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Summary

With support from the Bill & Melinda Gates Foundation, ThinkWell’s Bangladesh team implements the Enhancing Essential Services Provision for Universal Health Coverage (EESPUHC), in the context of Covid-19 activity, which supports the Government of Bangladesh (GoB), including Directorate General of Health Services, Directorate General of Family Planning, and the Health Economics Unit (HEU) at the Ministry of Health and Family Welfare (MOHFW), to prioritize and execute on planning and investments for regularizing and improving access to essential health services. This is based on deeper understanding and knowledge of essential health services trends, gaps, and resulting Covid-19 impact.

Breaking New Ground

This activity is the one of the first few evidence-generating activities in Bangladesh to explore the essential service delivery context during the Covid-19 pandemic from both the supply and demand side. In addition, it is the first activity to assess the health financing bottlenecks that the health system faced during the coronavirus health emergency. During the lockdowns of the pandemic’s initial months, anecdotal data suggested that essential health services were disrupted, however no reliable data is available. Following an initial decline in service delivery, the GoB is attempting to recover and to return to the service delivery state of 2019. To support this attempt, we’re generating evidence on service status and factors that need to be addressed to recover from the initial decline.

Challenges

Bangladesh has a robust primary health care (PHC) system, with a high density of community clinics and associated community health workers to provide essential health services to the population. The combination of limited documented evidence on Covid-19’s impact on essential health service provision, low service coverage, and inequitable health financing in Bangladesh created an uncertain state in health service uptake. Moreover, Bangladesh has one of the highest levels of out-of-pocket (OOP) spending in health in the world.

Formal documentation of the changes in use of essential services and the associated potential impact is not yet available, although various analyses might be ongoing. Preliminary estimates by different experts suggest decreases of 30-40% for some maternal and child health services and up to 60% for tuberculosis services (no published analyses are available yet). There is also evidence from previous global health emergencies of significant drops in essential service utilization and increase in maternal and newborn deaths. Immediate action is needed to avert this.

The MOHFW’s Health Economics Unit developed the “Health Care Financing Strategy 2012-2032” to address high out-of-pocket and catastrophic expenditures through social protection, contracting, and provider payment options. Irrespective of formally moving forward with the health financing strategy, there is limited availability for the health insurance system and contracting out essential services delivery through the private/NGO sector. We will explore these challenges to better understand their root causes. We also will try to define the way forward on health financing solutions for essential services and the country’s Covid-19 response.

Approach

We will conduct a rapid situational assessment of essential services provision (with a primary healthcare focus) and utilization. Our insights and actional recommendations will help ensure a comprehensive overview of PHC service delivery challenges and priority reform areas. We’ll also undertake qualitative assessments from the perspective of both service providers (supply-side) and service users (demand-side) to close key evidence gaps on essential health services trends, gaps, and Covid-19 impact.

Efforts under this area of work include:

  • Qualitative field assessment with primary data collection in eight districts: a combination of key informant interviews, focus group discussions, and consultative dialogues
  • Mapping of partner support on Covid-19 response and primary healthcare/essential services provision with a focus on partners and interventions directly involved in Covid-19 response and supporting essential service provision
  • Desk review and quantitative analyses on development partners who support the GoB to undertake quantitative assessments of service provision and utilization using routine data sources
  • Develop solutions, jointly with MOHFW, to mitigate the identified challenges in essential services provision service delivery

To explore healthcare provider and service user perspectives on healthcare financing bottlenecks in the context of Covid-19, we will review health financing bottlenecks, including insurance, contracting, and provider payment mechanisms. We’ll then provide actionable recommendations focused on the delivery of essential services and the Covid-19 response. Our research will contribute to better understanding of health financing bottlenecks and provider’s perceptions of promising strategies, like service contracting.

Efforts under this area of work include:

  • Rapid review of health financing bottlenecks and mapping of existing health financing approaches
  • Review options for contracting with private sector (not-for-profit and for-profit providers) for essential services and accordingly design/propose alternate options, if needed
  • Develop solutions, with MOHFW, to mitigate the identified health financing challenges at primary health care or related to essential services provision

Results

  1. Bangladesh’s health system rapidly addressed and mostly recovered from the initial shock of the COVID-19 pandemic in its provision of essential health services.
    • Bangladesh’s health system rapidly addressed and mostly recovered from the initial shock of COVID-19 pandemic in provision of essential health services
    • Service utilization has been increasing in recent months across services, though utilization is still below 2019 levels for most services
    • Further stakeholder consultations should be focused in order to understand the key drivers of this recovery to inform future resilience efforts
  2. During the COVID-19 pandemic, the government of Bangladesh proactively mitigated workforce shortages by recruiting pre-qualified doctors and nurses
    • Mechanisms of maintaining a pre-qualified pool of doctors and nurses should be explored to enable rapid deployment during any such future shocks
    • The inclusion of other cadres (e.g., lab staff and support workers) should be considered as currently these are not included in the pre-qualified pool of health workers
  3. Budget reallocations were extended to facilities to support COVID-related activities, though administrative and technical barriers meant these were largely not accessed
    • Capacity development of the health managers on administrative, public financial management, and leadership skills may help to improve utilization of budget reallocations
  4. Care seeking from community clinics increased at the community level as many people could not go to distant upazila or district facilities
    • Strengthening community clinics and their commodity supplies will serve some basic primary health care needs during emergency periods
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