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Alam K.,Center for Equity and Health Systems | Alam K.,Monash University | Khan J.A.,Center for Equity and Health Systems | Walker D.G.,Bill and Melinda Gates Foundation
BMC Health Services Research | Year: 2012

Background: The model of volunteer community health workers (CHWs) is a common approach to serving thepoor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, hasbeen using female CHWs as core workers in its community-based health programs since 1977. After 25 years ofimplementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through acommunity-based maternal health intervention. However, BRAC experiences high dropout rates among CHWssuggesting a need to better understand the impact of their dropout which would help to reduce dropout andincrease program sustainability. The main objective of the study was to estimate impact of dropout ofvolunteer CHWs from both BRAC and community perspectives. Also, we estimated cost of possible strategies toreduce dropout and compared whether these costs were more or less than the costs borne by BRAC and thecommunity.Methods: We used the ingredient approach to estimate the cost of recruiting and training of CHWs andthe so-called friction cost approach to estimate the cost of replacement of CHWs after adapting. Finally, weestimated forgone services in the community due to CHW dropout applying the concept of the friction period.Results: In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if aCHW participated a three-week basic training, a one-day refresher training, one incentive day and worked for amonth in the community after recruitment. One month absence of a CHW with standard performance in thecommunity meant substantial forgone health services like health education, antenatal visits, deliveries, referralsof complicated cases, and distribution of drugs and health commodities. However, with an additionalinvestment of US$ 121 yearly per CHW BRAC could save another US$ 60 invested an ad-hoc CHW plus forgoneservices in the community.Conclusion: Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immenseboth in financial term and forgone services. High cost of dropout makes the program less sustainable. However,simple and financially competitive strategies can improve the sustainability of the program. © 2012 Alam et al.; licensee BioMed Central Ltd.

Alam K.,Monash University | Alam K.,Center for Equity and Health Systems | Mahal A.,Monash University
BMC Public Health | Year: 2014

Background: Globally, an estimated 54 million people have angina, 16 million of whom are from the WHO South-East Asia region. Despite the increasing burden of cardiovascular disease (CVD) in South Asia, there is no evidence of an economic burden of angina on households in this region. We investigated the economic burden of angina on households in South Asia. Methods. We applied a novel propensity score matching approach to assess the economic burden of angina on household out-of-pocket (OOP) health spending, borrowing or selling assets, non-medical consumption expenditure, and employment status of angina-affected individual using nationally representative World Health Survey data from Bangladesh, India, Nepal and Sri Lanka collected during 2002-2003. We used multiple matching methods to match households where the respondent reported symptomatic or diagnosed angina with control households with similar propensity scores. Results: Angina-affected households had significantly higher OOP health spending per person in the four weeks preceding the survey than matched controls, in Bangladesh (I$1.94, p = 0.04), in Nepal (I$4.68, p = 0.03) and in Sri Lanka (I$1.99, p < 0.01). Nearly half of this difference was accounted for by drug expenditures. Catastrophic spending, defined as the ratio of OOP health spending to total household expenditure in excess of 20%, was significantly higher in angina-affected households relative to matched controls in India (9.60%, p < 0.01), Nepal (4.90%, p = 0.02) and Sri Lanka (9.10%, p < 0.01). Angina-affected households significantly relied on borrowing or selling assets to finance OOP health expenses in Bangladesh (6%, p = 0.03), India (8.20%, p < 0.01) and Sri Lanka (7.80%, p = 0.01). However, impoverishment, non-medical consumption expenditure and employment status of the angina-affected individual remained mostly unaffected. We adjusted our estimates for comorbidities, but limitations on comorbidity data in the WHS mean that our results may be upwardly biased. Conclusions: Households that had the respondent reporting angina in South Asia face an economic burden of OOP health expenses (primarily on drugs and other outpatient expenses), and tend to rely on borrowing or selling assets. Our analysis underscores the need to protect South Asian households from the financial burden of CVD. © 2014 Alam and Mahal; licensee BioMed Central Ltd.

Ahmed S.M.,Center for Equity and Health Systems | Ahmed S.M.,Brac University | Evans T.G.,The World Bank | Standing H.,University of Sussex | Mahmud S.,Brac University
The Lancet | Year: 2013

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, defi ned by the participation of a multiplicity of diff erent stakeholders and agents and by ad hoc, diff used forms of management has contributed to these outcomes by creating conditions for rapid change. We use a combination of data from offi cial sources, research studies, case studies of specifi c 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 eff ects 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 defi nes the nature and the challenge of 21st century health systems, the experience of Bangladesh is relevant to many countries across the world.

Kabir H.,Center for Equity and Health Systems | Saha N.C.,icddr | Oliveras E.,icddr | Gazi R.,Center for Equity and Health Systems
Reproductive Health | Year: 2013

Objective. The study was conducted to identify selected programmatic factors relating to low contraceptive-use in a low-performing rural sub-district in Sylhet division of Bangladesh. Methods. A cross-sectional survey was carried out among 6983 currently-married women of reproductive age (MWRA) (15-49 years). To estimate the association between current contraceptive-use and other selected factors, multivariate analyse were performed, estimating the crude and adjusted odds ratios (OR), including 95% confidence intervals (CI). Results: The use of health facility by the MWRA in the last three months, distance from the residence to the nearest health facility, and contact with field workers in the last six months was significantly associated with contraceptive prevalence rate (CPR). There were potential differences regarding CPR, sources of contraceptive supply and Family Welfare Assistant (FWA) visit between hard to reach and non-hard to reach unions of Nabiganj sub-district. Conclusion: Strategies should be devised to increase the accessibility of MWRA to contraceptive methods by increased partnership with non-public sector and increased contacts with outreach workers through introducing community volunteers, and mobile phones help lines, by organizing frequent satellite clinics (SCs) and making community clinics (CCs) functional. Innovative strategies should be piloted for improving use of contraception in such hard to reach and low performing locality. © 2013 Kabir et al.; licensee BioMed Central Ltd.

Adams A.M.,Center for Equity and Health Systems | Rabbani A.,University of Dhaka | Ahmed S.,Center for Equity and Health Systems | Mahmood S.S.,Center for Equity and Health Systems | And 4 more authors.
The Lancet | Year: 2013

By disaggregating gains in child health in Bangladesh over the past several decades, signifi cant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identifi ed that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain signifi cant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to eff ectively promote inclusive and equitable development within and beyond the health system.

Sarma H.,Center for Nutrition and Food Security | Islam M.A.,Center for Nutrition and Food Security | Gazi R.,Center for Equity and Health Systems
BMC Public Health | Year: 2013

Background: Considering the significant impact of school-based HIV/AIDS education, in 2007, a curriculum on HIV/AIDS was incorporated in the national curriculum for high school students of Bangladesh through the Government's HIV-prevention program. Based on the curriculum, an intervention was designed to train teachers responsible for teaching HIV/AIDS in classes. Methods. In-depth interviews were conducted with teachers to understand their ability, skills, and confidence in conducting HIV/AIDS classes. Focus-group discussions (FGDs) were conducted with students who participated in HIV/AIDS classes. HIV/AIDS classes were also observed in randomly-selected schools. Thematic assessment was made to analyze data. Results: The findings showed that the trained teachers were more comfortable in using interactive teaching methods and in explaining sensitive issues to their students in HIV/AIDS classes. They were also competent in using interactive teaching methods and could ensure the participation of students in HIV/AIDS classes. Conclusions: The findings suggest that cascading training may be scaled up as it helped increase ability, skills, and confidence of teachers to successfully conduct HIV/AIDS classes. © 2013 Sarma et al.; licensee BioMed Central Ltd.

Roy S.,Center for Equity and Health Systems
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2014

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) affects economic growths by reducing the human capitals are among the most poorly understood aspect of the AIDS epidemic. This article analyzes the effects of the prevalence of HIV and full-blown AIDS on a country's human capitals and economic growths. Using a fixed effect model for panel data 1990-2010 from the Asia, I explored the dynamic relationships among HIV/AIDS, economic growths, and human capitals within countries over time. The econometric effects concerned that HIV/AIDS plays an important role in the field of economic growths and it is measured as a change in real gross domestic product (GDP) per capita and human capitals. The modeling results for the Asian countries indicates HIV/AIDS prevalence that has a hurtful effect on GDP per capita by reducing human capitals within countries over time. © 2014 Taylor & Francis.

Gazi R.,Center for Equity and Health Systems | Kabir H.,Center for Equity and Health Systems | Saha N.C.,Center for Equity and Health Systems
BMC Public Health | Year: 2014

Background: Three-year duration Demand-Based Reproductive Commodity Project (DBRHCP) was launched in three low performing areas: rural Nabiganj (population 323,357), Raipur (population 260,983) and urban slum in Dhaka (population 141,912). Objectives: Assessing changes in knowledge among married women of reproductive age on selected reproductive health issues and to explore their service utilization patterns over the project period in selected low performing areas of Bangladesh. Methods. The study adopted a pre- posts design. In the project areas, the entire chain of service provision were modified through the interventions under the DBRHCP, including training of the providers, enhanced behavioral change communication activities, follow-up and counseling, record keeping, reporting and monitoring, as well as improvement in logistics and supplies. Peer promoters were established as linkages between clients and service providers. All households were enlisted. Baseline and end line surveys were done using representative simple random sampling method, capturing changes over one year intervention period. Descriptive analysis was done using SPSS package, version 10. Proportional tests using Stata, version 8 were done to assess changes from baseline to end line. Results: The overall contraceptive prevalence was markedly different in the three study areas but significantly increased in both Dhaka urban slums and Nabiganj. In the rural areas, a higher proportion of the women in endline compared to baseline obtained contraceptive methods from the public sectors. Irrespective of study sites, significantly higher proportion of women received ANC (Antenatal Care) and PNC (Post natal care) in endline compared to baseline. In all study sites higher proportions of women were aware of maternal complications at endline. Services were obtained from qualified persons for reported symptoms of sexually transmitted infections by a higher proportion of women at endline compared to baseline. There were improvements in other RH indicators, such as use of skilled birth attendants and overall utilization of health care facilities by women. Conclusions: The improvements in several important RH indicators in the intervention areas suggest that the interventions affected selected outcomes reported in the study. The study findings also suggest that investment in the reproductive health sector, particularly in existing government programs, improves RH outcomes. © 2014Gazi et al.; licensee BioMed Central Ltd.

BACKGROUND: Since 2007, BRAC has been implementing malaria prevention and control programme in 13 endemic districts of Bangladesh under the National Malaria Control Programme. This study was done to examine the role of different communication media in bringing about changes in knowledge and awareness which facilitate informed decision-making for managing malaria-like illnesses.METHODS: A baseline survey in 2007 before inception of the programme, and a follow-up survey in 2012 were done to study changes in different aspects of programme interventions including the communication component. Both the surveys used the same sampling technique to select 25 households at random from each of the 30 mauza/villages in a district. A pre-tested, semi-structured questionnaire was used to collect relevant information from respondents in face-to-face interview. Analysis was done comparing the study areas at two different times. Statistical tests were done as necessary to examine the differences.RESULTS: The intervention succeeded in improving knowledge in some trivial areas (e.g., most frequent symptom suggestive of malaria, importance of using insecticidal bed nets) but not in critical domains necessary for taking informed action (e.g., mode of malaria transmission, awareness about facilities providing free malaria treatment). Inequity in knowledge and practice was quite common depending upon household affluence, location of households in high or low endemic districts, and sex. Of the different media used in Information, Education and communication (IEC) campaigns during the study period, interpersonal communication with community health workers/relatives/neighbours/friends was found to be more effective in improving knowledge and practice than conventional print and audio-visual media.CONCLUSION: This study reiterates the fact that conventional media may not be user-friendly or culture-sensitive for this semi-literate/illiterate community where dissemination through 'words of mouth' is more common, and as such, interpersonal communication is more effective. This is especially important for initiating informed action by the community in managing malaria-like illnesses.

Adams A.M.,Center for Equity and Health Systems | Islam R.,Center for Equity and Health Systems | Ahmed T.,Center for Equity and Health Systems
Health Policy and Planning | Year: 2015

In Bangladesh, the health risks of unplanned urbanization are disproportionately shouldered by the urban poor. At the same time, affordable formal primary care services are scarce, and what exists is almost exclusively provided by non-government organizations (NGOs) working on a project basis. So where do the poor go for health care? A health facility mapping of six urban slum settlements in Dhaka was undertaken to explore the configuration of healthcare services proximate to where the poor reside. Three methods were employed: (1) Social mapping and listing of all Health Service Delivery Points (HSDPs); (2) Creation of a geospatial map including Global Positioning System (GPS) co-ordinates of all HSPDs in the six study areas and (3) Implementation of a facility survey of all HSDPs within six study areas. Descriptive statistics are used to examine the number, type and concentration of service provider types, as well as indicators of their accessibility in terms of location and hours of service. A total of 1041 HSDPs were mapped, of which 80% are privately operated and the rest by NGOs and the public sector. Phamacies and non-formal or traditional doctors make up 75% of the private sector while consultation chambers account for 20%. Most NGO and Urban Primary Health Care Project (UPHCP) static clinics are open 5-6 days/week, but close by 4-5 pm in the afternoon. Evening services are almost exclusively offered by private HSDPs; however, only 37% of private sector health staff possess some kind of formal medical qualification. This spatial analysis of health service supply in poor urban settlements emphasizes the importance of taking the informal private sector into account in efforts to increase effective coverage of quality services. Features of informal private sector service provision that have facilitated market penetration may be relevant in designing formal services that better meet the needs of the urban poor. © The Author 2015; all rights reserved.

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