Adopting workload-based staffing norms at public sector health facilities in Bangladesh: evidence from two districts.

BACKGROUND: Bangladesh's Health system is characterized by severe shortage and unequitable distribution of the formally trained health workforce. In this context, government of Bangladesh uses fixed staffing norms for its health facilities. These norms do not always reflect the actual requirement in reality. This study was conducted in public sector health facilities in two selected districts to assess the existing staffing norms with the purpose of adopting better norms and a more efficient utilization of the existing workforce. METHODS: To carry out this assessment, WHO's Workload Indicators of Staffing Need (WISN) method was applied. Selection of the two districts out of 64 and a total of 24 health facilities were made in consultation with the formally established steering committee of the Ministry of Health. Health facilities, which were performing well in serving the patients during 2016-2017, were selected. This assessment examined staffing requirement of 20 staff categories. RESULTS: Based on the computer-generated WISN results, most of the staff categories were found to have a workload pressure of Very High (seven out of 20 staff categories), followed by Extremely High (five staff categories). Two staff categories had high, three had moderately high, two normal, and one low workload. Nurses were found to be predominantly occupied with support activities (50-60% of working time), instead of actual nursing care. Regarding vacancy, if all the vacant posts were filled, understandably, the workload would reduce, but not yet sufficient to meet the existing staff requirements such as consultants, general physicians and nurses at the district and sub-district/upazila-based hospitals. CONCLUSION: The existing staffing norms fall short of the WISN staffing requirement. The results provide evidence to prompt a revisit of the staffing policies and adopt workload-based norms. This can be supplemented by reviewing the scope of practice of the staff categories in their respective health facilities. In the short term, government might consider redistributing existing workforce as per workload. In the long term, revision of staffing norms is needed to provide quality health services for all.

Trauma Care Scenarios Following Road Traffic Crashes in Bangladesh: A Scoping Review.

INTRODUCTION: We conducted a scoping review of the trauma care situation following road traffic crashes (RTCs) in Bangladesh to inform the design of a comprehensive program for mitigating associated morbidity and mortality. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis approach to select relevant articles, documents, and reports following a set of inclusion and exclusion criteria. In total, 52 articles and 8 reports and program documents were included in the analysis. We adopted a mixed studies review method for synthesizing evidence and organized information by key themes using a data extraction matrix. RESULTS: Findings revealed RTC mortality to be 15.3 per 100,000 population in 2019. Pedestrians, cyclists, and motorcyclists were the most vulnerable groups succumbing to moderate to grave injuries. We found that 81% of motorcycle victims did not use any safety device, an estimated 1,844 people per day suffered different degrees of injury, and 29 people per day became permanently disabled. The ambulance-based prehospital care operated in a disjointed and disorganized manner without standard operating procedures and dispatch structure. This disorganization and a lack of a universal communication system led to treatment delay, resulting in chronic disability for the victims. Injury-related patients occupied about 33% of hospital beds, 19% of which were RTC victims. The cost of care for these victims involved substantial out-of-pocket spending, which sometimes reached catastrophic levels. Since 2009, the management of RTCs has deteriorated with a concomitant increase in morbidity and mortality, resulting in a drain on people's lives and livelihoods. CONCLUSION: The current situation regarding post-crash care in the country, especially when RTCs are on the rise, is not compatible with reaching the SDG targets 3.6 and 11.2 or the government's stated goal of achieving universal health coverage by 2030.

A qualitative exploration of the facility-based trauma care for Road Traffic Crash patients in Bangladesh: When only numbers do not tell the whole story.

OBJECTIVE: Bangladesh is currently undergoing an epidemic of road traffic crashes (RTCs). In addition to morbidity and mortality, the economic loss from RTC as per cent of gross domestic product is comparatively higher than in countries with similar socioeconomic conditions. However, trauma care remained poorly developed as a specialty and service delivery mechanism. This study aimed to examine the current situation of in-hospital trauma care after RTCs to inform the design of a comprehensive service for Bangladesh. DESIGN, SETTING AND PARTICIPANTS: This qualitative study attempted to elicit stakeholders' perceptions and experiences of managing RTCs through in-depth interviews and focus group discussions. Three districts and Dhaka city were selected based on the frequency of occurrence of RTCs. Fifteen in-depth interviews and 5 focus group discussions were conducted with 38 RTC patients, their relatives and community members in the catchment areas of 11 facilities managing trauma patients. Key informant interviews were conducted with 21 service providers and 17 key stakeholders/policy-makers. RESULTS: Hospital-based trauma care was generally poor in primary and secondary-level facilities. There was no triage area or triage protocol in the emergency rooms, no trained staff for trauma care, no dedicated RTC patient register and scarce life-saving equipment. Only in Dhaka-based tertiary hospitals was trauma care prioritised. These hospitals follow Advanced Trauma Life Support guidelines and maintain an RTC logbook. Emergency diagnostic services were not always available in the hospitals. Most RTC patients were males; the female participants were additionally vulnerable to physical and mental trauma. Affected people avoided taking legal action considering it a lengthy, complicated and ultimately ineffective process. CONCLUSION: The trauma care services currently available in the studied health facilities are very rudimentary and without the necessary human and financial resources. This needs urgent attention from policymakers, programmers and practitioners to reduce morbidity and mortality from the current epidemic of RTCs in Bangladesh.

The Implementation of National Action Plan (NAP) on Antimicrobial Resistance (AMR) in Bangladesh: Challenges and Lessons Learned from a Cross-Sectional Qualitative Study.

This study explored the current situation of the National Action Plan (NAP) on Antimicrobial Resistance (AMR) implementation in Bangladesh and examined how different sectors (human, animal, and environment) addressed the AMR problem in policy and practice, as well as associated challenges and barriers to identifying policy lessons and practices. Informed by a rapid review of the available literature and following the World Health Organization (WHO) AMR situation analysis framework, a guideline was developed to conduct in-depth interviews with selected stakeholders from January to December 2021. Data were analysed using an adapted version of Anderson's governance framework. Findings reveal the absence of required inter-sectoral coordination essential to a multisectoral approach. There was substantial coordination between the human health and livestock/fisheries sectors, but the environment sector was conspicuously absent. The government initiated some hospital-based awareness programs and surveillance activities, yet no national Monitoring and Evaluation (M&E) framework was established for NAP activities. Progress of implementation was slow, constrained by the shortage of a trained health workforce and financial resources, as well as the COVID-19 pandemic. To summarise, five years into the development of the NAP in Bangladesh, its implementation is not up to the level that the urgency of the situation requires. The policy and practice need to be cognisant of this fact and do the needful things to avoid a catastrophe.

Exploring the knowledge, attitudes, practices and lived experiences of frontline health workers in the times of COVID-19 : a qualitative study from Bangladesh.

OBJECTIVE: This study explored Frontline Health Workers' (FLWs) knowledge, attitude and practice (KAP) on COVID-19 and their lived experiences, in both their personal and work lives, at the early stage of the pandemic in Bangladesh. DESIGN, SETTING AND PARTICIPANTS: This was a qualitative study conducted through telephone interviews in May 2020. A total of 41 FLWs including physicians, nurses, paramedics, community healthcare workers and hospital support staff from 34 public and private facilities of both urban and rural parts of Bangladesh participated in the interview. A purposive sampling technique supplemented by a snowball sampling method was followed to select the participants. The in-depth interviews followed a semi-structured interview guide, and we applied the thematic analysis method for the qualitative data analysis. FINDINGS: Except physicians, the FLWs did not receive any institutional training on COVID-19, including its prevention and management, in most instances. Also, they had no training in the use of personal protective equipment (PPE). Their common source of knowledge was the different websites or social media platforms. The FLWs were at risk while delivering services because patients were found to hide histories and not maintaining safety rules, including physical distancing. Moreover, inadequate supply of PPE, fear of getting infected, risk to family members and ostracisation by the neighbours were mentioned to be quite common by them. This situation eventually led to the development of mental stress and anxiety; however, they tried to cope up with this dire situation and attend to the call of humanity. CONCLUSION: The uncertain work environment during the COVID-19 pandemic simultaneously affected FLWs' physical and emotional health in Bangladesh. However, they showed professional devotion in overcoming such obstacles and continued to deliver essential services. This could be further facilitated by a quick and targeted training package on COVID-19, and the provision of supplies for delivering services with appropriate safety precautions.

Reactions to the media coverage during the first wave of COVID-19 in Bangladesh.

BACKGROUND: The news media play a critical role in disseminating accurate and reliable information during an outbreak like COVID-19, especially in LMICs. Studying how people react and reflect on the information provided and how it affects their trust in health systems is essential for effective risk communication. This study was undertaken to explore and analyse newspaper readers' reactions to the unfolding news of the COVID-19 outbreak in Bangladesh and how this affected and shaped their compliance with the mitigation measures advised by the Government. METHODS: We collected readers' comments on relevant news and features on the COVID-19 outbreak (n = 1,055) which were posted in the online versions of the four top circulating Bangla newspapers and one online news portal published during Jan.-Apr. 2020. A search protocol was developed and a team of three researchers searched and extracted data for content analysis according to some pre-determined study themes. RESULTS: Data analysis revealed several characteristics with implications for risk-communication: a faith-based and fatalistic attitude to the unfolding pandemic, a "denial" syndrome in the initial stage, a returning expatriate-bashing for specific countries, and a concern about the safety of the frontline health workers. The readers were resentful of the all-pervasive corruption in the health sector even in times of a pandemic and the Government's poorly coordinated, fragmented, and delayed COVID-19 response. The pandemic severely shook their trust in the already weak health system and perceived it to be incompetent, corrupt, and non-responsive. They had deplorable personal and family experiences while seeking treatment for COVID-19 patients. Expert committees were formed to advise the Government, but few recommendations were implemented on the ground. This helpless scenario made people sharply critical of the political leadership, especially for the failure of providing stewardship at the moment of crisis. CONCLUSIONS: The COVID-19 related information reaching the people, including misinformation, disinformation, and rumours was equivocal in the early months of the pandemic and failed to build the trust and transparency that is necessary for an inclusive response across constituencies. The Government should pay attention and weightage to people's perceptions about its COVID-19 response and take appropriate measures to re-build trust for implementing pandemic control measures.

Health, illness and healthcare-seeking behaviour of the street dwellers of Dhaka City, Bangladesh: qualitative exploratory study.

OBJECTIVE: This study explored the illness experiences and healthcare-seeking behaviour of a cross-section of street dwellers of Dhaka City for designing a customised intervention. DESIGN: A qualitative exploratory study of a sample of street dwellers of Dhaka City. SETTING: Samples were taken from three purposively selected spots of Dhaka City with a high concentration of the target population. PARTICIPANTS: Fifteen in-depth interviews and six informal group discussions with 40 street dwellers (≥18 years), and key informant interviews with service providers (n=6) and policymakers (n=3) were conducted during January-June 2019 to elicit necessary data. PRIMARY OUTCOME MEASURES: Qualitative narrative of illness experiences of the sampled street dwellers, relevant healthcare-seeking behaviour and experiences of interactions with health systems. RESULTS: We focused on three main themes, namely, reported illnesses, relevant healthcare-seeking behaviour and health system experiences of the street dwellers. Findings reveal that most of the street dwellers suffered from fever and respiratory illnesses in the last 6 months; however, a majority did not visit formal facilities. They preferred visiting retail drug shops for advice and treatment or waited for self-recovery. Formal facilities were visited only when treatment from drug shops failed to cure them or they suffered serious illnesses or traumatic injury. The reproductive-age women did not seek pregnancy care and most deliveries took place in the street dwellings. Lack of awareness, financial constraints and fear of visiting formal facilities were some of the reasons mentioned. Those who visited formal facilities faced barriers like the cost of medicines and diagnostic tests, long waiting time and opportunity cost. CONCLUSIONS: The street dwellers lacked access to formal health systems for needed services as the latter lags far behind to outreach this extremely vulnerable population. What they need is explicit targeting with a customised package of services based on their illness profile, at a time and place convenient to them with minimum or no cost implications.

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region.

Governance failures undermine efforts to achieve universal health coverage and improve health in low- and middle-income countries by decreasing efficiency and equity. Punitive measures to improve governance are largely ineffective. Social accountability strategies are perceived to enhance transparency and accountability through bottom-up approaches, but their effectiveness has not been explored comprehensively in the health systems of low- and middle-income countries in south and Southeast Asia where these strategies have been promoted. We conducted a narrative literature review to explore innovative social accountability approaches in Bangladesh, Bhutan, India, Indonesia, the Maldives, Myanmar and Nepal spanning the period 2007-August 2017, searching PubMed, Scopus and Google Scholar. To augment this, we also performed additional PubMed and Google Scholar searches (September 2017-December 2019) to identify recent papers, resulting in 38 documents (24 peer-reviewed articles and 14 grey sources), which we reviewed. Findings were analysed using framework analysis and categorized into three major themes: transparency/governance (eight), accountability (11) and community participation (five) papers. The majority of the reviewed approaches were implemented in Bangladesh, India and Nepal. The interventions differed on context (geographical to social), range (boarder reform to specific approaches), actors (public to private) and levels (community-specific to system level). The initiatives were associated with a variety of positive outcomes (e.g. improved monitoring, resource mobilization, service provision plus as a bridge between the engaged community and the health system), yet the evidence is inconclusive as to the extent that these influence health outcomes and access to health care. The review shows that there is no common blueprint which makes accountability mechanisms viable and effective; the effectiveness of these initiatives depended largely on context, capacity, information, spectrum of actor involvement, independence from power agendas and leadership. Major challenges that undermined effective implementation include lack of capacity, poor commitment and design and insufficient community participation.

Assessment of staffing needs for physicians and nurses at Upazila health complexes in Bangladesh using WHO workload indicators of staffing need (WISN) method.

OBJECTIVE: This study aimed to assess the current workload and staffing need of physicians and nurses for delivering optimum healthcare services at the Upazila Health Complexes (UpHCs) in Bangladesh. DESIGN: Mixed-methods, combining qualitative (eg, document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey). SETTING: Study was conducted in 24 health facilities of Bangladesh. However, UpHCs being the nucleus of primary healthcare in Bangladesh, this manuscript limits itself to reporting the findings from the providers at four UpHCs under this project. PARTICIPANTS: 18 physicians and 51 nurses, males and females. PRIMARY OUTCOME MEASURES: Workload components were defined based on inputs from five experts, refined by nine service providers. Using WHO Workload Indicator of Staffing Need (WISN) software, standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference and WISN ratio were calculated. RESULTS: Physicians have very high (WISN ratio 0.43) and nurse high (WISN ratio 0.69) workload pressure. 50% of nurses' time are occupied with support activities, instead of nursing care. There are different workloads among the same staff category in different health facilities. If only the vacant posts are filled, the workload is reduced. In fact, sanctioned number of physicians and nurses is more than actual need. CONCLUSIONS: It is evident that high workload pressures prevail for physicians and nurses at the UpHCs. This reveals high demand for these health workforces in the respective subdistricts. WISN method can aid the policy-makers in optimising utilisation of existing human resources. Therefore, the government should adopt flexible health workforce planning and recruitment policy to manage the patient load and disease burden. WISN should, thus, be incorporated as a planning tool for health managers. There should be a regular review of health workforce management decisions, and these should be amended based on periodic reviews.