The Implementation of National Action Plan (NAP) on Antimicrobial Resistance (AMR) in Bangladesh: Challenges and Lessons Learned from a Cross-Sectional Qualitative Study

This study explored the current situation of the National Action Plan (NAP) on Antimicrobial Resistance (AMR) implementation in Bangladesh and examined how different sectors (human, animal, and environment) addressed the AMR problem in policy and practice, as well as associated challenges and barriers to identifying policy lessons and practices. Informed by a rapid review of the available literature and following the World Health Organization (WHO) AMR situation analysis framework, a guideline was developed to conduct in-depth interviews with selected stakeholders from January to December 2021. Data were analysed using an adapted version of Anderson’s governance framework. Findings reveal the absence of required inter-sectoral coordination essential to a multisectoral approach. There was substantial coordination between the human health and livestock/fisheries sectors, but the environment sector was conspicuously absent. The government initiated some hospital-based awareness programs and surveillance activities, yet no national Monitoring and Evaluation (M&E) framework was established for NAP activities. Progress of implementation was slow, constrained by the shortage of a trained health workforce and financial resources, as well as the COVID-19 pandemic. To summarise, five years into the development of the NAP in Bangladesh, its implementation is not up to the level that the urgency of the situation requires. The policy and practice need to be cognisant of this fact and do the needful things to avoid a catastrophe

Exploring the knowledge, attitudes, practices and lived experiences of frontline health workers in the times of COVID-19: A qualitative study from Bangladesh

Objective: This study explored Frontline Health Workers’ (FLWs) knowledge, attitude and practice (KAP) on COVID-19 and their lived experiences, in both their personal and work lives, at the early stage of the pandemic in Bangladesh. Design, setting and participants: This was a qualitative study conducted through telephone interviews in May 2020. A total of 41 FLWs including physicians, nurses, paramedics, community healthcare workers and hospital support staff from 34 public and private facilities of both urban and rural parts of Bangladesh participated in the interview. A purposive sampling technique supplemented by a snowball sampling method was followed to select the participants. The in-depth interviews followed a semi-structured interview guide, and we applied the thematic analysis method for the qualitative data analysis. Findings: Except physicians, the FLWs did not receive any institutional training on COVID-19, including its prevention and management, in most instances. Also, they had no training in the use of personal protective equipment (PPE). Their common source of knowledge was the different websites or social media platforms. The FLWs were at risk while delivering services because patients were found to hide histories and not maintaining safety rules, including physical distancing. Moreover, inadequate supply of PPE, fear of getting infected, risk to family members and ostracisation by the neighbours were mentioned to be quite common by them. This situation eventually led to the development of mental stress and anxiety; however, they tried to cope up with this dire situation and attend to the call of humanity. Conclusion: The uncertain work environment during the COVID-19 pandemic simultaneously affected FLWs’ physical and emotional health in Bangladesh. However, they showed professional devotion in overcoming such obstacles and continued to deliver essential services. This could be further facilitated by a quick and targeted training package on COVID-19, and the provision of supplies for delivering services with appropriate safety precautions.PRIFPRI3; 5 Strengthening Institutions and Governance; DCA; ISIPHN

Assessment of staffing need through a workload analysis in Jhenaidah and Moulvibazar, Bangladesh: a Workload Indicator of Staffing Need (WISN) study

Background: Improvement of health workers' performance is vital for the improvement of health-care service delivery, and workload management is an important factor in improving performance. This study aimed to assess the current workload and staffing need for delivering optimum health-care services in the public-sector district health system in Bangladesh. Methods: Between July 2, 2017, and Nov 30, 2017, we followed the steps of WHO's Workload Indicator of Staffing Need (WISN) methodology. We combined qualitative (document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey), to collect data in 24 health facilities from district hospitals up to community clinics in Jhenaidah and Moulvibazar districts, Bangladesh. The study included physicians, nurses, medical assistants, family welfare visitors, community care providers, and family welfare assistants. Workload components were defined on the basis of inputs from experts (n=5), refined further by actual service providers (n=87). We used WHO WISN software to calculate standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference, and WISN ratio. Findings: Seven of the 20 staff categories had a very high workload (WISN ratio 0·30–0·49), and five staff categories had extremely high workload (0·10–0·29) indicating an overall high workload in the service providers studied. Medical consultants had the highest workload (WISN ratio 0·16), followed by other specialists. The staff category with the most number of positions needing to be filled was nurses at district hospitals (a mean of 136 vacant positions per facility), followed by general physicians (35). We noted that nurses were predominantly occupied with support activities (60% in the case of district nurses and 50% in sub-district facilities), instead of actual nursing care. If the vacant posts were filled, the workload for existing workers is reduced. However, simply filling the vacant posts would not be sufficient to reduce staff workload in some staff categories, such as nursing. Interpretation: WISN method of estimating workload and staff requirements can aid policymakers in making the best uses of existing human resources. Thus, WISN should be incorporated as a planning tool for managers at the district level. Implementation research should be carried out on how the workload-based staffing decisions can be effectively integrated into health systems. Funding: WHO Bangladesh

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region.

Governance failures undermine efforts to achieve universal health coverage and improve health in low- and middle-income countries by decreasing efficiency and equity. Punitive measures to improve governance are largely ineffective. Social accountability strategies are perceived to enhance transparency and accountability through bottom-up approaches, but their effectiveness has not been explored comprehensively in the health systems of low- and middle-income countries in south and Southeast Asia where these strategies have been promoted. We conducted a narrative literature review to explore innovative social accountability approaches in Bangladesh, Bhutan, India, Indonesia, the Maldives, Myanmar and Nepal spanning the period 2007-August 2017, searching PubMed, Scopus and Google Scholar. To augment this, we also performed additional PubMed and Google Scholar searches (September 2017-December 2019) to identify recent papers, resulting in 38 documents (24 peer-reviewed articles and 14 grey sources), which we reviewed. Findings were analysed using framework analysis and categorized into three major themes: transparency/governance (eight), accountability (11) and community participation (five) papers. The majority of the reviewed approaches were implemented in Bangladesh, India and Nepal. The interventions differed on context (geographical to social), range (boarder reform to specific approaches), actors (public to private) and levels (community-specific to system level). The initiatives were associated with a variety of positive outcomes (e.g. improved monitoring, resource mobilization, service provision plus as a bridge between the engaged community and the health system), yet the evidence is inconclusive as to the extent that these influence health outcomes and access to health care. The review shows that there is no common blueprint which makes accountability mechanisms viable and effective; the effectiveness of these initiatives depended largely on context, capacity, information, spectrum of actor involvement, independence from power agendas and leadership. Major challenges that undermined effective implementation include lack of capacity, poor commitment and design and insufficient community participation