Making healthcare accessible in Bangladesh
Despite extreme poverty, Bangladesh has made great strides towards improving the health of women and children. Since the mid-1980s, the maternal mortality rate has fallen by one-third, and in the last decade the child mortality rate has been cut in half. Improved life expectancy, immunization coverage, and tuberculosis and diarrhea control are also part of this remarkable success story.
Even so, the country is still far from its goal of universal health coverage. Bangladesh aims to provide all citizens and communities with the health services they need, at a price they can afford, by 2032. Among the challenges in achieving this goal are rapid urbanization, deep poverty, and inadequate nutrition.
A dramatic rise in chronic, non-communicable diseases (NCDs), particularly among the poor, aggravates these challenges. Estimates suggest that NCDs — which include diabetes, cardiovascular disease, respiratory disease, and cancers — now account for half of all deaths each year. Treating these diseases requires a sustained effort. Unfortunately, the existing health system depends largely on out-of-pocket payments that the poor can ill afford.
Information and communication technologies (ICTs) could help deliver quality, affordable healthcare to the most vulnerable populations. Research in Bangladesh has shown, however, that to be effective, new tools must be backed by locally-relevant frameworks that integrate issues of health equity, governance, and accountability into program design, delivery, and evaluation.
Pinning high hopes on ICTs
Poor access to quality health services and high costs threaten Bangladesh’s momentum towards universal health coverage. A serious shortage and unequal distribution of qualified health personnel are major stumbling blocks: only 25% of health workers serve rural areas, but this is where 70% of the population lives.
Given these shortages and distribution patterns, there has been a growing interest in using ICTs, particularly mobile phones, to improve access to affordable healthcare. These technologies are being increasingly used in both developed and developing countries to deliver a variety of health services, often referred to as eHealth, or mHealth when they rely on mobile technologies.
EHealth and mHealth activities were introduced in Bangladesh in the late 1990s. A study of these services by researchers from the International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), funded by IDRC, identified more than 50 of these interventions. This inventory shows that the Government of Bangladesh is the largest funder of eHealth projects, followed by bilateral, private sector, and multilateral organizations.
A chaotic sector
The government has installed basic eHealth infrastructure in various parts of the healthcare system. It has also developed a draft guideline for eHealth standards and an interoperability framework to reduce duplication of effort and facilitate sharing of information between initiatives. The cabinet has not yet adopted these measures.
The government has made little effort to coordinate or regulate the development of eHealth and mHealth initiatives by non-governmental actors. There are no standards on the types of services a company can provide, qualifications of the people providing advice, ownership of companies, or pricing policies. This raises questions about how the poor are encouraged to use services and whether these services can meet their needs without increasing their spending on health.
Through this project, icddr,b found that few projects had a monitoring framework and fewer than one-quarter had undertaken any evaluation. Most of the initiatives used a health management information system to monitor implementation, but these systems didn’t allow for effective sharing of information. The researchers also found that very few people in Bangladesh had any eHealth management or implementation training.
More importantly, despite intentions to reach the poor and move toward universal health coverage, hardly any projects considered issues of health equity, accountability, or governance in their design, implementation, or evaluation.
A 10-point framework for equity and accountability
Building on this information, the team developed a framework for integrating equity, accountability, and system integration considerations in the design, development, and evaluation of eHealth projects. They identified 10 criteria for examining projects: strategic vision, participation, transparency, responsiveness, equity, ethics, information governance, rule of law, performance, and sustainability.
A team of national and international policymakers, private sector representatives, academics and researchers, and members of the telecom industry gathered to discuss and validate the framework. Focusing on five types of eHealth projects, this group found that all lacked regulatory and legal standards. For example, there are no clear ethical guidelines to deal with issues such as the participation of unqualified health practitioners in teleconsultations or prescribing medications at a distance without seeing the patient. In addition, there are no laws or guiding principles to govern the development and dissemination of health text-messages. The lack of standards has deep-rooted implications for health equity, ethics, and accountability.
Researchers have also found that most initiatives had been developed in isolation. As a result, health data and other protected information was not shared across systems serving similar populations or addressing similar health conditions, nor were there guidelines for information and data management, such as data confidentiality.
Helping projects live up to their potential
The study also revealed a deep inequity in the use of existing services. While mobile phones are widespread in Bangladesh, they are seldom used to seek health information. Those who do use them for this purpose are younger, educated adults.
These concerns and the framework have been shared widely, including through a course on “eHealth for Universal Health Coverage” for government officials, private implementers, academic institutions, telecom companies, and research institutes. As the researchers conclude, the right elements exist in Bangladesh to harness ICTs to improve healthcare. The current unplanned and unregulated application, however, leads to the misuse of resources, greater fragmentation of the health system, and disillusionment among decision-makers, health providers, and citizens.
The new framework will help any new initiative live up to its potential. It will also ensure that government and eHealth implementers consider equity and accountability when designing new projects — important steps to achieving universal health coverage.