Community based peer-led TB screening intervention: an innovative approach to increase TB knowledge, presumptive case identification, and referral among sexual minority people in urban Bangladesh.

INTRODUCTION: One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh. METHODS: This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches. RESULTS: The 'Six Steps in Quality Intervention Development' framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators. CONCLUSION: This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program.

Making doctors stay: Rethinking doctor retention policy in a contracted-out primary healthcare setting in urban Bangladesh.

BACKGROUND: "Contracting Out" is a popular strategy to expand coverage and utilization of health services. Bangladesh began contracting out primary healthcare services to NGOs in urban areas through the Urban Primary Health Care Project (UPHCP) in 1998. Over the three phases of this project, retention of trained and skilled human resources, especially doctors, proved to be an intractable challenge. This paper highlights the issues influencing doctor's retention both in managerial as well as service provision level in the contracted-out setting. METHODOLOGY: In this qualitative study, 42 Key Informant Interviews were undertaken with individuals involved with UPHCP in various levels including relevant ministries, project personnel representing the City Corporations and municipalities, NGO managers and doctors. Verbatim transcripts were coded in ATLAS.ti and analyzed using the thematic analysis. Document review was done for data triangulation. RESULTS: The most cited problem was a low salary structure in contrast to public sector pay scale followed by a dearth of other financial incentives such as performance-based incentives, provident funds and gratuities. Lack of career ladder, for those in both managerial and service delivery roles, was also identified as a factor hindering staff retention. Other disincentives included inadequate opportunities for training to improve clinical skills, ineffective staffing arrangements, security issues during night shifts, abuse from community members in the context of critical patient management, and lack of job security after project completion. CONCLUSIONS: An adequate, efficient and dedicated health workforce is a pre-requisite for quality service provision and patient utilization of these services. Improved career development opportunities, the provision of salaries and incentives, and a safer working environment are necessary actions to retain and motivate those serving in managerial and service delivery positions in contracting out arrangements.

Developing and testing community-based tuberculosis (TB) screening intervention to increase TB referral, case detection and knowledge among sexual minority people in urban Bangladesh: a mixed-method study protocol.

INTRODUCTION: Although Bangladesh is a country of generalised tuberculosis (TB) epidemic, the HIV prevalence is low among general populations, and 3.9% among key populations. Despite the high possibility of HIV-TB coinfection, scientifically tested approaches for increasing TB case detection among sexual minority people are yet to be developed and implemented in Bangladesh. Such approaches could foster service delivery linkages between communities and the government health system. Findings of this experimental research are likely to provide new insights for programme managers and policy planners for adopting a similar approach in order to enhance TB referral, thus ultimately increasing TB case detections and reducing the likelihood of TB-related mortalities and morbidities, irrespective of HIV status. METHODS AND ANALYSIS: This operational research will follow a quasi-experimental design, applying both qualitative and quantitative methods, in two drop-in centres in three phases. Phase 1 will encompass baseline data collection and development of a community-based TB screening approach. In phase 2, the newly developed intervention will be implemented, followed by end-line data collection in phase 3. Qualitative data collection will be continued throughout the first and second phases. The baseline and end-line data will be compared both in the intervention and comparison areas to measure the impact of the intervention. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board of International Centre for Diarrhoeal Disease Research, Bangladesh. The findings will be disseminated through diverse scientific forums including peer-reviewed journals, presentation at conferences and among the policy-makers for policy implication. The study started in January 2019 and will continue until June 2020.

Perceptions and experiences with district health information system software to collect and utilize health data in Bangladesh: a qualitative exploratory study.

BACKGROUND: Accurate and high-quality data are important for improving program effectiveness and informing policy. In 2009 Bangladesh's health management information system (HMIS) adopted the District Health Information Software, Version 2 (DHIS2) to capture real-time health service utilization data. However, routinely collected data are being underused because of poor data quality and reporting. We aimed to understand the facilitators and barriers to implementing DHIS2 as a way to retrieve meaningful and accurate data for reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services. METHODS: This qualitative study was conducted in two districts of Bangladesh from September 2017 to 2018. Data collection included key informant interviews (n = 11), in-depth interviews (n = 23), and focus group discussions (n = 2). The study participants were involved with DHIS2 implementation from the community level to the national level. The data were analyzed thematically. RESULTS: DHIS2 could improve the timeliness and completeness of data reporting over time. The reported facilitating factors were strong government commitment, extensive donor support, and positive attitudes toward technology among staff. Quality checks and feedback loops at multiple levels of data gathering points are helpful for minimizing data errors. Introducing a dashboard makes DHIS2 compatible to use as a monitoring tool. Barriers to effective DHIS2 implementation were lack of human resources, slow Internet connectivity, frequent changes to DHIS2 versions, and maintaining both manual and electronic system side-by-side. The data in DHIS2 remains incomplete because it does not capture data from private health facilities. Having two parallel HMIS reporting the same RMNCAH indicators threatens data quality and increases the reporting workload. CONCLUSION: The overall insights from this study are expected to contribute to the development of effective strategies for successful DHIS2 implementation and building a responsive HMIS. Focused strategic direction is needed to sustain the achievements of digital data culture. Periodic refresher trainings, incentives for increased performance, and an automated single reporting system for multiple stakeholders could make the system more user-friendly. A national electronic health strategy and implementation framework can facilitate creating a culture of DHIS2 use for planning, setting priorities, and decision making among stakeholder groups.

Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience.

BACKGROUND: Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries. METHODS: This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes. RESULTS: In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts. CONCLUSIONS: This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.