International Journal of Health Care Quality Assurance Introducing modern technology to promote transparency in health services Mohammad Shafiqul Islam
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To cite this document: Mohammad Shafiqul Islam , (2015),"Introducing modern technology to promote transparency in health services", International Journal of Health Care Quality Assurance, Vol. 28 Iss 6 pp. 611 - 620 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2015-0016 Downloaded on: 30 January 2016, At: 11:46 (PT) References: this document contains references to 28 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 138 times since 2015*
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Introducing modern technology to promote transparency in health services Mohammad Shafiqul Islam School of Environment, Flinders University, Adelaide, Australia
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Abstract
Transparency in health services 611 Received 6 September 2014 Revised 31 January 2015 17 March 2015 Accepted 6 May 2015
Purpose – Quantitative indicators show that Bangladeshi maternal and child healthcare is progressing satisfactorily. However, healthcare quality is still inadequate. It is hypothesised that modern technology enhances healthcare quality. Therefore, the purpose of this paper is to investigate how modern technology such as electronic record keeping and the internet can contribute to enhancing Bangladeshi healthcare quality. This study also explores how socio-economic and political factors affect the healthcare quality. Design/methodology/approach – This paper is based on a qualitative case study involving 68 in-depth interviews with healthcare professionals, elected representatives, local informants and five focus group discussions with healthcare service users to understand technology’s effect on health service quality. The study has been conducted in one rural and one urban service organisations to understand how various factors contribute differently to healthcare quality. Findings – The findings show that modern technology, such as the internet and electronic devices for record keeping, contribute significantly to enhancing health service transparency, which in turn leads to quality health and family planning services. The findings also show that information and communication technology (ICT) is an effective mechanism for reducing corruption and promoting transparency. However, resource constraints impact adversely on the introduction of technology, which leads to less transparent healthcare. Progress in education and general socio-economic conditions makes it suitable to enhance ICT usage, which could lead to healthcare transparency, but political and bureaucratic factors pose a major challenge to ensure transparency. Practical implications – This paper can be a useful guide for promoting governance and healthcare quality in developing countries including Bangladesh. It analyses the ICT challenges that healthcare staff face when promoting transparent healthcare. Originality/value – This paper provides a deeper understanding of transparency and healthcare quality in an ICT context using empirical data, which has not been explored in Bangladesh. This critical thinking is useful for policy makers and healthcare practitioners for promoting health service quality. Keywords Bangladesh, Communication technology, Healthcare quality, Transparency, Access to information, Socio-economic factors, Political factors Paper type Research paper
Introduction Bangladesh has made enormous progress in maternal and child health, life expectancy and other demographic measures. It has the lowest fertility rate in South Asia, despite spending less money on healthcare than its neighbouring countries. The World Bank (2013) shows that life expectancy at birth in Bangladesh has increased from 45 years in 1970 to 70 in 2013, the maternal mortality ratio has declined from 322 per 100,000 live births in 2001 to 170 in 2013 and the infant mortality rate has declined from 94 per 1,000 live births in 1990 to 33 in 2013. These indicators show significant improvement over time. However, the Bangladesh Health Facility Survey (BHFS, 2012) shows that The author is grateful to the respondents for providing valuable information. The academic supervisors are thanked for their valuable comments. The author is indebted to Flinders University, Australia for providing a PhD scholarship.
International Journal of Health Care Quality Assurance Vol. 28 No. 6, 2015 pp. 611-620 © Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-01-2015-0016
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health service quality in the country is unsatisfactory. The BHFS study also identifies some contextual and demographic factors for understanding poor governance and inadequate healthcare delivery in the country: persistent high poverty rates; poor nutritional status; inadequate service accessibility; and rapid unplanned urbanisation (BHFS, 2012). Additionally, health sector resource availability has remained much lower than the minimum expenditure required for essential health services. The survey, however, points out that quality health services require managerial efficiency, improved supervision, better incentives for providers and non-government health service organisation involvement (BHFS, 2012). Therefore, good governance, through promoting transparency can significantly enhance quality healthcare comprising accessibility, affordability and good quality. One aspect in enhancing transparency and quality healthcare is information and communication technology (ICT). This study, therefore, endeavours to look at how management, resources and socio-economic factors contribute to ICT and transparency and to what extent they affect Bangladesh health service quality. Background The health system in Bangladesh is highly centralised. The Ministry of Health and Family Welfare staff are responsible for administrating, monitoring and coordinating field-level health service organisations. Figure 1 shows that the Bangladeshi health system is hierarchical. The top health service organisations are tertiary hospitals, e.g., medical colleges and hospitals provide specialised healthcare including primary health services. But Upazila (sub-district) hospitals and their subordinate health service agencies are able to provide only primary healthcare because hospitals have inadequate medical equipment and staffing for specialised services. Ahmed et al. (2013) show that Bangladesh has 459 hospitals at the Upazila level and below with 18,340 beds and 11,816 community clinics. These organisations provide primary healthcare for most people. There are also many private and non-government (NGO) health service organisations that provide primary healthcare including specialised health services all over Bangladesh. Bangladesh has insufficient skilled health workers including physicians, nurses and dentists. Ahmed et al. (2013) show that in Bangladesh, there are 7.7 physicians, nurses and dentists and 9.6 community health workers per 10,000 population. Overall, only 50.5 per cent of specialist positions and 55.8 per cent of general physician positions are filled. The Upazila health complex (UHC) has 48.3 per cent consultant positions and 75.1 per cent general physician positions filled. The proportion of nurse positions filled is about 86 per cent for district hospitals, 78 per cent for UHCs and 62 per cent for
Tertiary hospital District hospital
Upazila health complex Union health and family welfare centre Community clinic
Figure 1. Hierarchical public sector provision
Village dispensary
Source: Ahmed et al. (2013)
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maternal and child welfare centres. Additionally, UHCs have midwifery professionals and most sanctioned positions are filled (BHFS, 2012). The WHO (2008) estimates show that an additional 2.4 million doctors, nurses and midwives are required to meet global health development goals. Another WHO (2010b) estimate shows that 49 low-income countries have 23 doctors, nurses and midwives per 10,000 population. Margolis et al. (2011) state that WHO has determined that 2.3 doctors, nurses and midwives per 1,000 people is the minimum threshold needed to adequately cover the population with essential health services. Margolis also shows that Bangladesh still has a substantial crisis in the health workforce, which affects healthcare quality. Osman (2008) states that health sector financial sources include households, government revenue, donors and community through non-governmental organisations (NGOs). She also states that the household’s finance chief source is out of pocket expenditure, which accounts for about 47.3 per cent of the total health expenditure. Of the reminder, 26.6 per cent comes from government revenue, 25.8 per cent from external donors and 2 per cent from community NGO sources. Additionally, she argues that a donor consortium, which includes international development organisations led by the World Bank provides financial and technical assistance continuously to the health sector for enhancing health service governance. Health service delivery improvements depend on government finance allocation. The Annual Development Programme (ADP, 2010) report shows that the government’s allocation to the Bangladesh health sector is relatively poor compared to neighbouring countries. Osman (2004) demonstrates that health expenditure per capita is $20 in India and $29 in Sri Lanka whereas it is $12 per capita in Bangladesh. Studies show that politics and bureaucracy significantly influence health policies (Osman, 2008; Jahan, 2003; Gwin and Buse, 1998; WHO, 2010a). However, other studies show that national health policies, including various plans and programmes, are dominated by health professionals, particularly the Bangladesh Medical Association for enhancing self-interest rather than for the common people’s benefit (Rabbani, 2010; Hossain and Osman, 2007). Additionally, Jahan’s (2003) study shows that some factors such as poor medical equipment, elite influence and inadequate initiatives invite limited participation, including the civil society, thus leading to weak health policies and programmes. Other studies show that external resources influence health-policy formulation (Gwin and Buse, 1998; ICDDR, 2006; Jahan, 2003). All these studies looked at various health-policy formulation weaknesses with reference to politics, bureaucracy and resources, but they neglected transparency issues and healthcare quality. Although resource constraints such as an insufficient skilled workforce and finances affect health-policy implementation in Bangladesh (WHO, 2010a). Planning Commission members argues that poor supervision and monitoring cause poor health-policy implementation (Planning Commission, 2009). However, the ICDDR (2006) report identifies organisational, financial and technological problems when implementing health policy. Studies show that human resources, inadequate facilities, socio-economic disparities, power and politics, poor knowledge and education affect participation, which lead to poor implementation (Siddiquee, 1997; Mahmud, 2004; Islam and Ullah, 2009). Sen (2013) addressed four aspects that successfully advance health in Bangladesh: (1) women’s active role in society and economy, which has been a productive move in Bangladesh; (2) multiplicity of instruments in public and private sectors promote rapid social advancement;
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(3) intelligently using community-based approaches in health services; and (4) a country’s improved ability to face natural disasters. All these factors contribute to successful health progress in Bangladesh. In fact, the studies reviewed above found that poor health-policy implementation includes: resource constraints, managerial inefficiency, over-centralised health system, poor technology and socio-economic and political barriers. However, transparency when enhancing governance has not been addressed. Further, although health service quality is important for enhancing Bangladeshi quality of life, there is not a single study that addresses introducing technology for enhancing transparency. Therefore, we aim to: examine how technology can promote transparency and health service quality; explore to what extent various socio-economic factors may affect healthcare quality and how these factors work differently in rural and urban health service organisations. Methodology Understanding complex social problems concerning transparency’s impact on implementing health policies can best be obtained by using interpretative qualitative research methods, such as open-ended interviews, focus group discussions and document analysis ( Janesick, 2011; Yin, 1994). Baum (1995) argues that examining governance (transparency) effect through various socio-economic and political factors, particularly in public healthcare, are suitable for conducting qualitative case studies. Additionally, she shows that governance impact on health professional activity, including communities and individuals, are best suited to qualitative case studies (Baum, 1995). Our study is based on 68 in-depth interviews and five focus group discussions in the two Bangladesh areas: Chhatak and Savar sub-districts. In-depth interviews were conducted with eight national-level respondents, 37 health professionals, seven local elected representatives and 16 local informants. These respondents were selected because they are crucial informants in the study and are responsible for promoting governance and healthcare quality in selected research locations. The respondents were selected by purposive and snowball sampling techniques for understanding transparency impact on healthcare delivery. The interviews were based on semi-structured questionnaires prepared according to respondents’ duties and responsibilities. The questionnaires were administered to respondents for gathering data about introducing technology to enhance transparency and healthcare quality. Interview data were interpreted using Nvivo software for assessing the results and to understand transparency and healthcare quality. Five focus group discussions (39 informants) were conducted with staff from randomly selected health service organisations to collect service user views to give understanding about transparency and how socio-economic factors contribute to promoting healthcare quality. This enables us to understand direct community perceptions on enhancing transparency and healthcare quality. Moreover, secondary data are from health departments were used for understanding the Bangladesh health system and web-based journal articles were used for the literature review. Findings Internet access Upazila health service organisations now have internet connections that enables staff to collect useful health service information, which significantly improves health services, e.g., if the government announces a Vitamin A camp and puts this announcement on the Ministry of Health web site then field office staff, i.e., Upazila Council (UHC) are able to get this information via the internet and know what
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items will be covered in the programme. Such facility enhances healthcare information management and transparency. The Upazila health and family planning officer (UHFPO), Savar, points out that internet accessibility helps promote online services, e.g., annual report, health updates, basic health information, etc., more efficiently. Another use of new technology is when an authority up the command chain sends information to local officials thereby making the information transparent and quickly available. However, technological equipment and materials are not always available at UHC for providing health services. The UHC staff have limited access to the internet and computers and also insufficient skilled technicians. This affects health service quality. Despite this limitation, Savar staff are able to use the internet to organise meetings. The resident medical officer informed the researcher that monthly meetings are organised online for all medical officers and other staff. Figure 2 shows that Savar office staff are able to communicate with other organisations using faxes, which assists rapid information collection. Savar family planning staff are up-to-date regarding using the internet for health service delivery. The family planning officer states that the Prime Minister’s office has opened a web site to make service related information available. In this web site, family planning department staff have been ranked first by the government based on internet performance. Basic education and health services provided via the internet are supervised by the ICT staff.
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Mobile phones Figure 3 shows that mobile phones improve communication for promoting accessibility and health service affordability, and ensures transparency. Mobile phones are used for organising field-level health programmes; e.g., a health inspector might send a message
Internet Facilities
Making information available with regard to material and medicine, health report, basic health information, e-mail service
Promotes Transparency
Accessibility Affordability Service efficiency
Organising health programme
Importance of mobile phone
Figure 2. Internet facility promotes transparency and healthcare quality
Improved Transparency
Connecting people Quality of health care: Accessibility Affordability
Emergency services Hospital services i Supervision
Figure 3. Mobile phone impact on transparency and healthcare quality
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via a mobile phone to schedule grassroots health programmes and expand the immunisation programme (EPI) to make services available to clients. Some healthcare providers are able to use smartphones to make communication quicker and easier by sending health service messages. Service users claim that sometimes field workers cannot transmit information quickly to people living in remote areas. Consequently, mobile phones play a significant role when informing service users. Additionally, field workers have immunised children’s mobile phone numbers, which enables them to communicate effectively with families and practitioners. Most people in remote areas have a mobile phone, which enables people to connect with service users easily and rapidly. One assistant health inspector pointed out that a mobile phone is any easy way to mobilise people generally and service users particularly. Healthcare providers can send their messages rapidly; e.g., it is an easy way to contact healthcare staff and take steps quickly through providing adequate medical service and advice. Health workers can refer emergency cases to hospital via mobile phones. A local reporter in Chhatak believes that such referrals through mobile phones reduce maternal and child mortality, particularly in the remote areas. Mobile phones are used to communicate with community health workers providing emergency healthcare by bringing people from rural to urban localities. This enables health workers to promote maternal and child health through emergency services; e.g., mobile phones enable women to actively participate in their and their family’s healthcare, which demonstrates that mobile phones facilitate communication and decision making in reproductive health (Desouza et al., 2014). Service users state that mobile phones improve awareness among women through communicating with healthcare providers, which empowers and helps decision making in the family. Every UHC has a mobile phone provided by the head office for enhancing supervision and for investigating doctor availability. Sometimes head office staff call to a UHC medical officer to find out his/her position, presence and the activities. Additionally, UHC staff provide medical services through a mobile phone; numbers are available to hospital staff so that clients have access to services. A mobile phone is carried by a doctor on duty who provides health services such medicines advice in accordance with client needs. Additionally, community health workers can communicate with service users who live away and have difficulty accessing a hospital. Mobile phones enable health workers to provide useful medical suggestions and primary health services. Field inspectors state that extra allowances for mobile recharge calls can improve accessibility and promote healthcare delivery. One family planning inspector points out that every employee should have a mobile phone and that the government should pay for calls related to official matters to promote communication and enhance healthcare accessibility; e.g., it is a mandatory duty to record a pregnant women’s mobile number to monitor their health condition. Health workers sometime provide emergency services for pregnant women or bring them to the nearest health centre by communicating via mobile phones. Health workers claim that providing such services requires that a phone allowance must be paid by the government because it is a crucial healthcare delivery. Computer improves administrative efficiency Computers can make enhance quality health by making them more accessible. Sub-district health service organisation staff have limited computer access for performing administrative work. Computers help to generate reports for and enable staff to communicate via e-mail. Savar UHC EPI department staff use computer software provided by the government to calculate data easily, quickly and appropriately. Respondents point out that computers are
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available only for administrative activities. Healthcare providers at field level have limited computer facilities, therefore, they create their field report manually. Field officials are only able to send hard copies to higher authorities. Respondents argue that computers make the administrative jobs easier and convenient, but no patient record has been preserved through computers. The UHFPO argues that the government has a scheme to provide sufficient computers and skilled staff gradually to enhance quality health services. Implementation is slow owing to bureaucratic complexity and weak political commitment.
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Electronic media enhances transparency Electronic media plays a significant role in enhancing health services transparency. It provides useful information simply and easily. Television broadcasts expand the health programmes. Such advertisement contributes to enhancing public awareness so that people receive information quickly. The private Channel i and the Bangladesh state-owned television services broadcast family planning, maternal and child health programmes. Consequently, family planning awareness has improved significantly. Radio channels broadcast small dramas that promote health education awareness and family planning activities. Family planning staff also organise documentary films that promote awareness. Additionally, newspapers publish family planning methods and circulate important maternal and child health service information. Electronic devices in UHC can have an important effect on information accessibility through publicising hospital information and health awareness programmes. Savar medical officers argue that electronic devices can be useful mechanisms for providing information regarding maternal and child health and for patients seeking hospital services. Patients also learn about health information while waiting for health services. However, this facility is not available to public health service organisations, which limits access to information and reduces transparency. e-Governance promotes health service quality Technological innovations such as internet and electronic devices promote e-governance and health service quality. e-Governance is a useful mechanism for promoting quality health service delivery reducing corruption by increasing transparency within public organisations (Hossan and Bartram, 2010) (Figure 4). But, in reality, poor technology and inadequate resources limit e-governance and service delivery at UHC and the Union Sub Centre. Union Parishad information centre staff should provide healthcare information but unfortunately the responsible staff are mostly absent. Additionally, transparency requires updated and enriched information for making services more people centred. Some health service information has not been updated, which limits healthcare accessibility.
Provide quality of health care
Promote Transparency
e-Governance
Reduce Corruption
Figure 4. e-Governance impact on health service delivery
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Another matter is a skilled workforce for promoting e-governance. Managers should be providing technology training so that staff can provide efficient services. One nationallevel informant argues that service users do not trust e-services because they are not familiar with the services. A document without a signature reduces confidence. There is poor understanding about modern technology and its application because people are not sufficiently educated to use this technology. Society is not that advanced and is still developing to adapt modern technology and services through technological innovations. Confidence needs to be developed through promoting technology education and awareness so that its application for promoting quality healthcare is understood. Technological advancement in the UHCs Service demand has grown owing to new technology; however, UHC staff still uses analogue machines for medical examinations and reporting. These machines do not produce efficient reports to meet demand. Currently, the government has digital machines at district hospital level and at medical colleges. The government is planning to supply a digital x-ray machine for medical examination at every UHC to make health services accessible and affordable. Respondents argue that their UHC has an old x-ray machine, but it is working therefore, service providers are satisfied. Savar UHC has an operating theatre and provides efficient caesarean delivery but it is not available in Chhatak Upazila. No modern technology is available in Savar hospital. But this hospital has some equipment which is rare in a rural Upazila hospital. Alternatively, the government provided a laptop for the Chhatak medical technologist EPI, but not to Savar UHC. So, technological enhancement is different from one organisation to another, which depends on government policy and demand in a specific locality. Generally, departments have limited technology for checking new born health children and their mothers. e-Services have not been developed at the Upazila level. People, therefore, do not search for information. The directorate general office is currently planning to introduce e-medicine services through new software. But it is not popular because people have no understanding. National respondents argue that technology is misused at UHC because education and understanding is lacking. Most respondents argue that this wastes government resources. One respondent claims that many development activities have been done through technological devices; e.g., the family planning directorate has a section about management information system, which operates through online services. Upazila staff also communicates using online services. Family planning staff have a laptop at every union level and have software for promoting healthcare. This scheme strengthens information management that enhances quality healthcare. Family planning staff allocate money for enhancing technology from a development budget. But a local reporter argues that ICT is still in its initial stages and improved outcome through technology is far away. Moreover, the government invests money but it is not used efficiently. Consequently, achievement is limited and is invisible. Conclusion Bangladesh has made remarkable progress with its maternal and child health. However, technology for promoting governance and health service delivery is limited. Field data demonstrate that technological innovations have not enhanced service quality. Therefore, adequate transparency for promoting good governance is still a challenge in health service organisations. Promoting e-governance at UHC level requires adequate budgets and skilled staff. Coordination among government and
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NGOs is essential to promote e-governance and transparency. The ICT policy, therefore, should be enhanced for wider use so that transparent healthcare can be ensured. Additionally, adequate decentralised health systems can influence transparency and health service delivery. References Ahmed, S.M., Evans, T.G., Standing, H. and Mahmud, S. (2013), “Harnessing pluralism for better health in Bangladesh: innovation for universal health coverage 2”, The Lancet, Vol. 382 No. 9906, pp. 1746-1755. Annual Development Programme (ADP) (2010), “Annual Development Programme (ADP) 201011”, Planning Division, Ministry of Planning, Government of the People’s Republic of Bangladesh, available at: www.plandiv.gov.bd (accessed 20 August 2014). Bangladesh Health Facility Survey (BHFS) (2012), “Bangladesh Health Facility Surve”, revised final report, University of South Carolina, Columbia, SC, February, and ACPR, Dhaka, through a subcontract with Tulane University, New Orleans, LA. Baum, F. (1995), “Researching public health: behind the qualitative-quantitative methodological debate”, Journal of Social Science Medicine, Vol. 40 No. 4, pp. 459-468. Desouza, S.I., Rashmi, M.R., Vasanthi, A.P., Joseph, S.M. and Rodrigues, R. (2014), “Mobile phones: the next step towards healthcare delivery in rural India”, Plos One, Vol. 9 No. 8, pp. 1-9. Gwin, C. and Buse, K. (1998), “The world bank and global cooperation in health: the case of Bangladesh”, The Lancet, Vol. 351 No. 9103, pp. 665-669. Hossain, N. and Osman, F. (2007), “Politics and governance in the social sectors in Bangladesh, 19912006”, Research Monograph Series No. 34, Research and Evaluation Division, BRAC, Dhaka. Hossan, C. and Bartram, T. (2010), “The battle against corruption and inefficiency with the help of e-government in Bangladesh”, Electronic Government, An International Journal, Vol. 7 No. 1, pp. 89-100. ICDDR (2006), “Annual report-2006”, International Centre for Diarrhoeal Disease Research, Mohakhali. Islam, M.S. and Ullah, M.W. (2009), “People’s participation in health services: a study of Bangladesh’s rural health complex”, Working Paper Series, Bangladesh Development Research Center, Virginia, pp. 1-23. Jahan, R. (2003), “Restructuring the health system: experiences of advocates for gender equity in Bangladesh”, Reproductive Health Matters, Vol. 11 No. 21, pp. 183-191. Janesick, V.J. (2011), Stretching’ Exercise for Quality Researchers, 3rd ed., University of South Florida, SAGE Publications, London. Mahmud, S. (2004), “Citizen participation in the health sector in rural Bangladesh: perceptions and reality”, IDS Bulletin, Vol. 35 No. 2 pp. 11-18. Margolis, S.P., Crystal, C.M. and Noronha, S. (2011), “Technical brief: population growth and the global health workforce crisis”, Capacity Plus: saving health workers, saving lives, Geneva, available at: www.capacityplus.org (accessed 20 September 2014). Osman, F.A. (2004), Policy Making in Bangladesh – A Study of the Health Policy Process, 1st ed., AH Development Publishing House, Dhaka. Osman, F.A. (2008), “Health policy, programmes and system in Bangladesh: achievements and challenges”, South Asian Survey, Vol. 15 No. 2, pp. 263-288. Planning Commission (2009), “The millennium development goals (MDGs)”, progress report 2009, General Economic Division, available at: www.plancomm.gov.bd.mdg_report2009.asp (accessed 25 February 2012).
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Rabbani, M.G. (2010), “Agenda setting on community health in Bangladesh”, master thesis, Department of General and Continuing Education, North South University, Dhaka. Sen, A. (2013), “What’s happening in Bangladesh?”, The Lancet, Vol. 382 No. 9909, pp. 1966-1968, available at: www.thelancet.com (accessed 28 November 2013). Siddiquee, N.A. (1997), Decentralization and Development in Bangladesh – Theory and Practice, 1st ed., University Press Limited, Dhaka. WHO (2008), Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guideline, WHO, Geneva. WHO (2010a), The World Health Report, Health System Financing: The Path to Universal Coverage, WHO, Geneva. WHO (2010b), “Health workforce: achieving the health related MDGs”, available at: www.who.int/ hrh/workforce_mdgs/en/ (accessed 15 August 2014). World Bank (2013), “Country report on health, Bangladesh”, available at: http://data.worldbank. org/country/banagladesh (accessed 8 July 2014). Yin, R.K. (1994), Case Study Research – Design and Methods, Applied Social Research Method Series, 2nd ed., Vol. 5, Sage Publications, London. Further reading Afzal, N. and Zainab, B. (2012), “Determinants and status of vaccination in Bangladesh”, Dhaka University Journal of Science, Vol.60 No.1, pp. 47-51. Quaiyaum, M.A., Gazi, R., Khan, A.I., Uddin, J., Islam, M., Ahmed, F. and Saha, N.C. (2011), “Programmatic aspects of dropouts in child vaccination in Bangladesh: findings from a prospective study”, Asia-Pacific Journal of Public Health, Vol. 23 No. 2, pp. 141-150. WHO (2013), Global Action Vaccine Action Plan 2011-2020, WHO, Geneva. Corresponding author Mohammad Shafiqul Islam can be contacted at: [email protected]
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To cite this document: Mohammad Shafiqul Islam , (2015),"Introducing modern technology to promote transparency in health services", International Journal of Health Care Quality Assurance, Vol. 28 Iss 6 pp. 611 - 620 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2015-0016 Downloaded on: 30 January 2016, At: 11:46 (PT) References: this document contains references to 28 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 138 times since 2015*
Users who downloaded this article also downloaded: Geneve M. Allison, Bernard Weigel, Christina Holcroft, (2015),"Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?", International Journal of Health Care Quality Assurance, Vol. 28 Iss 6 pp. 564-573 http://dx.doi.org/10.1108/ IJHCQA-12-2014-0113 Aaron Gazley, Adam Hunt, Lachlan McLaren, (2015),"The effects of location-based-services on consumer purchase intention at point of purchase", European Journal of Marketing, Vol. 49 Iss 9/10 pp. 1686-1708 http://dx.doi.org/10.1108/EJM-01-2014-0012 Thomas Lager, Sven-Åke Hörte, (2002),"Success factors for improvement and innovation of process technology in process industry", Integrated Manufacturing Systems, Vol. 13 Iss 3 pp. 158-164 http:// dx.doi.org/10.1108/09576060210416607
Access to this document was granted through an Emerald subscription provided by emeraldsrm:397875 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.
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*Related content and download information correct at time of download.
The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm
Introducing modern technology to promote transparency in health services Mohammad Shafiqul Islam School of Environment, Flinders University, Adelaide, Australia
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Abstract
Transparency in health services 611 Received 6 September 2014 Revised 31 January 2015 17 March 2015 Accepted 6 May 2015
Purpose – Quantitative indicators show that Bangladeshi maternal and child healthcare is progressing satisfactorily. However, healthcare quality is still inadequate. It is hypothesised that modern technology enhances healthcare quality. Therefore, the purpose of this paper is to investigate how modern technology such as electronic record keeping and the internet can contribute to enhancing Bangladeshi healthcare quality. This study also explores how socio-economic and political factors affect the healthcare quality. Design/methodology/approach – This paper is based on a qualitative case study involving 68 in-depth interviews with healthcare professionals, elected representatives, local informants and five focus group discussions with healthcare service users to understand technology’s effect on health service quality. The study has been conducted in one rural and one urban service organisations to understand how various factors contribute differently to healthcare quality. Findings – The findings show that modern technology, such as the internet and electronic devices for record keeping, contribute significantly to enhancing health service transparency, which in turn leads to quality health and family planning services. The findings also show that information and communication technology (ICT) is an effective mechanism for reducing corruption and promoting transparency. However, resource constraints impact adversely on the introduction of technology, which leads to less transparent healthcare. Progress in education and general socio-economic conditions makes it suitable to enhance ICT usage, which could lead to healthcare transparency, but political and bureaucratic factors pose a major challenge to ensure transparency. Practical implications – This paper can be a useful guide for promoting governance and healthcare quality in developing countries including Bangladesh. It analyses the ICT challenges that healthcare staff face when promoting transparent healthcare. Originality/value – This paper provides a deeper understanding of transparency and healthcare quality in an ICT context using empirical data, which has not been explored in Bangladesh. This critical thinking is useful for policy makers and healthcare practitioners for promoting health service quality. Keywords Bangladesh, Communication technology, Healthcare quality, Transparency, Access to information, Socio-economic factors, Political factors Paper type Research paper
Introduction Bangladesh has made enormous progress in maternal and child health, life expectancy and other demographic measures. It has the lowest fertility rate in South Asia, despite spending less money on healthcare than its neighbouring countries. The World Bank (2013) shows that life expectancy at birth in Bangladesh has increased from 45 years in 1970 to 70 in 2013, the maternal mortality ratio has declined from 322 per 100,000 live births in 2001 to 170 in 2013 and the infant mortality rate has declined from 94 per 1,000 live births in 1990 to 33 in 2013. These indicators show significant improvement over time. However, the Bangladesh Health Facility Survey (BHFS, 2012) shows that The author is grateful to the respondents for providing valuable information. The academic supervisors are thanked for their valuable comments. The author is indebted to Flinders University, Australia for providing a PhD scholarship.
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health service quality in the country is unsatisfactory. The BHFS study also identifies some contextual and demographic factors for understanding poor governance and inadequate healthcare delivery in the country: persistent high poverty rates; poor nutritional status; inadequate service accessibility; and rapid unplanned urbanisation (BHFS, 2012). Additionally, health sector resource availability has remained much lower than the minimum expenditure required for essential health services. The survey, however, points out that quality health services require managerial efficiency, improved supervision, better incentives for providers and non-government health service organisation involvement (BHFS, 2012). Therefore, good governance, through promoting transparency can significantly enhance quality healthcare comprising accessibility, affordability and good quality. One aspect in enhancing transparency and quality healthcare is information and communication technology (ICT). This study, therefore, endeavours to look at how management, resources and socio-economic factors contribute to ICT and transparency and to what extent they affect Bangladesh health service quality. Background The health system in Bangladesh is highly centralised. The Ministry of Health and Family Welfare staff are responsible for administrating, monitoring and coordinating field-level health service organisations. Figure 1 shows that the Bangladeshi health system is hierarchical. The top health service organisations are tertiary hospitals, e.g., medical colleges and hospitals provide specialised healthcare including primary health services. But Upazila (sub-district) hospitals and their subordinate health service agencies are able to provide only primary healthcare because hospitals have inadequate medical equipment and staffing for specialised services. Ahmed et al. (2013) show that Bangladesh has 459 hospitals at the Upazila level and below with 18,340 beds and 11,816 community clinics. These organisations provide primary healthcare for most people. There are also many private and non-government (NGO) health service organisations that provide primary healthcare including specialised health services all over Bangladesh. Bangladesh has insufficient skilled health workers including physicians, nurses and dentists. Ahmed et al. (2013) show that in Bangladesh, there are 7.7 physicians, nurses and dentists and 9.6 community health workers per 10,000 population. Overall, only 50.5 per cent of specialist positions and 55.8 per cent of general physician positions are filled. The Upazila health complex (UHC) has 48.3 per cent consultant positions and 75.1 per cent general physician positions filled. The proportion of nurse positions filled is about 86 per cent for district hospitals, 78 per cent for UHCs and 62 per cent for
Tertiary hospital District hospital
Upazila health complex Union health and family welfare centre Community clinic
Figure 1. Hierarchical public sector provision
Village dispensary
Source: Ahmed et al. (2013)
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maternal and child welfare centres. Additionally, UHCs have midwifery professionals and most sanctioned positions are filled (BHFS, 2012). The WHO (2008) estimates show that an additional 2.4 million doctors, nurses and midwives are required to meet global health development goals. Another WHO (2010b) estimate shows that 49 low-income countries have 23 doctors, nurses and midwives per 10,000 population. Margolis et al. (2011) state that WHO has determined that 2.3 doctors, nurses and midwives per 1,000 people is the minimum threshold needed to adequately cover the population with essential health services. Margolis also shows that Bangladesh still has a substantial crisis in the health workforce, which affects healthcare quality. Osman (2008) states that health sector financial sources include households, government revenue, donors and community through non-governmental organisations (NGOs). She also states that the household’s finance chief source is out of pocket expenditure, which accounts for about 47.3 per cent of the total health expenditure. Of the reminder, 26.6 per cent comes from government revenue, 25.8 per cent from external donors and 2 per cent from community NGO sources. Additionally, she argues that a donor consortium, which includes international development organisations led by the World Bank provides financial and technical assistance continuously to the health sector for enhancing health service governance. Health service delivery improvements depend on government finance allocation. The Annual Development Programme (ADP, 2010) report shows that the government’s allocation to the Bangladesh health sector is relatively poor compared to neighbouring countries. Osman (2004) demonstrates that health expenditure per capita is $20 in India and $29 in Sri Lanka whereas it is $12 per capita in Bangladesh. Studies show that politics and bureaucracy significantly influence health policies (Osman, 2008; Jahan, 2003; Gwin and Buse, 1998; WHO, 2010a). However, other studies show that national health policies, including various plans and programmes, are dominated by health professionals, particularly the Bangladesh Medical Association for enhancing self-interest rather than for the common people’s benefit (Rabbani, 2010; Hossain and Osman, 2007). Additionally, Jahan’s (2003) study shows that some factors such as poor medical equipment, elite influence and inadequate initiatives invite limited participation, including the civil society, thus leading to weak health policies and programmes. Other studies show that external resources influence health-policy formulation (Gwin and Buse, 1998; ICDDR, 2006; Jahan, 2003). All these studies looked at various health-policy formulation weaknesses with reference to politics, bureaucracy and resources, but they neglected transparency issues and healthcare quality. Although resource constraints such as an insufficient skilled workforce and finances affect health-policy implementation in Bangladesh (WHO, 2010a). Planning Commission members argues that poor supervision and monitoring cause poor health-policy implementation (Planning Commission, 2009). However, the ICDDR (2006) report identifies organisational, financial and technological problems when implementing health policy. Studies show that human resources, inadequate facilities, socio-economic disparities, power and politics, poor knowledge and education affect participation, which lead to poor implementation (Siddiquee, 1997; Mahmud, 2004; Islam and Ullah, 2009). Sen (2013) addressed four aspects that successfully advance health in Bangladesh: (1) women’s active role in society and economy, which has been a productive move in Bangladesh; (2) multiplicity of instruments in public and private sectors promote rapid social advancement;
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(3) intelligently using community-based approaches in health services; and (4) a country’s improved ability to face natural disasters. All these factors contribute to successful health progress in Bangladesh. In fact, the studies reviewed above found that poor health-policy implementation includes: resource constraints, managerial inefficiency, over-centralised health system, poor technology and socio-economic and political barriers. However, transparency when enhancing governance has not been addressed. Further, although health service quality is important for enhancing Bangladeshi quality of life, there is not a single study that addresses introducing technology for enhancing transparency. Therefore, we aim to: examine how technology can promote transparency and health service quality; explore to what extent various socio-economic factors may affect healthcare quality and how these factors work differently in rural and urban health service organisations. Methodology Understanding complex social problems concerning transparency’s impact on implementing health policies can best be obtained by using interpretative qualitative research methods, such as open-ended interviews, focus group discussions and document analysis ( Janesick, 2011; Yin, 1994). Baum (1995) argues that examining governance (transparency) effect through various socio-economic and political factors, particularly in public healthcare, are suitable for conducting qualitative case studies. Additionally, she shows that governance impact on health professional activity, including communities and individuals, are best suited to qualitative case studies (Baum, 1995). Our study is based on 68 in-depth interviews and five focus group discussions in the two Bangladesh areas: Chhatak and Savar sub-districts. In-depth interviews were conducted with eight national-level respondents, 37 health professionals, seven local elected representatives and 16 local informants. These respondents were selected because they are crucial informants in the study and are responsible for promoting governance and healthcare quality in selected research locations. The respondents were selected by purposive and snowball sampling techniques for understanding transparency impact on healthcare delivery. The interviews were based on semi-structured questionnaires prepared according to respondents’ duties and responsibilities. The questionnaires were administered to respondents for gathering data about introducing technology to enhance transparency and healthcare quality. Interview data were interpreted using Nvivo software for assessing the results and to understand transparency and healthcare quality. Five focus group discussions (39 informants) were conducted with staff from randomly selected health service organisations to collect service user views to give understanding about transparency and how socio-economic factors contribute to promoting healthcare quality. This enables us to understand direct community perceptions on enhancing transparency and healthcare quality. Moreover, secondary data are from health departments were used for understanding the Bangladesh health system and web-based journal articles were used for the literature review. Findings Internet access Upazila health service organisations now have internet connections that enables staff to collect useful health service information, which significantly improves health services, e.g., if the government announces a Vitamin A camp and puts this announcement on the Ministry of Health web site then field office staff, i.e., Upazila Council (UHC) are able to get this information via the internet and know what
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items will be covered in the programme. Such facility enhances healthcare information management and transparency. The Upazila health and family planning officer (UHFPO), Savar, points out that internet accessibility helps promote online services, e.g., annual report, health updates, basic health information, etc., more efficiently. Another use of new technology is when an authority up the command chain sends information to local officials thereby making the information transparent and quickly available. However, technological equipment and materials are not always available at UHC for providing health services. The UHC staff have limited access to the internet and computers and also insufficient skilled technicians. This affects health service quality. Despite this limitation, Savar staff are able to use the internet to organise meetings. The resident medical officer informed the researcher that monthly meetings are organised online for all medical officers and other staff. Figure 2 shows that Savar office staff are able to communicate with other organisations using faxes, which assists rapid information collection. Savar family planning staff are up-to-date regarding using the internet for health service delivery. The family planning officer states that the Prime Minister’s office has opened a web site to make service related information available. In this web site, family planning department staff have been ranked first by the government based on internet performance. Basic education and health services provided via the internet are supervised by the ICT staff.
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Mobile phones Figure 3 shows that mobile phones improve communication for promoting accessibility and health service affordability, and ensures transparency. Mobile phones are used for organising field-level health programmes; e.g., a health inspector might send a message
Internet Facilities
Making information available with regard to material and medicine, health report, basic health information, e-mail service
Promotes Transparency
Accessibility Affordability Service efficiency
Organising health programme
Importance of mobile phone
Figure 2. Internet facility promotes transparency and healthcare quality
Improved Transparency
Connecting people Quality of health care: Accessibility Affordability
Emergency services Hospital services i Supervision
Figure 3. Mobile phone impact on transparency and healthcare quality
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via a mobile phone to schedule grassroots health programmes and expand the immunisation programme (EPI) to make services available to clients. Some healthcare providers are able to use smartphones to make communication quicker and easier by sending health service messages. Service users claim that sometimes field workers cannot transmit information quickly to people living in remote areas. Consequently, mobile phones play a significant role when informing service users. Additionally, field workers have immunised children’s mobile phone numbers, which enables them to communicate effectively with families and practitioners. Most people in remote areas have a mobile phone, which enables people to connect with service users easily and rapidly. One assistant health inspector pointed out that a mobile phone is any easy way to mobilise people generally and service users particularly. Healthcare providers can send their messages rapidly; e.g., it is an easy way to contact healthcare staff and take steps quickly through providing adequate medical service and advice. Health workers can refer emergency cases to hospital via mobile phones. A local reporter in Chhatak believes that such referrals through mobile phones reduce maternal and child mortality, particularly in the remote areas. Mobile phones are used to communicate with community health workers providing emergency healthcare by bringing people from rural to urban localities. This enables health workers to promote maternal and child health through emergency services; e.g., mobile phones enable women to actively participate in their and their family’s healthcare, which demonstrates that mobile phones facilitate communication and decision making in reproductive health (Desouza et al., 2014). Service users state that mobile phones improve awareness among women through communicating with healthcare providers, which empowers and helps decision making in the family. Every UHC has a mobile phone provided by the head office for enhancing supervision and for investigating doctor availability. Sometimes head office staff call to a UHC medical officer to find out his/her position, presence and the activities. Additionally, UHC staff provide medical services through a mobile phone; numbers are available to hospital staff so that clients have access to services. A mobile phone is carried by a doctor on duty who provides health services such medicines advice in accordance with client needs. Additionally, community health workers can communicate with service users who live away and have difficulty accessing a hospital. Mobile phones enable health workers to provide useful medical suggestions and primary health services. Field inspectors state that extra allowances for mobile recharge calls can improve accessibility and promote healthcare delivery. One family planning inspector points out that every employee should have a mobile phone and that the government should pay for calls related to official matters to promote communication and enhance healthcare accessibility; e.g., it is a mandatory duty to record a pregnant women’s mobile number to monitor their health condition. Health workers sometime provide emergency services for pregnant women or bring them to the nearest health centre by communicating via mobile phones. Health workers claim that providing such services requires that a phone allowance must be paid by the government because it is a crucial healthcare delivery. Computer improves administrative efficiency Computers can make enhance quality health by making them more accessible. Sub-district health service organisation staff have limited computer access for performing administrative work. Computers help to generate reports for and enable staff to communicate via e-mail. Savar UHC EPI department staff use computer software provided by the government to calculate data easily, quickly and appropriately. Respondents point out that computers are
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available only for administrative activities. Healthcare providers at field level have limited computer facilities, therefore, they create their field report manually. Field officials are only able to send hard copies to higher authorities. Respondents argue that computers make the administrative jobs easier and convenient, but no patient record has been preserved through computers. The UHFPO argues that the government has a scheme to provide sufficient computers and skilled staff gradually to enhance quality health services. Implementation is slow owing to bureaucratic complexity and weak political commitment.
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Electronic media enhances transparency Electronic media plays a significant role in enhancing health services transparency. It provides useful information simply and easily. Television broadcasts expand the health programmes. Such advertisement contributes to enhancing public awareness so that people receive information quickly. The private Channel i and the Bangladesh state-owned television services broadcast family planning, maternal and child health programmes. Consequently, family planning awareness has improved significantly. Radio channels broadcast small dramas that promote health education awareness and family planning activities. Family planning staff also organise documentary films that promote awareness. Additionally, newspapers publish family planning methods and circulate important maternal and child health service information. Electronic devices in UHC can have an important effect on information accessibility through publicising hospital information and health awareness programmes. Savar medical officers argue that electronic devices can be useful mechanisms for providing information regarding maternal and child health and for patients seeking hospital services. Patients also learn about health information while waiting for health services. However, this facility is not available to public health service organisations, which limits access to information and reduces transparency. e-Governance promotes health service quality Technological innovations such as internet and electronic devices promote e-governance and health service quality. e-Governance is a useful mechanism for promoting quality health service delivery reducing corruption by increasing transparency within public organisations (Hossan and Bartram, 2010) (Figure 4). But, in reality, poor technology and inadequate resources limit e-governance and service delivery at UHC and the Union Sub Centre. Union Parishad information centre staff should provide healthcare information but unfortunately the responsible staff are mostly absent. Additionally, transparency requires updated and enriched information for making services more people centred. Some health service information has not been updated, which limits healthcare accessibility.
Provide quality of health care
Promote Transparency
e-Governance
Reduce Corruption
Figure 4. e-Governance impact on health service delivery
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Another matter is a skilled workforce for promoting e-governance. Managers should be providing technology training so that staff can provide efficient services. One nationallevel informant argues that service users do not trust e-services because they are not familiar with the services. A document without a signature reduces confidence. There is poor understanding about modern technology and its application because people are not sufficiently educated to use this technology. Society is not that advanced and is still developing to adapt modern technology and services through technological innovations. Confidence needs to be developed through promoting technology education and awareness so that its application for promoting quality healthcare is understood. Technological advancement in the UHCs Service demand has grown owing to new technology; however, UHC staff still uses analogue machines for medical examinations and reporting. These machines do not produce efficient reports to meet demand. Currently, the government has digital machines at district hospital level and at medical colleges. The government is planning to supply a digital x-ray machine for medical examination at every UHC to make health services accessible and affordable. Respondents argue that their UHC has an old x-ray machine, but it is working therefore, service providers are satisfied. Savar UHC has an operating theatre and provides efficient caesarean delivery but it is not available in Chhatak Upazila. No modern technology is available in Savar hospital. But this hospital has some equipment which is rare in a rural Upazila hospital. Alternatively, the government provided a laptop for the Chhatak medical technologist EPI, but not to Savar UHC. So, technological enhancement is different from one organisation to another, which depends on government policy and demand in a specific locality. Generally, departments have limited technology for checking new born health children and their mothers. e-Services have not been developed at the Upazila level. People, therefore, do not search for information. The directorate general office is currently planning to introduce e-medicine services through new software. But it is not popular because people have no understanding. National respondents argue that technology is misused at UHC because education and understanding is lacking. Most respondents argue that this wastes government resources. One respondent claims that many development activities have been done through technological devices; e.g., the family planning directorate has a section about management information system, which operates through online services. Upazila staff also communicates using online services. Family planning staff have a laptop at every union level and have software for promoting healthcare. This scheme strengthens information management that enhances quality healthcare. Family planning staff allocate money for enhancing technology from a development budget. But a local reporter argues that ICT is still in its initial stages and improved outcome through technology is far away. Moreover, the government invests money but it is not used efficiently. Consequently, achievement is limited and is invisible. Conclusion Bangladesh has made remarkable progress with its maternal and child health. However, technology for promoting governance and health service delivery is limited. Field data demonstrate that technological innovations have not enhanced service quality. Therefore, adequate transparency for promoting good governance is still a challenge in health service organisations. Promoting e-governance at UHC level requires adequate budgets and skilled staff. Coordination among government and
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NGOs is essential to promote e-governance and transparency. The ICT policy, therefore, should be enhanced for wider use so that transparent healthcare can be ensured. Additionally, adequate decentralised health systems can influence transparency and health service delivery. References Ahmed, S.M., Evans, T.G., Standing, H. and Mahmud, S. (2013), “Harnessing pluralism for better health in Bangladesh: innovation for universal health coverage 2”, The Lancet, Vol. 382 No. 9906, pp. 1746-1755. Annual Development Programme (ADP) (2010), “Annual Development Programme (ADP) 201011”, Planning Division, Ministry of Planning, Government of the People’s Republic of Bangladesh, available at: www.plandiv.gov.bd (accessed 20 August 2014). Bangladesh Health Facility Survey (BHFS) (2012), “Bangladesh Health Facility Surve”, revised final report, University of South Carolina, Columbia, SC, February, and ACPR, Dhaka, through a subcontract with Tulane University, New Orleans, LA. Baum, F. (1995), “Researching public health: behind the qualitative-quantitative methodological debate”, Journal of Social Science Medicine, Vol. 40 No. 4, pp. 459-468. Desouza, S.I., Rashmi, M.R., Vasanthi, A.P., Joseph, S.M. and Rodrigues, R. (2014), “Mobile phones: the next step towards healthcare delivery in rural India”, Plos One, Vol. 9 No. 8, pp. 1-9. Gwin, C. and Buse, K. (1998), “The world bank and global cooperation in health: the case of Bangladesh”, The Lancet, Vol. 351 No. 9103, pp. 665-669. Hossain, N. and Osman, F. (2007), “Politics and governance in the social sectors in Bangladesh, 19912006”, Research Monograph Series No. 34, Research and Evaluation Division, BRAC, Dhaka. Hossan, C. and Bartram, T. (2010), “The battle against corruption and inefficiency with the help of e-government in Bangladesh”, Electronic Government, An International Journal, Vol. 7 No. 1, pp. 89-100. ICDDR (2006), “Annual report-2006”, International Centre for Diarrhoeal Disease Research, Mohakhali. Islam, M.S. and Ullah, M.W. (2009), “People’s participation in health services: a study of Bangladesh’s rural health complex”, Working Paper Series, Bangladesh Development Research Center, Virginia, pp. 1-23. Jahan, R. (2003), “Restructuring the health system: experiences of advocates for gender equity in Bangladesh”, Reproductive Health Matters, Vol. 11 No. 21, pp. 183-191. Janesick, V.J. (2011), Stretching’ Exercise for Quality Researchers, 3rd ed., University of South Florida, SAGE Publications, London. Mahmud, S. (2004), “Citizen participation in the health sector in rural Bangladesh: perceptions and reality”, IDS Bulletin, Vol. 35 No. 2 pp. 11-18. Margolis, S.P., Crystal, C.M. and Noronha, S. (2011), “Technical brief: population growth and the global health workforce crisis”, Capacity Plus: saving health workers, saving lives, Geneva, available at: www.capacityplus.org (accessed 20 September 2014). Osman, F.A. (2004), Policy Making in Bangladesh – A Study of the Health Policy Process, 1st ed., AH Development Publishing House, Dhaka. Osman, F.A. (2008), “Health policy, programmes and system in Bangladesh: achievements and challenges”, South Asian Survey, Vol. 15 No. 2, pp. 263-288. Planning Commission (2009), “The millennium development goals (MDGs)”, progress report 2009, General Economic Division, available at: www.plancomm.gov.bd.mdg_report2009.asp (accessed 25 February 2012).
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Rabbani, M.G. (2010), “Agenda setting on community health in Bangladesh”, master thesis, Department of General and Continuing Education, North South University, Dhaka. Sen, A. (2013), “What’s happening in Bangladesh?”, The Lancet, Vol. 382 No. 9909, pp. 1966-1968, available at: www.thelancet.com (accessed 28 November 2013). Siddiquee, N.A. (1997), Decentralization and Development in Bangladesh – Theory and Practice, 1st ed., University Press Limited, Dhaka. WHO (2008), Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guideline, WHO, Geneva. WHO (2010a), The World Health Report, Health System Financing: The Path to Universal Coverage, WHO, Geneva. WHO (2010b), “Health workforce: achieving the health related MDGs”, available at: www.who.int/ hrh/workforce_mdgs/en/ (accessed 15 August 2014). World Bank (2013), “Country report on health, Bangladesh”, available at: http://data.worldbank. org/country/banagladesh (accessed 8 July 2014). Yin, R.K. (1994), Case Study Research – Design and Methods, Applied Social Research Method Series, 2nd ed., Vol. 5, Sage Publications, London. Further reading Afzal, N. and Zainab, B. (2012), “Determinants and status of vaccination in Bangladesh”, Dhaka University Journal of Science, Vol.60 No.1, pp. 47-51. Quaiyaum, M.A., Gazi, R., Khan, A.I., Uddin, J., Islam, M., Ahmed, F. and Saha, N.C. (2011), “Programmatic aspects of dropouts in child vaccination in Bangladesh: findings from a prospective study”, Asia-Pacific Journal of Public Health, Vol. 23 No. 2, pp. 141-150. WHO (2013), Global Action Vaccine Action Plan 2011-2020, WHO, Geneva. Corresponding author Mohammad Shafiqul Islam can be contacted at: [email protected]
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