Understanding and Measuring Responsiveness of Human Resources for Health in Rural Bangladesh

Introduction Responsiveness of human resources for health (HRH) is defined as the social actions that health providers do to meet the legitimate expectations of service seekers. Lack of responsiveness may dissuade patients from early care seeking, diminish their interest in adopting preventive health information, decrease trust with health service providers, and marginalize at-risk population groups, leading to compromised wellbeing. Most importantly, responsiveness is related to the human rights of the patients. The overall goal of this dissertation was to examine HRH responsiveness in rural Bangladesh, to develop a scale to measure the responsiveness, and finally to demonstrate the application of the measurement method. This goal has been addressed in three separate manuscripts, which aimed to answer the following questions, respectively: 1. What are the perceptions of outpatient healthcare users and providers regarding what constitutes responsiveness of physicians in rural Bangladesh? 2. How can we measure the responsiveness of physicians in rural Bangladesh? 3. What are the differences in responsiveness of physicians between those working in the public sector as opposed to those working in the private sector in rural Bangladesh? Methods This study adopted a multiphase mixed methods design, in which the qualitative part was followed by a quantitative part in data collection (sequential).In the latter stage of the project, both qualitative and quantitative aspects simultaneously complemented each other in data analysis and interpretation (concurrent). Data collection took place in rural parts of Khulna, a southwestern division of Bangladesh. The qualitative portion consisted of in-depth interviews (IDI) of physicians (seven public, five private, five informal), in-depth interviews of clients (n=7), focus group discussions (FGD) with clients (two sessions each with males and females), and participant observations in consultation rooms of public, private, and informal sector healthcare providers (one week in each setting). The quantitative research consisted of structured observation (SO) of 393 physicians (195 from public and 198 from private sector). This data was collected for developing a scale of responsiveness through exploratory factor analysis (EFA), involving 64 items (generated through the qualitative part of this project). This data was also intended for applying the scale, once developed, to compare the responsiveness of public and private sector physicians. Inter-rater reliability was assessed by same three raters observing 30 consultations, using the scale (later named as Responsiveness of Physicians Scale or in short ROP-Scale). Study data were collected between August 2014 and January 2015.Qualitative data were analyzed by the framework analysis method. World Health Organization’s (WHO) health systems responsiveness framework was modified, based on literature review and expert opinions, to include the following domains for qualitative analysis: Friendliness, Respecting, Informing and guiding, Gaining trust, and Optimizing benefit. Quantitative data were analyzed by EFA, followed by assessment of internal consistency by ordinal alpha coefficient and inter-rater reliability by intra-class correlation coefficient (ICC). For comparing responsiveness of public and private sector physicians two sample t-test, multiple linear regression (MLR), multivariate analysis of variance (MANOVA), and descriptive discriminant analysis (DDA) were used. This dissertation presents three manuscripts. Manuscript-1 presents the qualitative component to facilitate understanding of the local perceptions around responsiveness of physicians. Manuscript-2 presents the quantitative data to develop a psychometric scale to measure responsiveness of physicians and then to evaluate the reliability and validity of the scale. Manuscript-3 used a mixed methods approach to compare responsiveness of public and private sector physicians. Results Manuscript-1 showed that user and provider perceptions of responsiveness of physicians in rural Bangladesh often overlapped but at times diverged. Due to high patient load, physicians in the public sector usually failed to spend enough time with patients for proper history taking, asking questions, examining, and reassuring. Although not satisfactory, according to patients in qualitative part of the research, physicians in the private sector were more responsive towards the patients, especially in terms of conducting examinations with care, asking questions, and giving little reassurance. Most of the patients complained that physicians in general (i.e., both in public and private sectors)were not responsive, especially in terms of talking to them enough, compassionately touching them (for examining, for giving reassurance), and explaining their condition. They also complained of losing trust in physicians, as they seemed not to be caring, but businesslike. Patients demanded that, in order to be responsive, physicians should not only be prescribing drugs, but also be sensitive to patient’s financial status. Physicians should tell them the cost of treatment, try to understand whether patients can afford it, and if necessary, tailor the treatment accordingly. On the other hand, physicians also acknowledged their inadequacies, but attributed these to the overall health systems constraints, patient loads, lack of proper training on responsiveness issues, and often abuse by the patients. Psychometric analyses, described in manuscript-2, identified 34 items grouped under five domains (or subscales) to constitute the Responsiveness of Physicians Scale or, in short, ROP-Scale. The five domains, derived through EFA and later named through discussing with the relevant experts, are as follows: Friendliness, Respecting, Informing and guiding, Gaining trust, and Financial sensitivity. There were high inter-factor correlations between Respecting and Informing and guiding, and between Respecting and Friendliness. The scale has a very high internal consistency with ordinal alpha coefficient of 0.91. Inter-rater reliability was also very high with intra-class correlation coefficient (ICC) (2, k) of 0.84. The scale also demonstrated face validity (through expert consultation), content validity (through qualitative research and literature review) and criterion validity(concurrent validity by correlation coefficient of 0.51 with consultation time; and known-group validity by comparing public and private sector physicians’ responsiveness with private sector scoring 0.18 higher mean score). The quantitative part of manuscript-3 was based on the application of ROP-Scale, in which an average of the score of 34 items was considered as the overall responsiveness score. Each item had four response categories, with the lowest score of one (signifying lack of responsiveness) and the highest of four (signifying best practice). The study found the mean responsiveness score of public sector physicians to be1.98 and that of private sector physicians(in this manuscript only formal private sector was considered in both qualitative and quantitative analysis)2.16; and the difference statistically significant in t-test with t statistic of -6.04 (p-value <0.01). The difference remained statistically significant in the multivariable models after adjusting for the confounding covariates such as age, gender and local origin of the physician and age, gender and level of education of the patient. Qualitative data added value to this finding by suggesting that, despite slightly better responsiveness of private sector physicians, none of the sectors were sufficiently responsive, according to service seekers. In domain-specific evaluation of responsiveness, the public sector outperformed the private sector in domains of Gaining trust and Financial sensitivity. The domain Respecting was identified in DDA as the most important domain in dividing the public and private sector based on responsiveness. The qualitative part of the study found the private sector physicians to be more tolerant, polite, and courteous than the public sector physicians, as opined by patients. Nevertheless, private sector physicians were criticized by patients for attending more patients than their capacity, prescribing more diagnostic tests, and showing reluctance to refer patients who they failed to treat. Qualitative findings supported the quantitative findings that public sector physicians were more prudent in gaining trust and being financially sensitive to the patients. Conclusions This study demonstrated the detailed process of development and application of a psychometrically validated ROP-Scale. In this process, I reviewed the earlier work on health systems as well as HRH responsiveness, defined the HRH responsiveness, discussed caveats in different aspects of understanding and measuring responsiveness, proposed a conceptual framework to examine HRH responsiveness, identified five domains of HRH responsiveness, presented the findings across the domains of responsiveness, and compared the responsiveness of public and private sector physicians’ responsiveness. This study can pave the way for further research work, for example, on determinants of responsiveness, on contribution of responsiveness on health outcomes, validation studies in other settings and among other cadre, and comparative studies. This study can also contribute in the national and international policy decision-making. For example, at national level, this study can aid in in-depth understanding of expectation of people around performance of HRH, developing a context specific curriculum on doctor-patient communication, developing a guideline for regulatory interventions, and improving community ownership over health services. At international level, similar type of locally relevant testing of constructs and items can be tested, benefitting from the methodological and conceptual inputs from this study. This research can open up further avenues in the health policy and system research (HPSR) concerning the HRH both at local and global level

Trust in the Bangladeshi health system during the COVID-19 pandemic: a mixed-methods exploration

Lack of trust in public health institutions hinders pandemic management. Our aim was to determine levels of impersonal and interpersonal trust in the context of coronavirus disease 2019 (COVID-19) pandemic response in Bangladesh. As this mixed-methods research was conducted during the pandemic, data was gathered via an online survey involving 508 respondents, along with seven online focus group discussions with 50 purposively selected participants. Survey respondents have less trust in the health system than in the service providers. The lowest level of trust was observed in the Fairness content area of trust. While some non-clinical participants blamed doctors for shying away from caregiving during the pandemic, most praised them for providing care, risking their lives, and even sacrificing their lives in the process. Several participants also cited a lack of fairness in pandemic management, such as visible attempts by the decision-makers to protect the business interests without consideration for the safety of the poor. However, both clinicians and non-clinicians concurred on the need for the service providers to improve communication related to COVID-19 management. Health sector stewards in Bangladesh should take a science-based, equity-focused pandemic response to gain both impersonal and interpersonal trust and build a resilient health system in the long run

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

Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis

INTRODUCTION: Retention of human resources for health (HRH), particularly physicians and nurses in rural and remote areas, is a major problem in Bangladesh. We reviewed relevant policies and provisions in relation to HRH aiming to develop appropriate rural retention strategies in Bangladesh. METHODS: We conducted a document review, thorough search and review of relevant literature published from 1971 through May 2013, key informant interviews with policy elites (health policy makers, managers, researchers, etc.), and a roundtable discussion with key stakeholders and policy makers. We used the World Health Organization\u27s (WHO\u27s) guidelines as an analytical matrix to examine the rural retention policies under 4 domains, i) educational, ii) regulatory, iii) financial, and iv) professional and personal development, and 16 sub-domains. RESULTS: Over the past four decades, Bangladesh has developed and implemented a number of health-related policies and provisions concerning retention of HRH. The district quota system in admissions is in practice to improve geographical representation of the students. Students of special background including children of freedom fighters and tribal population have allocated quotas. In private medical and nursing schools, at least 5% of seats are allocated for scholarships. Medical education has a provision for clinical rotation in rural health facilities. Further, in the public sector, every newly recruited medical doctor must serve at least 2 years at the upazila level. To encourage serving in hard-to-reach areas, particularly in three Hill Tract districts of Chittagong division, the government provides an additional 33% of the basic salary, but not exceeding US$ 38 per month. This amount is not attractive enough, and such provision is absent for those working in other rural areas. Although the government has career development and promotion plans for doctors and nurses, these plans are often not clearly specified and not implemented effectively. CONCLUSION: The government is committed to address the rural retention problem as shown through the formulation and implementation of related policies and strategies. However, Bangladesh needs more effective policies and provisions designed specifically for attraction, deployment, and retention of HRH in rural areas, and the execution of these policies and provisions must be monitored and evaluated effectively

Retaining Doctors in Rural Bangladesh: A Policy Analysis

Abstract 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

What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research

Understanding and Measuring Responsiveness of Human Resources for Health in Rural Bangladesh

Introduction Responsiveness of human resources for health (HRH) is defined as the social actions that health providers do to meet the legitimate expectations of service seekers. Lack of responsiveness may dissuade patients from early care seeking, diminish their interest in adopting preventive health information, decrease trust with health service providers, and marginalize at-risk population groups, leading to compromised wellbeing. Most importantly, responsiveness is related to the human rights of the patients. The overall goal of this dissertation was to examine HRH responsiveness in rural Bangladesh, to develop a scale to measure the responsiveness, and finally to demonstrate the application of the measurement method. This goal has been addressed in three separate manuscripts, which aimed to answer the following questions, respectively: 1. What are the perceptions of outpatient healthcare users and providers regarding what constitutes responsiveness of physicians in rural Bangladesh? 2. How can we measure the responsiveness of physicians in rural Bangladesh? 3. What are the differences in responsiveness of physicians between those working in the public sector as opposed to those working in the private sector in rural Bangladesh? Methods This study adopted a multiphase mixed methods design, in which the qualitative part was followed by a quantitative part in data collection (sequential).In the latter stage of the project, both qualitative and quantitative aspects simultaneously complemented each other in data analysis and interpretation (concurrent). Data collection took place in rural parts of Khulna, a southwestern division of Bangladesh. The qualitative portion consisted of in-depth interviews (IDI) of physicians (seven public, five private, five informal), in-depth interviews of clients (n=7), focus group discussions (FGD) with clients (two sessions each with males and females), and participant observations in consultation rooms of public, private, and informal sector healthcare providers (one week in each setting). The quantitative research consisted of structured observation (SO) of 393 physicians (195 from public and 198 from private sector). This data was collected for developing a scale of responsiveness through exploratory factor analysis (EFA), involving 64 items (generated through the qualitative part of this project). This data was also intended for applying the scale, once developed, to compare the responsiveness of public and private sector physicians. Inter-rater reliability was assessed by same three raters observing 30 consultations, using the scale (later named as Responsiveness of Physicians Scale or in short ROP-Scale). Study data were collected between August 2014 and January 2015.Qualitative data were analyzed by the framework analysis method. World Health Organization’s (WHO) health systems responsiveness framework was modified, based on literature review and expert opinions, to include the following domains for qualitative analysis: Friendliness, Respecting, Informing and guiding, Gaining trust, and Optimizing benefit. Quantitative data were analyzed by EFA, followed by assessment of internal consistency by ordinal alpha coefficient and inter-rater reliability by intra-class correlation coefficient (ICC). For comparing responsiveness of public and private sector physicians two sample t-test, multiple linear regression (MLR), multivariate analysis of variance (MANOVA), and descriptive discriminant analysis (DDA) were used. This dissertation presents three manuscripts. Manuscript-1 presents the qualitative component to facilitate understanding of the local perceptions around responsiveness of physicians. Manuscript-2 presents the quantitative data to develop a psychometric scale to measure responsiveness of physicians and then to evaluate the reliability and validity of the scale. Manuscript-3 used a mixed methods approach to compare responsiveness of public and private sector physicians. Results Manuscript-1 showed that user and provider perceptions of responsiveness of physicians in rural Bangladesh often overlapped but at times diverged. Due to high patient load, physicians in the public sector usually failed to spend enough time with patients for proper history taking, asking questions, examining, and reassuring. Although not satisfactory, according to patients in qualitative part of the research, physicians in the private sector were more responsive towards the patients, especially in terms of conducting examinations with care, asking questions, and giving little reassurance. Most of the patients complained that physicians in general (i.e., both in public and private sectors)were not responsive, especially in terms of talking to them enough, compassionately touching them (for examining, for giving reassurance), and explaining their condition. They also complained of losing trust in physicians, as they seemed not to be caring, but businesslike. Patients demanded that, in order to be responsive, physicians should not only be prescribing drugs, but also be sensitive to patient’s financial status. Physicians should tell them the cost of treatment, try to understand whether patients can afford it, and if necessary, tailor the treatment accordingly. On the other hand, physicians also acknowledged their inadequacies, but attributed these to the overall health systems constraints, patient loads, lack of proper training on responsiveness issues, and often abuse by the patients. Psychometric analyses, described in manuscript-2, identified 34 items grouped under five domains (or subscales) to constitute the Responsiveness of Physicians Scale or, in short, ROP-Scale. The five domains, derived through EFA and later named through discussing with the relevant experts, are as follows: Friendliness, Respecting, Informing and guiding, Gaining trust, and Financial sensitivity. There were high inter-factor correlations between Respecting and Informing and guiding, and between Respecting and Friendliness. The scale has a very high internal consistency with ordinal alpha coefficient of 0.91. Inter-rater reliability was also very high with intra-class correlation coefficient (ICC) (2, k) of 0.84. The scale also demonstrated face validity (through expert consultation), content validity (through qualitative research and literature review) and criterion validity(concurrent validity by correlation coefficient of 0.51 with consultation time; and known-group validity by comparing public and private sector physicians’ responsiveness with private sector scoring 0.18 higher mean score). The quantitative part of manuscript-3 was based on the application of ROP-Scale, in which an average of the score of 34 items was considered as the overall responsiveness score. Each item had four response categories, with the lowest score of one (signifying lack of responsiveness) and the highest of four (signifying best practice). The study found the mean responsiveness score of public sector physicians to be1.98 and that of private sector physicians(in this manuscript only formal private sector was considered in both qualitative and quantitative analysis)2.16; and the difference statistically significant in t-test with t statistic of -6.04 (p-value <0.01). The difference remained statistically significant in the multivariable models after adjusting for the confounding covariates such as age, gender and local origin of the physician and age, gender and level of education of the patient. Qualitative data added value to this finding by suggesting that, despite slightly better responsiveness of private sector physicians, none of the sectors were sufficiently responsive, according to service seekers. In domain-specific evaluation of responsiveness, the public sector outperformed the private sector in domains of Gaining trust and Financial sensitivity. The domain Respecting was identified in DDA as the most important domain in dividing the public and private sector based on responsiveness. The qualitative part of the study found the private sector physicians to be more tolerant, polite, and courteous than the public sector physicians, as opined by patients. Nevertheless, private sector physicians were criticized by patients for attending more patients than their capacity, prescribing more diagnostic tests, and showing reluctance to refer patients who they failed to treat. Qualitative findings supported the quantitative findings that public sector physicians were more prudent in gaining trust and being financially sensitive to the patients. Conclusions This study demonstrated the detailed process of development and application of a psychometrically validated ROP-Scale. In this process, I reviewed the earlier work on health systems as well as HRH responsiveness, defined the HRH responsiveness, discussed caveats in different aspects of understanding and measuring responsiveness, proposed a conceptual framework to examine HRH responsiveness, identified five domains of HRH responsiveness, presented the findings across the domains of responsiveness, and compared the responsiveness of public and private sector physicians’ responsiveness. This study can pave the way for further research work, for example, on determinants of responsiveness, on contribution of responsiveness on health outcomes, validation studies in other settings and among other cadre, and comparative studies. This study can also contribute in the national and international policy decision-making. For example, at national level, this study can aid in in-depth understanding of expectation of people around performance of HRH, developing a context specific curriculum on doctor-patient communication, developing a guideline for regulatory interventions, and improving community ownership over health services. At international level, similar type of locally relevant testing of constructs and items can be tested, benefitting from the methodological and conceptual inputs from this study. This research can open up further avenues in the health policy and system research (HPSR) concerning the HRH both at local and global level

Achieving universal health coverage through community empowerment: a proposition for Bangladesh

This note was published in Indian Journal of Community Medicine [© 2014 Medknow Publications] and the definite version is available at: http://www.ijcm.org.in/article.asp?issn=0970-0218;year=2014;volume=39;issue=3;spage=129;epage=131;aulast=JoarderPublishe

Meaning of death: an exploration of perception of elderly in a Bangladeshi village

The aim of this qualitative study was to explore the perceptions of meaning of death among the elderly in a Bangladeshi community, and to understand how the meaning of death affects one’s overall well-being. Understandings of death were explored through the explanations respondents provided on the journey of the soul during lifetime and the afterlife, concepts of body-soul duality, and perceived “good” and “bad” deaths. The relationship to well-being was expressed in terms of longevity, anxiety/acceptance of death, and preferred circumstances for death. Seven in-depth interviews and one informal discussion session provided the bulk of the data, while Participatory Rapid Appraisal (PRA) tools, including daily routines and body mapping, supplemented our findings. Elderly members of the community had very specific ideas about the meaning of death, and provided clear explanations regarding the journey of the soul, drawing on ideas of body-soul duality to substantiate claims. Due to long coexistence fusion of Hindu and Muslim ideas around death was found. Anxiety/fear of death was associated with some secular issues, on the contrary the perception of longevity was found linked with spirituality. Insights revealed from this study of subtle differences in the perceptions regarding issues around death may aid the policy makers develop effective end-of-life interventions