Let’s Talk About Universal Health Coverage

By Dr. Nahitun Naher

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Put very simply, universal health coverage (UHC) means “every person, everywhere, has access to quality healthcare without suffering financial hardship.” This goal is rooted in the concept of human rights to health, which also makes sense economically. However health system gaps remain a barrier, jeopardising the lives and financial wellbeing of millions of people globally. There are still too many countries that have failed to invest enough in health.

The journey towards achieving UHC actually began in 1978 through the Alma Ata Declaration of “Health for All”. But almost three decades later, the WHO Health Systems Financing Report in 2010 finally emphasised for the first time that it is possible for every country to mobilise necessary funds towards achieving UHC. Following that, in a historic resolution in 2012, the United Nations unanimously endorsed UHC as a priority for every country.

The momentum towards UHC turned into a commitment when more than 500 organisations across the health and development sector joined the Rockefeller Foundation in launching the first-ever UHC Day with the slogan ‘Health for All, Everywhere’ on December 12, 2014. Ever since, the global consensus that UHC is a smart investment and an achievable goal has grown.

The striking fact that 400 million people around the world lack basic healthcare services while 17 per cent are impoverished by health costs came out in the first UHC Global Monitoring Report in 2015. This triggered the drive towards UHC and was endorsed by 267 economists who declared UHC a smarter investment.

The year 2016 started with high hopes for UHC as world leaders including the G7 and African heads of state launched UHC campaigns in their countries. This affirmed that health is a human right and no one should go bankrupt when they get sick. Finally, in September 2016, WHO Director General Margaret Chan announced the International Health Partnership for accelerating progress toward UHC by 2030.

Throughout this journey, an international coalition for UHC has emerged involving 739 organisations in 117 countries, which celebrates Universal Health Coverage Day on December 12. This has become the annual rallying point for the growing movement towards health for all.

In Bangladesh, high out-of-pocket expenditure for health is driving people into poverty. Inadequate healthcare financing, inequity in health financing and utilisation, inefficient use of existing resource, inadequate health workforce and their skill-mix imbalance, and the rapid rise of non-communicable diseases are placing more barriers in our paths towards achieving UHC.

However it is promising to see that the Government of Bangladesh has expressed a strong commitment towards achieving UHC. This is reflected in the Government’s seventh Five-Year Plan where UHC has been prioritised. The Health Care Financing Strategy 2012-2032, and National Social Security Strategy 2015 have incorporated UHC by focusing on strengthening financial risk protection and extending health services and population coverage especially to poor and vulnerable populations.uhc-day-badge

This UHC Day, you too can “Act with Ambition” to express solidarity towards achieving UHC. If you are in Dhaka, Bangladesh, please do join our UHC Day Rally on December 12. For more information, please check the Facebook Event page here.


Dr. Nahitun Naher is a senior research associate at the Centre of Excellence for Universal Health Coverage at James P Grant School of Public Health, BRAC University.

Keeping Up with Public Health Challenges: Training Opportunities for Practitioners and Stakeholders

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Evolving 21st century public health challenges make it critical for professionals to keep their requisite skills up-to-date. Although in recent years we have seen exceptional health achievements in Bangladesh, public health practitioners must have access to continual training opportunities to keep innovating locally relevant community solutions.

Recognising this demand, JPGSPH established a training unit in 2007 (recently renamed the Centre for Professional Skills Development; CPSD), training over 5,000 development professionals to date. “The Centre aims to expand the breadth and depth of knowledge and skills of professionals at different levels coming from the fields of public health, development and academia,” said Hossain Ishrath Adib, Head of Education at JPGSPH. These include key health sector players – beyond just practitioners – like policymakers, development partners, government officials, advocates, educators, researchers and frontline health workers.

Aiming to serve as a national and international training hub, the Centre offers around 20 courses, workshops, seminars and training every year facilitated by highly qualified professionals. In addition to the School’s in-house facilitators with multidisciplinary backgrounds (ie, medical professionals, anthropologists, epidemiologists, statisticians, academics, social scientists, etc.), CPSD brings in expert trainers from leading international health research institute, icddr,b and others, notably WHO, UNICEF, Harvard Medical School, and more. The School also organises training led by officials from various government ministries, including the Ministry of Health and Family Welfare.cpsd-2

Courses are designed around critical and emerging public health issues, capacity building in key technical areas, including use of statistical tools, research methods, project management, and monitoring and evaluation skills. Taking a more innovative approach to teaching, they incorporate field visits to programme sites and hands-on learning.

Direct access to BRAC’s network also makes the Centre attractive, particularly to those seeking to learn from the world’s largest NGO. In 2015, members of Mozambique’s Ministry of Health reached out the School to come to Bangladesh and see BRAC’s work in nutrition firsthand.

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“As government officials, examining BRAC’s community nutrition programme during the short course at JPGSPH helped us understand the implementer’s perspective.”

Sara Paulino
Delegate from Ministry of Health, Mozambique 

The Centre has also led the way in organising several pioneering courses focusing on issues such as the Ebola Virus, public-private partnership in healthcare, and evaluation of development programmes. Trainings on sexual and reproductive health rights (SRHR) are offered to inspire critical thinking and reflection among practitioners such as the flagship course on Men, Masculinity and SRHR.

“Participating in the course on Men, Masculinity and SRHR allowed us to learn more about how gender and masculinity are connected by patriarchy. This was an eye-opening experience and very helpful for myself and my fellow colleagues as we work in this field.”

Shaikh Md. Mominul Islam
Student of MA Development Studies at North Western University, Khulna, and Community Organiser at Vivid Rainbow 

cpsdfunders.jpgIntroductory courses on universal health coverage are facilitated in collaboration with the Centre of Universal Health Coverage at the School with support from the Health Economics Unit of the Ministry of Health and Family Welfare (MoHFW). The course on urban health and governance took participants on a field visit to the slums of Dhaka to sensitise them to the lived realities of the urban poor when problem solving for solutions. To continue developing capacity of researchers, courses in quantitative and qualitative research methods are also offered, with one of the more popular courses being for scientific writing. The Strategic Communications for Public Health course shows participants how to apply behaviour change communication to interventions effectively.

These courses intend to arm today’s practitioners, researchers, and policymakers alike with the means to continue making improvements to public health programming. “We have innovative teaching methods, and practical hands-on learning that is focused on developing the skills of diverse professionals, who must critically reflect on public health problems and find solutions,” said Sabina Faiz Rashid, Dean of the School. “We want to ensure that they can work cross-sectorally, collaborate on research, and keep building on new or existing interventions and policies.”


For more information on the Centre for Professional Skills Development and upcoming courses visit: http://sph.bracu.ac.bd/index.php/2015-09-08-04-34-47

Inside Look at the MPH Programme

Since 2005, JPGSPH has been facilitating its Master of Public Health (MPH) programme with the aim to develop public health leaders of the future. The School offers a global classroom of learners with diverse disciplinary and professional backgrounds with 476 graduates to date from across 26 countries. Charu Chhetri is one such learner from Nepal, who is part of the current and 12th batch. This month, #VitalSigns brings you an exclusive look at the MPH through the eyes of an international student.


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#VitalSigns (VS): Hi Charu! Tell us a little about yourself.

Charu Chhetri (CC): Hi! I am Charu from Kathmandu, and I completed my MBBS from Universal College of Medical Science in Bhairahawa, Nepal.

VS: You mentioned earlier being really excited about getting accepted to JPGSPH’s MPH programme.

CC: Yes! I became interested in getting an MPH when I was working in the Primary Healthcare Centre in Kathmandu as a medical officer. I wasn’t sure whether I would go for an MD since it takes three years to complete. I always wanted to study something that I can use to work for the community. I began preparing to apply to schools abroad when I came across the programme at JPGSPH, and got to know about the WHO-TDR scholarship. A colleague suggested that this scholarship and programme would help open many doors for my career since the WHO recognised JPGSPH as one of the top six schools in the region promoting and practicing innovative higher public health education.

VS: What was your first impression about the programme?

dsc_1179 CC: I arrived in Dhaka along with three other students from Nepal. I remember first seeing them when we had to take our BRAC University entrance exams. After spending the first few weeks with the rest of the international students, we became acquainted with the Bangladeshi students.

Later we were taken outside the city to BRAC University’s campus in Savar for our official orientation. There we met faculty members like Dr Alayne Adams who coordinated our Anthropological Approaches to Public Health and Qualitative Research Methods modules.

Senior lecturer on Global Health from Harvard University, Richard Cash (winner of the Prince Mahidol Award) is also one of key course instructors who teaches Epidemiology of Infectious Diseases. The programme has had world-class faculty who have come to teach us from other prestigious Bangladesh-based and international institutions. Being able to engage with instructors who are leaders in their field with multi-country expertise has been an extremely valuable component of this experience.

The level of experiential learning we are exposed to is also remarkable. We were able to visit multiple field sites belonging to the School’s institutional partners –  BRAC (the world’s largest NGO!) and its nationwide health programme, and the research and population labs of icddr,b.

 VS: Tell me more about the Summative Learning Process (SLP) experience. 

 CC: The SLP is our final group project, which gives us the chance to apply the full range of public health skills and competencies we have acquired. Each group is assigned a specific and current public health problem to understand and tackle critically. My group and I are working on addressing factors for the rise of C-Sections in Bangladesh. The SLP is extra challenging, because we are also simultaneously taking our other classes, so it is definitely complex and stressful! Group work is not easy, but we are learning to combine our different ideas and support each other as a team.

VS: What do you do when you aren’t doing coursework and working on your SLP?

CC: This year’s batch has become like a family. When we aren’t studying and have some time to spare, we like to explore Dhaka city together, go shopping or eat at different restaurants. A few of our classmates have gotten married this year so we were able to attending their weddings. Besides meeting and learning from people from various backgrounds, and the expertise we are gaining from the programme, I am striving to take in this one-of-a-kind, hands-on MPH experience to the best of my abilities.

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To learn more about the MPH programme visit: http://jpgsph.org/index.php/admission-main

Why Does Child Marriage Happen?

By Seama Mowri and Saraban Ether

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Poster on child marriage seen during a field visit to Bhashantek slum. It reads, “Out of 100 Bangladeshis, 66 young girls are victims of child marriage.”

Although only 16 years old, Ayesha had already been married for nine months when we met her in the Bhashantek slum in Mirpur, Dhaka. While conducting research for the Preventing Early Child Marriage in Urban Slums project, we spoke to Ayesha to get a better understanding of the reasons behind her decision to marry. This is her story.

As an orphan from birth, the responsibility for Ayesha’s care fell on her grandmother. But when her grandmother also died, Ayesha was passed on to the care of one of her paternal aunts. Unfortunately, this arrangement didn’t last either, as Ayesha’s uncle was not keen on having another mouth to feed.

She was then sent to live with another aunt and her cousin who wilfully took her in their care. They loved Ayesha and it seemed that she was finally happy. But when her cousin married a few years later, his new wife disliked Ayesha’s presence and treated her badly. She refused to sit or eat at the same table as Ayesha and blamed her for everything that went wrong in the house. This made life so unbearable for Ayesha that she decided her only option was to get married and move out of the house.

The first suitor her aunt found for Ayesha was interested in the union until his family found out she was an orphan. “His parents were concerned that their son would miss out on jamai-ador (the cultural tradition of pampering the son-in-law with food, accommodation, dowry and all other means of hospitality),” said Ayesha.

The next suitor was Ayesha’s distant cousin. “I heard that he loved me,” she said. “I was so desperate to get married and have a home that I said yes to him. I did not think of anything else.” But after they got married, Ayesha realized the magnitude of responsibilities that came along with being a wife. “I had never seen a wooden stove before getting married,” she said. “But I needed to cook on that stove now. I never cooked or washed clothes before [getting married]; now I have to do all that and more.”

Even though she performs her daily chores, Ayesha’s husband is still displeased and uses any opportunity to beat her. “I cannot sleep on my right side from the beating he gave me last time.”

Now she regrets the decisions she made, which led up to her getting married in such haste. She says that one of the greatest impacts of her marriage is the loss of her independence. “I could go to my cousin’s house whenever I wanted to go. I used to visit Dhanmondi Lake every afternoon with my aunt. But now I don’t have that independence. I want to visit her, but I can’t.”

In addition to Ayesha’s loss of freedom, she now faces pressure to have a baby. “My husband and in-laws want me to have a baby as soon as possible,” she said. “They do not think of my age and that I am only 16.”

Ayesha decided to get married because she felt she had no other way out. She could no longer tolerate the difficulty of living in the same house as her cousin’s new wife. She believed that marriage would give her a better life. But at just 16 years old, she has lost her childhood and opportunities for a brighter future.

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Women in Bhashantek with adolescent children participate in a focus group discussion for the Preventing Early Child Marriage project. The majority of these mothers were married as young children themselves.

In a country where 64% of girls are married before the age of 18, it is crucial to examine how to end this all too common practice, and empower girls to overcome the hardships, which lead them to seek early marriage as a means to escape their difficulties.

This particular project on preventing early child marriage is examining the underlying factors that lead girls and their families to make such decisions. While Ayesha’s story is only a snapshot of the research being conducted, the three-year long project will delve deeper into identifying how to delay early marriage and its impact on both girls and boys. Ultimately, the findings from this project aims to help the Government of Bangladesh inform future programme interventions and policies to better serve girls like Ayesha.


Seama Mowri, Project Manager and Saraban Ether, Research Associate work on the Preventing Child Marriage in Urban Slums project under JPGSPH and International Development Research Center (IDRC). Stay tuned for more updates on this project here on the #VitalSigns blog.

New Study: Husbands and Mothers-in-Law Can Help Decrease Adolescent Pregnancy in Bangladesh

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Photo credit: Allison Joyce, 2015

Bangladesh has actually done exceptionally well in increasing contraceptive use by more than 50% in the last 40 years. Yet it still has the highest rate of adolescent pregnancy (31%) in all of South Asia. In a society where child marriage remains common practice, tackling adolescent pregnancy can be an uphill battle.

But a recent study conducted about decision-making and contraception use among married girls in Bangladesh has helped shed more light on how to address this issue. Findings revealed that approaching husbands and mothers-in-law through targeted interventions may serve as an effective method to encourage more use of contraception.

The study took place in Rangpur district, which has the country’s highest number of adolescent pregnancies. Conducted by a research team including JPGSPH’s very own Malabika Sarker, the study followed 35 married adolescent girls for a year through interviews about their maternal healthcare-seeking behaviour.

The aim was to understand the girls’ rationales for using or not using contraception. The most common reason they gave for having a child right after marriage was the expectation to bear a child from their husbands and mothers-in-law. They also conveyed a mistrust and fear about the quality and usage of contraception. Further apprehension is caused by misconceptions from other women in the family or neighbourhood, who become the primary sources of information for girls after marriage.

In rural Bangladesh, husbands and mothers-in-law act as the main decision makers in all matters related to childbearing. As the main breadwinners, men ultimately get to make all household decisions regarding health care. But because family planning is still considered a “woman’s issue,” mothers-in-law are also given authority to make decisions.

Thus by creating interventions that target husbands and their mothers and educating them about the benefits of contraception use and the severe detrimental effects associated with adolescent pregnancy, several of the barriers keeping girls from making these decisions can be lifted.

Child marriage cannot be expected to end overnight, but public health practitioners and policymakers need to start considering the matters at hand. Community health workers with the most exposure to these populations must also be trained in order to provide accurate information so that people fully trust and understand why and how to use contraceptives.

However, these findings are not a means to an end; it is now imperative that the wider community and societal actors begin implementing programmes to increase the uptake of contraception to delay pregnancy among adolescent girls. Only then can further policy formulation and implication lead towards decreasing the rate of adolescent pregnancy in Bangladesh.


To find out more about the study, read it here

 

Mapping Uncharted Territory – Sexual Rights and Reproductive Health of Bangladesh’s Urban Youth Using Digital Technology

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The Centre for Gender, Sexual and Reproductive Health and Rights at BRAC University, in partnership with University of Amsterdam (UvA) are excited to announce the launch of an innovative research project, Digital Sister for Urban Youth: Using New Technology for Effective SRHR Communication for Urban Youth of Bangladesh (Digital Sister in short).

Funded by the prestigious NWO-WOTRO Science for Global Development programme, the project is joining forces with ground-breaking technology company, Maya.com.bd, which developed the first ever anonymous online and app-based help service, Maya Apa that provides tailor-made solutions in areas of medical, legal, and psychosocial problems using the digital platform in matters of hours. The support service is free for all users, of any age.  

Because of the anonymity feature of Maya Apa, users from all around the country (and Bangladeshis living abroad), send highly personal problems which are otherwise kept secret in a society of fear and stigma, especially around the issues of sexual reproductive health, mental well-being, and bodily rights.  The Digital Sister project aims to understand the realities and challenges associated with sexual rights and reproductive health (SRHR) of especially young people in urban areas by analysing questions from Maya Apa and using it as an effective communication tool for the youth of Bangladesh.

What makes this research unique is its aim to provide insight on a population otherwise overlooked. With an overwhelming amount of public health research on poor rural populations, and an impressive track record in implementation of family planning across the country, there is now a growing demand for understanding SRHR-related behaviors of Bangladesh’s growing middle-income population – particularly urban-based adolescents and young adults.  

According to a report by the POLICY project, Bangladesh’s adolescent population (ages 15–24) was estimated at about 28 million in 2000, and is projected to increase by 21 percent to reach 35 million by 2020.  This is also the first generation of Bangladeshis to have access to affordable technological devices such as smartphones, computers, with built in Internet services. In 2013, there were over 29 million Internet users and over 100 million mobile subscribers, making Bangladesh one of the most lucrative nations for ICT-based growth and development.

Yet with a lack of SRHR education available at school, adolescents appear to be poorly informed with regard to their own sexuality, physical well-being, health, and bodies. Whatever knowledge they have been able to gather is disjointed and confused. Moreover, in addition to limited sex education, the taboo-nature of such issues and inhibited cultural attitudes towards sex also contribute to this ignorance.

That’s where Maya Apa comes in – the anonymous nature of the app has subsequently helped to remove the cultural stigma associated with asking their burning questions, decreasing the barriers that keep people from seeking access to information they crucially need. So far the platform has answered nearly 100,000 questions, with a vast majority coming from the 15-30 age group on a wide range of issues pertaining to SRHR.

The questions that have accumulated on the platform serve as an excellent database to study the SRHR-related behaviors and concerns of Bangladesh’s young people. By examining the questions, the researcher will be able to better understand the needs of this growing urban population segment. The projected strives to identify and address the gaps by providing recommendations to further improve Maya Apa, or even develop new communication tools to supplement the digital platform and other potential adolescent health policy implications that arise as a result of this research.


Stay tuned on the #VitalSigns blog for more updates from the Digital Sister project!

Exploring Lessons Learnt From CTC Worker Programmes: A Symposium

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On 12 June 2016, REACHOUT team members from all six of its working countries came under one roof for a symposium on ‘Strategies for Optimizing Close To Community (CTC) Worker Programmes to Create more Resilient and Responsive Health Systems’. As part of a larger consortium of eight partners, the sixth consortium meeting was held in Bangladesh from 6-15 June, hosted by the REACHOUT Bangladesh team, at BRAC University’s James P Grant School of Public Health (JPGSPH).

Panel presentations highlighted lessons learnt from CTC programmes in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique. From each country, we see that CTC health providers stand at the intersection of several forces – such as the community, the health system and the market. They are not only deliverers of programmes, but often also health activists, engaging the community. They are also increasingly subjected to the forces the evolving health market, and must navigate this with very little guidance.

As a result, these health workers face a range of challenges. In Kenya, for instance, the programme is confronted with high dropout rates due to financial constraints. In Malawi, a lack of senior officers makes supervision of CTC workers more difficult. Meanwhile in Bangladesh, where CTC health workers mainly tend to hard-to-reach populations and rural villages, the programme now has to adapt to provide access to healthcare in urban slums, a dynamic space with pluralistic health services.

Overall, across each country, the findings show the need to provide support on both the supply and demand side; this includes retaining staff, sustaining CTC worker motivation, addressing lack of governance, and the overall sustainability of these programmes. There also needs to be greater investment in training and tools.

Looking at the obstacles and what the future holds for these programmes is particularly crucial as we go on to address more complex health targets. However there is a lot of scope to develop and assess interventions with the potential to make improvements to CTC services. Speakers from Malawi and Kenya discussed the opportunity to incorporate the use of mobile phones to strengthen and increase accuracy in data management. In Kenya, mobile applications for training CTC workers have also been established to reinforce their capacity development efforts. These are some examples of solutions to issues that seem to similarly challenge programmes in all six countries.

REACHOUT examines the big picture across each country and across time – this will not only reveal the larger story but also help each country learn from one another and implement improvements according to their context. Bringing REACHOUT team members together to examine the findings thus far continues to help generate informed, evidence-based and context-appropriate policies for future CTC services.

As we transition from Millennium Development Goals to the next set of Sustainable Development Goals, countries striving to achieve universal health coverage are increasingly depending on CTC health services. Now more than ever, there is a need for health systems to understand the context and conditions in which these services operate in order to realise their potential.


For more information on the work REACHOUT is doing in Bangladesh, click here