much less than expected because these services do not reach all regions effectively • Two divisions, Sylhet and Chittagong remain the most disadvantaged both in terms of health and population outcomes and access to services, compounded by the poor utilization of facilities in these areas. • There are regional variations in TFR. Khulna, Rajshahi and Dhaka have reached replacement level fertility (1.9, 2.1 and 2.2 respectively). But, in both Chittagong and Sylhet, it is 2.8 and 3.1 respectively 15
  16. 16. Challenges in achieving UHC Inequitable services in different regions: • Significant regional variation in the contraceptive prevalence rate (CPR) is also observed. CPR remains substantially low in Sylhet and Chittagong divisions. CPR ranges from 69% in Rangpur and 67% in Rajshahi and Khulna, it is still 45% in Sylhet and 51% in Chittagong • Due to geophysical characteristics as the Chiitagong and Sylhet regions are occupied by hills and haors, the accessibility to health and family planning services often difficult to these hard to reach areas • Around 14 million people in 22 districts (mostly in Sylhet and Chittagong regions) are living in rural hard-to-reach areas of Bangladesh 16
  17. 17. Challenges in achieving UHC Inequitable services between rural and urban areas • The TFR for rural women is higher than that for urban women (2.5 compared with 2.0 births per woman). • The rural-urban difference in fertility has narrowed over the decades. But it is still a challenge in respect of universal health coverage. Between 2007 and 2011 the decline in fertility was greater in urban areas (17%) compared to the rural areas (11%) • Contraceptive use varies by place of residence. Contraceptive use continues to be higher in urban (64%) than rural areas (60%) 17
  18. 18. Challenges in achieving UHC Inequitable services between urban slum and non slum • Use of ESP services (almost all indicators) is much lower among slum dwellers compared to non-slum dwellers • The situation is much worse for street dwellers and street children Inequitable distribution of human resources • Perhaps the most critical challenge faced by the health system in Bangladesh is in the arena of human resources for health: - Urban vs. rural District and upazila vs community level 18
  19. 19. Challenges in achieving UHC Income inequity: • As the poor has less access to health care services, they share a disproportionate burden of disease and deprivation • Among the lowest wealth quintile (the poorest segment of the population), medically trained provider attended only 11.5% of deliveries. The corresponding figure for the highest wealth quintile (the richest segment of the population) was 63.8%. • Only 30.4% women from the lowest wealth quintile received antenatal care, 87.4% women from the highest wealth quintile did so 19
  20. 20. Challenges in achieving UHC Income inequity: • Only 24.7% children from the lowest wealth quintile received ARI, while the corresponding figure for the highest wealth quintile was 57.5% • Disparities between the rich and poor continue to persist in other areas too, such as malnutrition, anaemia during pregnancy among women, and the percentage of fully vaccinated children 20
  21. 21. Successful interventions undertaken to overcome the challenges 21
  22. 22. Improving Low Child Immunization Coverage in Urban Slums of Bangladesh Collaborative Effort International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) EPI Programme, DGHS Dhaka City Corporation Non-government Organizations 22
  23. 23. Objective Assess the effectiveness of a combination of strategies for increasing immunization coverage in urban slums Interventions • A modified EPI service schedule • Training of service providers on valid doses (appropriate timing) and side effects • A screening tool to identify immunization needs among clinic attendants • An EPI support group to ensure regular EPI sessions 23
  24. 24. Methods Study Design: Before-After Control (BAC) design Study Area: Two slums in zone 8 of Dhaka City Study Period: September 2006 to August 2007 Data collection: Survey, Service statistics & Qualitative techniques Analysis: Before-After changes in selected immunization indicators 24
  25. 25. Results Valid coverage among 12-23 month old children (card + history) Coverage (%) Categories Baseline (n=529) Endline (n=526) P-value Fully vaccinated 43 99 0.000 Drop outs 33 1 0.000 Left outs 2 0 - Invalid doses (card only) 22 0 - 25
  26. 26. Percentage of children aged 12-23 months who received specific vaccination (Valid) 100 98 *100 *100 *99 *99 90 77 80 Percentage 70 60 54 50 43 40 Baseline Endline 30 20 10 0 BCG DPT3 Measles Fully immunized *p<0.001 26
  27. 27. Improving Low Child Immunization Coverage in Rural Hard-to-reach Areas of Bangladesh Collaborative Effort International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) EPI Programme, Directorate General of Health Services, MOHFW
  28. 28. Objective of the Study • Assess the effectiveness of a combination of strategies for improving child immunization coverage in rural hard-to-reach areas of Bangladesh 28
  29. 29. Interventions Active Intervention Areas (Derai & Kaptai) I. Training II. Elimination of official barriers about geographical boundaries III. Modified EPI service schedule IV. EPI support group Passive Intervention Areas (Sulla & Kawkhali) I. Training II. Elimination of official barriers about geographical boundaries III. Use of screening checklist 29
  30. 30. Interventions Implementation Process Interventions Process followed Training • Trained field staff and supervisors on valid doses Elimination of geographical barriers • Vaccines sent from adjacent upazilas by their own porters Modified EPI sessions • Holding of EPI sessions bi-monthly for 2/3 consecutive days • Vaccines sent one day ahead of the sessions Use of screening tool • Use of checklist in all ESP clinics to identify not fully immunized children (missed opportunities) EPI support group TOR for groups: • Assist in holding regularly scheduled EPI sessions [197 in Sulla & 80 in Kaptai] • Inform community about modified EPI service schedule • Advocacy • Monitor EPI activities 30
  31. 31. Overall Valid Coverage Active intervention areas (haor & hill) % 100 90 80 70 60 50 40 30 20 10 0 87** 49 38 32 23 11 9** Fully immunized 1** Drop-outs Baseline (n=1440) 10 Left-outs Endline (n=1443) 8 3** 5 Invalid doses Difference (% point) ** p<0.001 31
  32. 32. Overall Valid Coverage Passive intervention areas (haor & hill) 100 82** 80 60 % 40 54 28 26 12** 20 14 7 13 3** 4 3** 10 0 Fully immunized Baseline (n=1440) Drop-outs Endline (n=1441) Left-outs Invalid doses Difference (% point) ** p<0.001 32
  33. 33. Develop and Test Strategies for Providing Essential Healthcare Services to Urban Street Dwellers in Bangladesh International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Directorate General of Health Services, MOHFW Dhaka City Corporation Non-government Organizations
  34. 34. Objectives of the Study Overall: Develop and test strategies for providing essential healthcare services to urban street dwellers in Bangladesh. Specific: • Assess changes in health service utilization among street dwellers after implementation of two models: - static clinic - satellite clinics • Determine relative effectiveness of the two approaches
  35. 35. Methods • Study design: Intervention trial • Study areas: 1. Karwan Bazar 2. Kamlapur 3. Bir Sherstha Shahid Shipahi Mostafa Kamal Stadium (Mugda) Period: May 2009-April 2010
  36. 36. Methods (cont..) Interventions: Two models were tested: Model 1: Static clinic a. DCC Office, Karwanbazar Model 2: Satellite clinics: a. Kamlapur Railway Station b. Bir Sherstha Shahid Shipahi Mostafa Kamal Stadium (Mugda)
  37. 37. Interventions Implementation Process  Team: - Paramedics (female & male) - Supervisor - Van puller  Delivery of essential services as per HNPSP  Service provision was free of cost  Information management: - Family health card & patient register - Computerized database
  38. 38. Interventions Implementation Process  Local street dwellers volunteered  Involved local drug sellers and other public healthcare providers  Established a referral linkage with public and NGO health facilities  Used a rickshaw van as a low cost carrier of providers and logistics
  39. 39. Use of Healthcare Services among Females Model-1 Model - 2 96** 100 100 80 80 56 60 % 40 40 62 ** 60 40 20 31 20 0 31 0 Baseline (n=186) **p<0.001 End line (n=146) Difference (% points) Baseline (n=179) End line (n=157) Difference (% points)
  40. 40. Use of Healthcare Services among Males Model - 1 Model-2 99** 100 100 80 72 74** 80 60 60 % 40 27 40 20 34 20 0 40 0 Baseline (n=195) **p<0.001 End line (n=167) Difference (% points) Baseline (n=176) End line (n=178) Difference (% points)
  41. 41. Summary Although Bangladesh has a very good service coverage system, but there are lots of challenges in achieving UHC. Need based and targeted approaches are needed to achieve the UHC in this country.
  42. 42. 42

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