Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh.

INTRODUCTION: Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the performance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. METHODS: This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. RESULTS: Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. DISCUSSION: Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to enable systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without adequate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.

Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis.

To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist-anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities.

"Side effects affected my daily activities a lot": a qualitative exploration of the impact of contraceptive side effects in Bangladesh.

PURPOSE: In a country like Bangladesh that has made great progress in contraceptive use with one of the lowest levels of fertility and highest levels of contraceptive use, understanding what factors influence women's decisions to discontinue a contraceptive method and not switch to a new method is critical in designing interventions and programs that will help enable Bangladesh to reach its FP2020 goals. Research on side effects has focused on physical manifestations like headaches, moodiness, abdominal pain, and menstrual irregularities. While physical effects alone may stop women from continuing a contraceptive method, less is known about how side effects influence women's daily activities and lives. The purpose of this study is to understand the ways that side effects affect Bangladeshi women's participation in different social settings. METHODS: Thirty-five in-depth interviews with married women who recently discontinued or switched to a different contraceptive method were conducted in Sylhet and Khulna Divisions. Interviews explored reasons for discontinuation including experience of side effects and impact of side effects on women's lives. RESULTS: Key themes emerged including that side effects are not only experienced physically but are barriers to women's participation in many aspects of their lives. The spheres of life that most commonly appeared to be influenced by side effects include religion, household, and sexual intimacy irrespective of method used or residence. CONCLUSION: Family planning providers need to be aware of these additional consequences associated with contraceptive side effects to provide tailored counseling that recognizes these issues and helps women to mitigate them. For Bangladesh to achieve its FP2020 goals, understanding the broader context in which family planning decisions are made vis-à-vis side effects is critical to design programs and interventions that meet all the needs of women beyond just their fertility intentions.

Increasing access to safe menstrual regulation services in Bangladesh by offering medical menstrual regulation.

In spite of wide availability of menstrual regulation services, women often resort to a variety of medicines for inducing abortion. The Bangladeshi Government is now supporting attempts to investigate the introduction of medical menstrual regulation in the public sector. This study examined the acceptability of medical menstrual regulation in public sector urban-based clinics, public sector rural-based clinics and urban-based clinics run by Marie Stopes, a non-governmental organization. Of the 2,976 women who attended for menstrual regulation services during the eight-month study period, 68% attended urban Maternal and Child Welfare Centres and the Marie Stopes clinics, while 32% went to the rural public facilities of the Union Health and Family Welfare Centre. Women were offered both medical and manual vacuum aspiration methods of menstrual regulation; 1,875 (63%) chose the medical method and 1,101 (37%) chose manual vacuum aspiration. Around 7.1% of women at Maternal and Child Welfare centres and 11.9% at the Marie Stopes clinics knew about medical menstrual regulation before taking the service, compared to a much higher proportion (43%) at the rural facilities. Overall 61.4% of women who used medical menstrual regulation found the method satisfactory, and 34.2% were very satisfied. Of the 3.9% of women who were not satisfied, most received services from rural facilities.

Distance, transportation cost, and mode of transport in the utilization of facility-based maternity services: evidence from rural Bangladesh.

Although the maternal mortality ratio in Bangladesh has decreased, significant underutilization of facilities continues to be a persistent challenge to policy makers. Women face long distances and significant transportation cost to deliver at health facilities. This study identifies the distance traveled to utilize facilities, associated transportation cost, and transport mode used for maternal healthcare services. A total of 3,300 mothers aged 18-49 years, who had given birth in the year before the survey, were interviewed from 22 sub-districts in 2010. Findings suggest that facility-based maternal healthcare service utilization was very poor. Only 53% of women received antenatal care, 20% used delivery care. and 10% used postnatal care from health centers. Median distance traveled for antenatal and postnatal check-ups was 2 kilometers but 4 kilometers for complication management care and delivery. Most women used non-motorized rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1.40) as transportation cost for antenatal care, Taka 432 (US$6.17) for delivery, and Taka 132 (US$1.89) for postnatal check-up. For each additional kilometer, the cost increased by Taka 9 (US$0.13) for antenatal, Taka 31 (US$0.44) for delivery, and Taka 8 (US$0.11) for postnatal care.

Performance-based incentive for improving quality of maternal health services in Bangladesh.

Poor motivation of providers, primarily caused by low remuneration and/or non-existence of financial incentives, has been a key challenge to improve the quality of maternal health services in the public sector health facilities in rural Bangladesh. An operations research study examined the impact of performance-based incentive for service providers at the institutional level to improve the quality of maternal health services. Quality of care was assessed through monitoring visits of professionals from higher-level health facilities, which contributed to improved service provision within the facilities. Quality scores of the facilities increased from 55% to 78% in 14 months of intervention with significant improvement in antenatal care, postnatal counseling, and institutional delivery (p < 0.01). Importantly, client satisfaction increased remarkably in the intervention facilities. Performance-based incentive has the potential for motivating service providers in improving the quality of maternal health services and for increasing the utilization of facilities for maternal health services in Bangladesh.

Urbanization prospects in Asia: a six-country comparison.

Yet rural in nature, Asia is proceeding with a wide-ranging scale and fast pace of urbanization, resulting in accelerated economic growth. This article attempts a comparison on urbanization of six largest Asian countries: Bangladesh, China, India, Indonesia, Pakistan, and the Philippines. Among these countries, urban transition is underway in China, Indonesia, and the Philippines, which are also on track to mature as middle-income countries. India and Pakistan will soon graduate from low-income to lower-middle income countries, reaching the platform for faster urbanization with consequent economic growth. Regardless of the level of urbanization across countries, cities generate four-fifths of national income and the prominence of cities in generating country's national income is escalating. Still, urbanization primarily takes place through the development of large cities with surrounding industrial zones. Large cities will continue to play a significant role in absorbing future anticipated growth, but a decrease of growth rates in large cities is expected. Most of future city growth will occur in medium- and small-sized cities where existing coverage of basic public services is grossly inadequate, that entails greater concentration of power, investment, and services. To maximize the benefits of urbanization, countries need to judiciously plan the course of future urbanization-whether it should be a concentrated growth, a balanced growth, or a distributed growth.

Out-of-pocket expenses for maternity care in rural Bangladesh: a public-private comparison.

Out-of-pocket expenses incurred by women for availing maternal healthcare services at public and private health facilities in Bangladesh were examined using a baseline household survey evaluating the impact of demand side financing vouchers on utilization and service delivery for maternal healthcare. The survey was conducted in 2010 among 3,300 women who gave birth in the previous 12 months from the start of data collection. Information on costs incurred to receive antenatal, delivery, and postnatal care services was collected. Findings reveal that the majority of women reported paying out-of-pocket expenses for availing maternal healthcare services both at public and private health facilities. Out-of-pocket expenses include registration, consultation, laboratory examination, medicine, transportation, and other associated costs incurred for receiving maternal healthcare services. On average, women paid US$3.60 out-of-pocket expenses for receiving antenatal care at public health facilities and US$12.40 at private health facilities. Similarly, women paid one and half times more for normal (US$42.30) and cesarean deliveries (US$136.20) at private health facilities compared to public health facilities. On the other hand, costs for postnatal care services did not vary significantly between public and private health facilities. Utilization of maternal healthcare services can be improved if out-of-pocket expenses can be minimized. At the same time, effective demand generation strategies are necessary to encourage women to utilize health facilities.

Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia.

BACKGROUND: Cost of delivering reproductive health services to low income populations will always require total or partial subsidization by government and/or development partners. Broadly termed "demand-side financing" or "output-based aid", these strategies include a range of interventions that channel government or donor subsidies to the user rather than the service provider. Initial pilot assessments of reproductive health voucher programs suggest that they can increase access, reduce inequities, and enhance program efficiency and service quality. However, there is a paucity of evidence describing how these programs function in different settings for various reproductive health services. METHODS/DESIGN: Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the "voucher and accreditation" approaches to improving the reproductive health of low-income women in Cambodia. The study comprises of four populations: facilities, providers, women of reproductive age using facilities, and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in a sample of 20 health facilities that are accredited to provide maternal and newborn health and family planning services to women holding vouchers from operational districts in three provinces: Kampong Thom, Kampot and Prey Veng and a matched sample of non-accredited facilities in three other provinces. Health facility assessments will be conducted at baseline and endline to track temporal changes in quality-of-care, client out-of-pocket costs, and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3000 respondents will also be conducted in areas where vouchers are distributed and similar non-voucher locations. DISCUSSION: A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status and reducing inequities at the population level and assess effects on access, equity and quality of care at the facility level. If the voucher scheme in Cambodia is found effective, it may help other countries adopt this approach for improving utilization and access to reproductive health and family planning services.

Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and RH status: Bangladesh.

BACKGROUND: Cost of delivering reproductive health services to low-income populations will always require total or partial subsidization by the government and/or development partners. Broadly termed "Demand-Side Financing" or "Output-Based Aid", includes a range of interventions that channel government or donor subsidies to the service user rather than the service provider. Initial findings from the few assessments of reproductive health voucher-and-accreditation programs suggest that, if implemented well, these programs have great potential for achieving the policy objectives of increasing access and use, reducing inequities and enhancing program efficiency and service quality. At this point in time, however, there is a paucity of evidence describing how the various voucher programs function in different settings, for various reproductive health services. METHODS/DESIGN: Population Council-Nairobi, funded by the Bill and Melinda Gates Foundation, intends to address the lack of evidence around the pros and cons of 'voucher and accreditation' approaches to improving the reproductive health of low income women in five developing countries. In Bangladesh, the activities will be conducted in 11 accredited health facilities where Demand Side Financing program is being implemented and compared with populations drawn from areas served by similar non-accredited facilities. Facility inventories, client exit interviews and service provider interviews will be used to collect comparable data across each facility for assessing readiness and quality of care. In-depth interviews with key stakeholders will be conducted to gain a deeper understanding about the program. A population-based survey will also be carried out in two types of locations: areas where vouchers are distributed and similar locations where vouchers are not distributed. DISCUSSION: This is a quasi-experimental study which will investigate the impact of the voucher approach on improving maternal health behaviors and status and reducing inequities at the population level. We expect a significant increase in the utilization of maternal health care services by the accredited health facilities in the experimental areas compared to the control areas as a direct result of the interventions. If the voucher scheme in Bangladesh is found effective, it may help other countries to adopt this approach for improving utilization of maternity care services for reducing maternal mortality.

Unintended pregnancy among rural women in Bangladesh.

Unintended pregnancies are associated with unsafe abortion and greater risk of maternal morbidity and maternal deaths. In Bangladesh, approximately one-third of pregnancies are unintended. Considering the magnitude of the situation and its consequences, this article explores factors associated with the prevalence of unintended pregnancies in rural Bangladesh with implications for policy intervention. A total of 3300 women were interviewed from 22 sub-districts to collect information on unintended pregnancy related issues. Findings reveal that about 29% of the pregnancies were unintended and the frequency of unintended pregnancy was higher among the older, less educated, higher parity, and poor women. Findings also suggest that unintended pregnancy rate was higher (33%) among women who used contraceptive before their last pregnancy than women (23%) who did not use any contraceptive. The rate of unintended pregnancy also varied, by the types of contraceptive methods used before their last pregnancy. The women who were using traditional methods or temporary modern methods were more likely to experience unintended pregnancy than longer acting method users. The findings underscore the importance of measuring contraceptive discontinuation rates in addition to prevalence of all modern methods. When discussing policy interventions to generate demand for family planning, consideration of differences in method-specific discontinuation rates is important if policy objectives to reduce unintended pregnancies are to be achieved.

Equity in access to maternal and child health services in five developing countries: what works.

People living in rural areas are yet to have equitable access to maternal and child health services in many developing countries. This article examines selected health service delivery models that improved access to services in five developing countries. The article is based on the review of background papers on Bangladesh, Pakistan, Cambodia, Ghana, and Tanzania, prepared as part of a multi-country study on health systems and maternal and child health. Findings suggest that equity in access to health services largely depends on a system that ensures a combination of facility-based service delivery and outreach services with a functioning referral network. A key factor is the availability of health workforce at the community level. Community-based deployment of service providers or recruitment and training of community health workers is critical in enhancing service coverage and linking local populations to a health facility. Incentive is necessary to keep community health workers' interest in providing services. However, health workforce alone cannot ensure good health outcomes. They must be embedded in a functioning service delivery network to transform structural inputs into outcomes. Moreover, local-level health systems should have the ability to allocate resources in strategic ways addressing the pressing health needs of the people.

Using vouchers to increase access to maternal healthcare in Bangladesh.

The maternal mortality ratio (322) is comparatively high in Bangladesh. The utilization of maternity care provided by trained professionals during and after delivery is alarmingly low, primarily due to lack of knowledge and money. The overall objective of this operations research project was to test the feasibility and effectiveness of introducing financial support (voucher scheme) for poor rural women to improve utilization of antenatal care (ANC), delivery and postnatal check-up (PNC) from trained service providers. A pretest-posttest design was utilized. A total of 436 women were interviewed before and 414 after the intervention to evaluate the impact of interventions. In-depth interviews were conducted with users and non-users of vouchers. Findings show that institutional deliveries have increased from 2% to 18%. Utilization of ANC from trained providers has increased from 42% to 89%. Similarly, utilization of PNC from trained providers has increased from 10% to 60%.

Lessons learned from health sector reform: a four-country comparison.

Various reforms have been undertaken to improve the functioning of health systems in developing countries, but there is limited comparative analysis of reform initiatives. This article discusses health sector reform experiences of four developing countries and identifies the lessons learned. The article is based on the review of background papers on Bangladesh, Pakistan, Indonesia, and Tanzania prepared as part of a multi-country study on health sector reform. Findings suggest that decentralization works effectively while implementing primary and secondary health programs. Decentralization of power and authority to local authorities requires strengthening and supporting these units. Along with the public sector, the private sector plays an effective role in institutional and human resources development as well as in improving service delivery. Community participation facilitates recruitment and development of field workers, facility improvement, and service delivery. For providing financial protection to the poor, there is a need to review user fees and develop affordable health insurance with an exemption mechanism. There is no uniform health sector reform approach; therefore, the experiences of other countries will help countries undertake appropriate reforms. Here, it is important to examine the context and determine the reform measures that constitute the best means in terms of equity, efficiency, and sustainability.

Inequalities in maternal health care utilization in rural Bangladesh.

The article examines the inequalities in utilization of maternal health care in rural areas of Bangladesh. It also attempts to identify the expenditure pattern for these services. Findings suggest that large disparities in the maternal health care utilization exist between the poorest and the richest population in Bangladesh. Two in three women in the highest wealth group receive antenatal care from qualified doctors as opposed to one in five women in the lowest wealth group. Almost all the deliveries occur at home among the lowest wealth group, whereas 16% of deliveries occur at health facilities among the highest wealth group. Wealth is also associated with the seeking of care for delivery-related complications. The practice of seeking services during post-natal period is not common and it varies positively with economic condition. Family savings is found to be the dominant source of paying the maternal health care services among the women in the highest wealth group. Cost has been found to be the most commonly cited reason for not seeking care for delivery complications. Eighty-four percent of women in the lowest wealth group compared to 13% of women in the highest wealth group did not seek treatment for delivery complications due to cost. Lack of perceived need of antenatal care (ANC) and postnatal care is the most pressing reason for not seeking these services. The study findings contain a number of implications for policy purposes that could be useful in devising ways to increase the utilization of maternal health care services.

Achieving the Cairo Conference (ICPD) goal for youth in Bangladesh.

Sexual and reproductive health education is not yet formally introduced in Bangladesh without which the International Conference on Population and Development (ICPD) in Cairo's goal to ensure young people's right to access to such information and services will remain unfulfilled. The Population Council provided technical assistance to a governmental department to pilot youth reproductive health education. Study findings from the pre- and posttests of 379 matched respondents revealed significant changes in knowledge, attitudes, and life-skills. Knowledge about long-term contraceptives and skills on negotiating safe sex improved significantly by 63% and 26%, respectively. Youths who do not consider menstruation as a disease nearly doubled, and misunderstandings about the mother's role in sex determination of a child were significantly dispelled. Decisions not to accompany friends in visiting sex workers and to use condoms, ignoring friends' disapproval, were increased over 18%. Over 98% of students reported that teachers discussed condoms, while only 12% alleged unfriendly behavior. Findings motivated the department to scale up the reproductive health curriculum.

Reproductive and sexual health education for adolescents in Bangladesh: parents' view and opinion.

This study attempted to find out whether parents in Bangladesh considered it important to provide reproductive and sexual health education to their adolescent children. It investigated possibilities of making parents play effective role models in educating their children on reproductive and sexual health. Findings suggest considerable positive attitude of parents toward adolescent reproductive health education, including a positive environment for introducing reproductive and sexual health education in schools. Nevertheless, findings also revealed a serious lack of knowledge among parents on basic understanding of reproductive and sexual health matters. Some parents also had reservations about educating their children on these matters. Making parents more aware of reproductive and sexual health matters and developing their communication skill to talk to their children along with in-school education for adolescents should be given high priority in Bangladesh.