Capability Development among the Ultra-poor in Bangladesh: A Case Study

Microcredit is advocated as a development tool that has the potential to reduce poverty, empower participants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor, often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention integrates multiple components, including asset grants for income generation, skills training, a time-bound monthly stipend for subsistence, social development and mobilization of local elite, and health support. Results of an evaluation showed that, after 18 months, the programme positively impacted livelihood, economic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and joined (or intended to join) a regular microcredit programme. Impacts included improved income, improved food security, and improved health knowledge and behaviour. Applying a social exclusion framework to the intervention helps identify the different dynamic forces that can exclude or include the ultra-poor in Bangladesh in development interventions such as microcredit

Capability Development among the Ultra-poor in Bangladesh: A Case Study

Microcredit is advocated as a development tool that has the potential to reduce poverty, empower participants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor, often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention integrates multiple components, including asset grants for income generation, skills training, a time-bound monthly stipend for subsistence, social development and mobilization of local elite, and health support. Results of an evaluation showed that, after 18 months, the programme positively impacted livelihood, economic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and joined (or intended to join) a regular microcredit programme. Impacts included improved income, improved food security, and improved health knowledge and behaviour. Applying a social exclusion framework to the intervention helps identify the different dynamic forces that can exclude or include the ultrapoor in Bangladesh in development interventions such as microcredit

Availability and Rational Use of Drugs in Primary Healthcare Facilities Following the National Drug Policy of 1982: Is Bangladesh on Right Track?

In Bangladesh, the National Drug Policy (NDP) 1982 was instrumental in improving the supply of essential drugs of quality at an affordable price, especially in the early years. However, over time, evidence showed that the situation deteriorated in terms of both availability of essential drugs and their rational use. The study examined the current status of the outcome of the NDP objectives in terms of the availability and rational use of drugs in the primary healthcare (PHC) facilities in Bangladesh, including affordability by consumers. The study covered a random sample (n=30) of rural Upazila Health Complexes (UHCs) and a convenient sample (n=20) of urban clinics (UCs) in the Dhaka metropolitan area. Observations on prescribing and dispensing practices were made, and exit-interviews with patients and their attendants, and a mini-market survey were conducted to collect data on the core drug-use indicators of the World Health Organization from the health facilities. The findings revealed that the availability of essential drugs for common illnesses was poor, varying from 6% in the UHCs to 15% in the UCs. The number of drugs dispensed out of the total number of drugs prescribed was higher in the UHCs (76%) than in the UCs (44%). The dispensed drugs were not labelled properly, although >70% of patients/care-givers (n=1,496) reported to have understood the dosage schedule. The copy of the list of essential drugs was available in 55% and 47% of the UCs and UHCs respectively, with around two-thirds of the drugs being prescribed from the list. Polypharmacy was higher in the UCs (46%) than in the UHCs (33%). An antibiotic was prescribed in 44% of encounters (n=1,496), more frequently for fever (36-40%) and common cold (26-34%) than for lower respiratory tract infection, including pneumonia (10-20%). The prices of key essential drugs differed widely by brands (500% or more), seriously compromising the affordability of the poor people. Thus, the availability and rational use of drugs and the affordability of the poor people have remained to be achieved in Bangladesh even 27 years after approving the much-acclaimed NDP 1982

Intimate Partner Violence against Women: Experiences from a Woman-focused Development Programme in Matlab, Bangladesh

This paper explores the association between microcredit-based development programmes and domestic violence against women perpetrated by their husbands. A sub-set of cross-sectional data collected in 1999 from 60 BRAC-ICDDR,B study villages in Matlab, Bangladesh, was used. Data were analyzed to characterize group-level differences among study women regarding the reported occurrence of violence (physical and/or mental) and to identify its predictors. About 17.5% of women had experienced violence from their husbands in the past four months, the proportion being greater among BRAC house-holds (p=0.05). Results of logistic regression identified age, schooling, age of household head, and self-rated poverty status of household as important predictors of violence, but not level of BRAC member-ship. The study concludes that the greater level of domestic violence reported during the initial stages of BRAC membership subsided with the introduction of skill-development training among participant women over time

Availability and Rational Use of Drugs in Primary Healthcare Facilities Following the National Drug Policy of 1982: Is Bangladesh on Right Track?

In Bangladesh, the National Drug Policy (NDP) 1982 was instrumental in improving the supply of essential drugs of quality at an affordable price, especially in the early years. However, over time, evidence showed that the situation deteriorated in terms of both availability of essential drugs and their rational use. The study examined the current status of the outcome of the NDP objectives in terms of the availability and rational use of drugs in the primary healthcare (PHC) facilities in Bangladesh, including affordability by consumers. The study covered a random sample (n=30) of rural Upazila Health Complexes (UHCs) and a convenient sample (n=20) of urban clinics (UCs) in the Dhaka metropolitan area. Observations on prescribing and dispensing practices were made, and exit-interviews with patients and their attendants, and a mini-market survey were conducted to collect data on the core drug-use indicators of the World Health Organization from the health facilities. The findings revealed that the availability of essential drugs for common illnesses was poor, varying from 6% in the UHCs to 15% in the UCs. The number of drugs dispensed out of the total number of drugs prescribed was higher in the UHCs (76%) than in the UCs (44%). The dispensed drugs were not labelled properly, although >70% of patients/care-givers (n=1,496) reported to have understood the dosage schedule. The copy of the list of essential drugs was available in 55% and 47% of the UCs and UHCs respectively, with around two-thirds of the drugs being prescribed from the list. Polypharmacy was higher in the UCs (46%) than in the UHCs (33%). An antibiotic was prescribed in 44% of encounters (n=1,496), more frequently for fever (36-40%) and common cold (26-34%) than for lower respiratory tract infection, including pneumonia (10-20%). The prices of key essential drugs differed widely by brands (500% or more), seriously compromising the affordability of the poor people. Thus, the availability and rational use of drugs and the affordability of the poor people have remained to be achieved in Bangladesh even 27 years after approving the much-acclaimed NDP 1982

A Multidimensional Approach to Measure Poverty in Rural Bangladesh

Poverty is increasingly being understood as a multidimensional phenomenon. Other than income-consumption, which has been extensively studied in the past, health, education, shelter, and social involvement are among the most important dimensions of poverty. The present study attempts to develop a simple tool to measure poverty in its multidimensionality where it views poverty as an inadequate fulfillment of basic needs, such as food, clothing, shelter, health, education, and social involvement. The scale score ranges between 72 and 24 and is constructed in such a way that the score increases with increasing level of poverty. Using various techniques, the study evaluates the poverty-measurement tool and provides evidence for its reliability and validity by administering it in various areas of rural Bangladesh. The reliability coefficients, such as test-retest coefficient (0.85) and Cronbach's alpha (0.80) of the tool, were satisfactorily high. Based on the socioeconomic status defined by the participatory rural appraisal (PRA) exercise, the level of poverty identified by the scale was 33% in Chakaria, 26% in Matlab, and 32% in other rural areas of the country. The validity of these results was tested against some traditional methods of identifying the poor, and the association of the scores with that of the traditional indicators, such as ownership of land and occupation, asset index (r=0.72), and the wealth ranking obtained from the PRA exercise, was consistent. A statistically significant inverse relationship of the poverty scores with the socioeconomic status was observed in all cases. The scale also allowed the absolute level of poverty to be measured, and in the present study, the highest percentage of absolute poor was found in terms of health (44.2% in Chakaria, 36.4% in Matlab, and 39.1% in other rural areas), followed by social exclusion (35.7% in Chakaria, 28.5% in Matlab, and 22.3% in other rural areas), clothing (6.2% in Chakaria, 8.3% in Matlab, and 20% in other rural areas), education (14.7% in Chakaria, 8% in Matlab, and 16.8% in other rural areas), food (7.8% in Chakaria, 2.9% in Matlab and 3% in other rural areas), and shelter (0.8% in Chakaria, 1.4% in Matlab, and 3.7% in other rural areas). This instrument will also prove itself invaluable in assessing the individual effects of poverty-alleviation programmes or policies on all these different dimensions

A study of absenteeism among doctors in rural Bangladesh

Absenteeism – unauthorised employee absence from the workplace – is one of the most common forms of corruption among frontline health workers. Despite having an extensive infrastructure, the healthcare system in Bangladesh suffers from staff shortages, maldistribution of the workforce, and poor retention of employees and service providers, especially in rural and remote areas. Among doctors in particular, absenteeism has also been a long-standing problem. Although absenteeism has long been recognised by the Bangladesh national authorities, and multi-lateral and donor agencies, the regulatory approaches that they have employed have so far failed to yield successful results. This is, in part, because they have largely failed to consider or manage the challenges of implementing transparency and accountability measures in the face of poorly funded health systems, misaligned incentives and the influence of socio-political networks on the distribution of urban and rural positions. This study has been conducted to support the development of a new approach to anticorruption that takes the socio-economic and political context into account in the construction of novel interventions. It is a qualitative study that seeks to explore the realities of working in the Bangladesh health system, with a particular focus on the factors that influence and shape the nature of doctors’ absenteeism in rural facilities. We conducted 30 in-depth interviews with doctors of various levels (junior = 18, mid-level = 5, senior = 7) from three divisions: Sylhet (northern), Barisal (southern) and Dhaka (central). Rural facilities with higher vacancy rates were purposively selected from these divisions. The findings show that poor working conditions, threats to career progression, desires for private practice, gender inequality, poor social relations with the local community and weak regulatory mechanisms are important underlying factors influencing absenteeism. In addition, local political systems and poor infrastructure make rural placements difficult and, on some occasions, dangerous for health workers. Despite the equal distribution of these problems, challenges and threats in rural health centres, absenteeism among doctors manifests in different ways. Those doctors who are linked to political and economic elites manage to avoid rural placements easily; others who are from less powerful backgrounds but who have some useful political connections and financial resources manage absence from health centres by making unofficial payments to bureaucrats. In contrast, some doctors rarely take unauthorised time away from their work. Some adjust to their rural position; these doctors usually belong to that locality and/or have maintained good relations with the local community. Our findings indicate that the most important contributory factors that influence doctors’ absenteeism in rural Bangladesh can be traced to structural and health system issues. Those with influence, power and access to networks are able to be absent for longer periods, which overburdens and de-motivates the doctors who are present. A possible solution lies in the design of feasible incentives that tackle the most difficult health systems issues (relating to infrastructure and safety) and career progression, and that draw together forms of collective action among doctors who are differently positioned in the social and political networks

Progress and challenges to control malaria in a remote area of Chittagong hill tracts, Bangladesh

<p>Abstract</p> <p>Background</p> <p>Malaria is endemic in 13 eastern districts where the overall infection prevalence is 3.97%. In 2006, Bangladesh received US$ 36.9 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to support the national malaria control programme of Bangladesh.</p> <p>Objectives</p> <p>The objective of this study was to i) clarify factors associated with treatment seeking behaviours of malaria ii) distribution of LLIN, and iii) re-treatment of ITN in remote area of a CHT district of Bangladesh two years after implementation of national control programme.</p> <p>Methods</p> <p>All households of Rajasthali sub-district of Rangamati district (households about 5,322, population about 24,097), all BRAC health workers (n = 15), health facilities and drug vendors' locations were mapped. Distances from households to health facilities, BRAC health workers and drug vendors were calculated. Logistic regression analysis was performed to assess the associations between the choice of the treatment and the distance to various treatment sources, education, occupation and ethnicity. SaTScan was used to detect clustering of treatment-seeking approaches.</p> <p>Findings</p> <p>LLIN distribution and the re-treatment of ITN exceeded target goals. The most common treatment facility for malaria-associated fever was malaria control programme led by BRAC and government (66.6%) followed by the drug vendor (48.8%).</p> <p>Conclusion</p> <p>Closeness to health facilities run by the malaria control programme and drug vendors were significantly associated with the choice of treatment. A high proportion of people preferred drug vendors without having a proper diagnosis. Drug vendors are highly patronized and thus there is a need to improve their services for public health good. Otherwise it may cause incomplete treatment, misuse of anti-malarial drugs that will contribute to the risk of drug resistance and jeopardize the present malaria control efforts in Bangladesh.</p

Retaining Doctors in Rural Bangladesh: A Policy Analysis

Background Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes. Methods Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n = 11), and stakeholder analysis/position-mapping. Results In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector). Conclusion Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors