The Impact of Health Sector Reform on State and Society in Bangladesh, 1995-2005

Despite the fact that in recent years the Government of Bangladesh has invested substantially and initiated numbers of multi-sector and multilevel institutional and programmatic reforms to improve the health of the poor and women, the health status of the poor in Bangladesh is one of the worst in the world. In this context this thesis aims to answer do health reform policies benefit the poor? In order to address the central research question, from a bottom-up critical perspective, it aims to understand the impact of the health sector reform on state and society in Bangladesh. In doing so, thesis moves on with several assumptions. First, health is political. Second, reform is political because it involves restructuring of institutions, and restructuring of institutions creates reconfiguration of power relations in the society. Thus, health reform is profoundly a political process. Consequently, the third: the impact of health reform policy is also political which falls unevenly on the poor. The thesis assumes that the public policy process is an interactive phenomenon which suggests that the various phases of policy process, from agenda setting to evaluation, are embedded to each other and one can influence, at any point of time, outcome of the other. Based on these assumptions, I argue, whether the poor will gain any benefit, what and how much, from any reform policy is conditioned by the nature of the politics of the country. I argue, because of being a defective democracy, there has democratic deficit been grown in the policy arenas in general, and health sector in particular in Bangladesh. Therefore, it has been relatively easy for the hegemonic coalition to persuade and expand their ideas and interest through state policies. This means, the hegemonic policy coalition of health bureaucrats and professionals, donors, political leaders and NGO professionals by manipulating the democratic deficit of the state shapes the problem definition, influences policy goals and strategies based on their neoliberal ideological roots. Thus, the policy or organizational changes that are introduced under the reform are components of New Public Management. As a result, when the reform policy is implemented it protects and reproduces the interests and ideas and unequal power relation of the hegemonic coalition as the impact, thus the poor remain marginalized, excluded. Therefore, the benefit of the reform likely to remain limited within the narrow conception of health i.e. medical services; but the poor remains denied accessing the political benefit. I further argue, depending on actor’s constellation in the hegemony, elite’s interest, political context and embedded institutions the same reform program can produce different types of impacts on different part of a society. The study is inductive, multidisciplinary and heuristic in nature and thus, organized as a case study research design; however, within the framework of case study design, elements of experimental design have been well mingled. The study takes pluralism and neo-institutionalism as its explanatory paradigm. In conclusion the study finds, the health reform has produced positive impact in the area of maternal and child health, health knowledge, access and responsiveness. In other words, it has brought improvements only in the area of health of the poor which are allowed by the dominant health professional’s perspectives. As a result, the whole health agenda has been reduced into reproductive health. No impact has been felt on the collective dimension of human agency. Health rights, consumer rights, participation and accountability have not also been addressed through the reform program. The service users were considered as passive receiver of advices and drugs; their human agencies were not taken into account. No major difference is found between NGO and local government in most of the aspects with respect to their impact which implies the NGOs and local government agency does not have any qualitative difference in their approach to the health of the poor they both showed their institutional loyalty to the hegemonic perception of health. Evidence showed, because of a particular nature of the state and weak state-society relations through political parties, the dominant coalition of doctors, donors, bureaucrats and NGOs are influencing the policy process and getting their interests through. Evidence also showed that the policy taken by that hegemonic coalition only allows some limited, reduced services to the poor without allowing them to take part in decision making processes so that the existing uneven power relation remain unchanged. As a result, the poor gained some health benefit but no impact on the social, political determinants of health has been made, in other words political benefit is very low. The evidence also showed that if actors in the coalition represent some political representative institutions, can produce higher political benefits that could make health outcome sustainable. This study also exposed the very paradoxical nature of the neoliberal reform. Through the reform process, in one hand state is getting smaller; on the other hand it is extending control over social organizations. The reform disintegrated the previous hierarchical service structure and instead, in the process of reform implementation, an interdependent service network of actors emerges. The neoliberal health reform reduces power of conventional political institutions such as political parties, local government bodies, and local political leaders and gives more power to the non-state and non-political actors. As a result, the poor will suffer more because, the traditional political leaders were closer to people inefficient though; on the other new non-state actors are efficient but do not have the capacity to bridge gap between the people and service providers

Understanding cervical cancer awareness in hard-to-reach areas of Bangladesh:A cross-sectional study involving women and household decisionmakers

INTRODUCTION: In Bangladesh, the uptake of cervical cancer screening is low. Lack of knowledge and understanding of symptoms and risk factors contributes to low screening uptake. The purpose of this study was to explore the knowledge of cervical cancer risk factors and symptoms and to measure the association with socio-demographic characteristics among women and household decisionmakers living in hard-to-reach areas of Bangladesh.METHODS: A cross-sectional survey was conducted in five districts in Bangladesh among women aged between 30 and 60 years, their husbands, and their mothers-in-law from April to September 2022. Data were collected using a modified version of the validated AWACAN questionnaire tool. The significance level was considered at p-value &lt;0.05 and odds ratios with 95% confidence.RESULTS: Nearly 50% of participating women in hard-to-reach areas of Bangladesh and their family decisionmakers had low levels of knowledge of the risk factors and symptoms of cervical cancer. Only 20% of respondents in our survey knew about HPV, the most important risk factor for developing cervical cancer. Most respondents were familiar with the terminology of cervical cancer as a disease; however, approximately 40% of respondents did not know that not adhering to cervical cancer screening could be seen as a risk factor. Women do not make decisions about participation in cervical cancer screening on their own. Knowledge of cervical cancer risk factors and symptoms among decisionmakers was significantly associated with higher education and higher household monthly expenditure.CONCLUSION: Women, their husbands, and mothers-in-law in hard-to-reach areas of Bangladesh had limited knowledge about cervical cancer risk factors and symptoms. Engaging these key decision-makers in targeted health education is vital to improve screening uptake. Conduction of future research to identify and address screening barriers is also essential for effective prevention efforts.</p

Role of Community-based Organisations in Promoting Democratic Local Governance at the Grassroots in Bangladesh

Democratic local governance (DLG) is often regarded as a necessary precondition for transforming lives and livelihoods of people living in the rural areas of developing countries. This article tries to answer how community-based organisations (CBOs) shape the way services are delivered by local government agencies in Bangladesh. Furthermore, the article explores how the community’s, especially women’s, demands and interests are being negotiated at local political institutions. In doing so, the research focuses on Union Parishad (UP) as the core institution of the local power structure and Kachukata Gram Unnayan Parishad (GUP) as the case of a women-led CBO. It has been observed that Kachukata GUP has evolved as a full-fledged CBO over the years and currently mobilises marginalised groups to establish their rights and access to various government and non-government organisations. In addition to ensuring gender-responsive governance, GUP is also creating space for participation and developing interactive relationship between the people and power at the grassroots in Bangladesh

Multi-Level Governance in Global Health

Kaasch A, Islam KM, Kohlmorgen L. Multi-Level Governance in Global Health. In: Brunnengräber A, Burchardt H-J, Görg C, eds. Mit mehr Ebenen zu mehr Gestaltung? Multi-Level Governance in der transnationalen Sozial- und Umweltpolitik. Schriften zur Governance-Forschung. Vol 14. Baden-Baden: Nomos; 2008: 141-162

Does citizen participation make public servants more satisfied with their jobs? It depends on whether they are spectators or participants

Is citizen participation in policymaking and implementation desirable? Numerous studies have explored its effects on policy outcomes and citizen attitudes. We, instead, examine its effects on public servants. Citizen participation changes public sector job characteristics and thus potentially job attitudes. Looking at job satisfaction, we argue that citizen participation negatively affects public servants who observe, but do not participate in citizen participation initiatives in their institution's decisions (“Spectators”), yet not public servants who are “Participants.” “Participants” learn to appreciate the benefits of citizen participation while minimizing its cost. Survey data from public servants in one developing country, Bangladesh, provides empirical support

Does Political Corruption Reduce Pro-Social Behavior by Bureaucrats? Lab Experimental Evidence from Bangladesh

Numerous studies assess how politicians control and shape bureaucracy. Yet, how politicians’ behavior affects the norms and behaviors of bureaucrats through role modeling has not been studied. This is a curious omission, in light of evidence that social norms shape bureaucratic behavior. Through a lab experiment with over 900 bureaucrats in Bangladesh, we explore whether political corruption affects bureaucrats’ pro-social behavior and whether this effect is particularly pronounced for corruption of the current government, as a particularly relevant social norm referent. Using a political corruption prime, we present evidence that those bureaucrats who recall episodes of the current government’s political corruption when prompted to think about political corruption donate significantly lower real monetary amounts to charity. By contrast, we do not find clear effects of political corruption by other actors. Our findings underscore the importance of political leaders as role models for bureaucrats and the damage that political corruption may inflict on pro-social behavior in bureaucracies