Creating responsive health systems: improving the use of feedback from service users in quality assurance and human resource management in Bangladesh

Lead Research Organisation: University of Leeds
Department Name: School of Medicine

Abstract

This project aims to improve the responsiveness of the health system in Bangladesh. This addresses an issue of high interest to the country's policymakers.

Effective interaction and engagement between the health service users and practitioners and policymakers is an important attribute of responsive health systems. Central to this concept is the opportunity for users to provide feedback on their experiences engaging with the health system, and vitally the ability of the health system to respond to users' suggestions.

This project focuses on Bangladesh, a low income Asian country where the Ministry of Health and Family Welfare (MOHFW) is implementing a program allowing service users to send feedback via SMS texts. The texts from the whole country are aggregated in a web portal, which is monitored by the MOHFW staff, who are then expected to follow up each issue with both a sender and local authorities. Service users can also provide feedback directly to health management committees at Upazila level, and through suggestion boxes in each health facility. However, it is unclear how issues received directly at the Upazila level are followed-up and by whom. .

The AIM of this project is to assist the policymakers in designing a comprehensive health systems intervention to make Bangladesh's health system more responsive. Specific project OBJECTIVES are to work closely with national and local decision-makers to:
1. Develop an in-depth understanding of the nature and contents of, and key reasons for, feedback received from health service users at Upazila level;
2. Analyse the processes of collecting and responding to service users' feedback at Upazila level, as well as the key contextual facilitators and constraints influencing these processes;
3. Assess the approach to, and processes of, service quality assurance and human resource management, focusing specifically on the use of feedback from service users at Upazila level;
4. Using results of objectives 1-3, develop a comprehensive health systems intervention to improve the use of feedback from service users in quality assurance and human resource management processes at Upazila level.

This 18-months project will analyse the national-level user feedback data and collect more detailed qualitative information in one district in Bangladesh. Within the district, we will focus on two Upazila Health Complexes (UHC) which, being the first level referral services from the primary health care, are the backbone of the health system.

We will implement a multi-method health systems research using realist evaluation. Qualitative and quantitative data will be collected using combinations of:
1) in-depth interviews with purposefully-identified service users and gender and age-specific focus groups with communities to explore their knowledge of and use of feedback systems;
2) in-depth interviews to explore views of purposefully-selected service providers and managers at the UHC about the user feedback systems;
3) analysis of country-level secondary data on user feedback from the government web portal, to understand types of issues, their location and gender and age of users who initiated issues;
4) non-participant observation of: feedback environment in the district, health management committee meetings and UHC routine quality assurance and staff management practices;
5) review of key documents (e.g. feedback to users and actions taken, meeting minutes, quality assurance guidelines, staff performance appraisal and supervision records).

Throughout the project, we will work closely with decision-makers, to facilitate the shared understanding, adoption of results into policy and practice and achieving its highest impact. Project results will be communicated widely through policy briefs, presentations at management meetings, development of newsletters and press-releases, to ensure their uptake in policy and practice in Bangladesh and wider.

Technical Summary

The AIM of this project is to assist the policymakers in designing a comprehensive health systems intervention to make the Bangladesh's health system more responsive.

Specific project OBJECTIVES are to work closely with national and local decision-makers to:
1. Develop an in-depth understanding of the nature and contents of, and key reasons for, feedback received from health service users at Upazila level;
2. Analyse the processes of collecting and responding to service users' feedback at Upazila level, as well as the key contextual facilitators and constraints influencing these processes;
3. Assess the approach to, and processes of, service quality assurance and human resource management, focusing specifically on the use of feedback from service users at Upazila level;
4. Using results of objectives 1-3, develop a comprehensive health systems intervention to improve the use of feedback from service users in quality assurance and human resource management processes at Upazila level.

This project focuses on Bangladesh, a low income Asian country where the Ministry of Health and Family Welfare (MOHFW) is implementing a program allowing service users to send feedback via SMS texts. This 18-months project will analyse the national user feedback data and focus in-depth on two Upazila Health Complexes (UHC) in one district.

Throughout the project, we will work closely with decision-makers, to facilitate the shared understanding, adoption of results into policy and practice and achieving its highest impact.

The project results will be communicated widely through development of policy briefs, presentations at management meetings, development of newsletters and press-releases, to ensure their uptake in policy and practice in Bangladesh and wider.

Planned Impact

We expect our research to have high impact on policy and practice in Bangladesh and internationally, due to:
- improvements in the user feedback system, enhancing the responsiveness of Bangladesh's health system and further empowering the public to hold health system to account;
- development of expertise in how to advise policy-makers and practitioners on the development and implementation of context-specific comprehensive health systems intervention;
- utilisation of an innovative cross-disciplinary approach to assess the effectiveness of a complex intervention;
- capacity strengthening and use of an innovative research approach in one of the world's most densely populated countries;
- scientific advancement of theories on how to make health systems more responsive in the context of low- income countries.

The main beneficiaries are:
- Policy-makers and implementers at Upazila, District, Division, National, Asian and Global levels responsible for the development and implementation of policies and systems concerning user feedback, quality of care and human resource management
- Bangladesh's public and private service providers and practitioners
- Local, national and international civil society organisations and user associations with interest in advocacy and social accountability of the health systems
- National and international academia interested in health systems and policy research and evaluation of complex interventions using robust methodologies
- Local, national and international media with a focus on health and social issues.

The economic and societal impact will be generated through the following benefits:

1) Improved policymaking.
Bangladesh's policymakers will be provided with clear and robust results of analysis of the current system to collect and respond to user feedback. This will enable them to make informed decisions about the future implementation of the government SMS programme and future similar initiatives.
The comparative and in-depth analysis will equip policy-makers with a clear understanding of what works for whom and under what circumstances. It will allow further strengthening of the programme in other parts of the country.

2) Improved policy implementation
Bangladesh's policy implementers at all levels will improve their understanding of how to enhance the performance of the system to collect and respond to user feedback.
The research will inform the need, and possible paths, for a change in culture and practices within health facilities to improve the utilisation of the user-supplied information in improving quality of health services and improvement in human resource planning and management processes.
The research results will increase the public awareness in Bangladesh, and other similar countries, on how to improve accountability within national health systems. This information will be taken up by local, national and international by civil society organisations, user associations and media groups.

3) Improved health systems
The research will inform the development of responsive health system in Bangladesh, and in other low and middle income countries. This will be achieved through the initial strengthening of the user feedback system and its subsequent integration with quality assurance and human resource management.
International and national policymakers will be able to use the evidence for health systems strengthening through evidence-informed user feedback programme in Bangladesh and an improved understanding of the context-dependency of implementation of this complex intervention.

4) Improved health outcomes
Health service users in Bangladesh, specifically marginalised groups such as women with compounded effects of vulnerability (poverty, education, region, religion and ethnicity) will benefit from participation in research to gain improved awareness of feedback processes which in turn will raise their engagement with health systems.
 
Description Contribution to developing National Guidelines for Grievance Redressal in Bangladesh by Dr Rumana Huque
Geographic Reach National 
Policy Influence Type Participation in a advisory committee
Impact In December 2018, the RESPOND team leader in the ARK Foundation, Dr Rumana Huque, was invited by the Health Economics Unit of the national Ministry of Health and Family Welfare to join the Technical Working Group for developing National Guidelines for Grievance Redressal in Bangladesh. This was in recognition of the experience and results generated by the RESPOND project. The resultant guidelines will eventually be implemented nation-wide and will assist the health service providers to effectively and efficiently address patient feedback.
 
Description Media sensitisation event at the University of Dhaka, Bangladesh 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact In January 2018, Dr. Rumana Huque (of ARK Foundation) attended a 'media sensitization event' at the University of Dhaka, Bangladesh, where she introduced the work of the RESPOND project and also raised awareness about key challenges of grievance redress systems in Bangladesh. About 50 people including 26 journalists were present at the event. Stakeholder groups represented at the event were: i) Journalists, ii) third sector, iii) researchers; and iv) academics. In response to requests for further information, Dr Huque handed out the project awareness leaflet to those present at the workshop, for distribution among their networks.
Year(s) Of Engagement Activity 2018
 
Description Organised session on innovative approaches for enhancing the role of communities in health systems at HSR2018 chaired by Dr Tolib Mirzoev 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact In October 2018 the members of the REVAMP and RESPOND teams led an organised session at the 5th Global Symposium for Health Systems Research, to discuss innovative approaches to enhancing the role of communities in health systems: experiences from four different countries. The session provided a platform for participants to reflect and debate issues related to enhancing community engagement in promoting appropriate treatment-seeking practices at the grassroots levels in low- and middle-income countries. The session, which was organised across the different projects including the REVAMP and RESPOND, was chaired by the REVAMP and RESPOND PI Dr Tolib Mirzoev and included members of the REVAMP (Dr Bassey Ebenso, Dr Enyi Etiaba) and RESPOND (Dr Rumana Huque). It consolidated case studies from four (4) countries namely Bangladesh, Nepal, Nigeria and Vietnam, to enable participants to share their own experiences of community health systems. The workshop led to the identification of effective approaches used to improve community health systems across the four countries
Year(s) Of Engagement Activity 2018
 
Description Policy influence meeting with mid-level policymakers in Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact In December 2017, the RESPOND team organised a policy influence meeting with mid-level policymakers in Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of Bangladesh, to provide project updates to the HEU. Ten (10) people were present at the meeting, representing the following stakeholders groups: i) policymakers, ii) researchers; and iii) health practitioners. The meeting was also used to strengthen collaborative links between the RESPOND project, the HEU and other and development partners (e.g. UNICEF) for strengthening grievance redressal mechanisms in Bangladesh.
Year(s) Of Engagement Activity 2017
 
Description Policy influence meeting with the new appointed Director General and Additional Secretary of Health Economics Unit (HEU), Ministry of Health and Family Welfare of Bangladesh 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact In January 2018, the RESPOND three-member team held a policy influence meeting with the newly appointed Director General (DG) and Additional Secretary of Health Economics Unit (HEU), Ministry of Health and Family Welfare of Bangladesh (MOHFW). The meeting was used to introduce the project and seek the DG's support for project activities, which included working with policymakers and practitioners to design comprehensive interventions to improve patient feedback systems in Bangladesh. Eight (8) representatives of stakeholder groups attended the policy influence meeting. Groups represented were: i) policymakers, ii) third sector organization, iii) health professionals and iv) researchers. In response, the DG expressed his interest in collaborating with RESPOND group to strengthen the grievance mechanism within the health system.
Year(s) Of Engagement Activity 2018
 
Description Project awareness workshop with the Ministry of Health and Family Welfare 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact In early-March 2017, the RESPOND team in collaboration with Health Economics Unit (HEU) of the Bangladesh's Ministry of Health and Family Welfare organized a 0.5-day workshop in Dhaka with key stakeholders working on voice and accountability issues. A total of about 30 participants attended the event. Stakeholder groups represented include: i) policymakers at the HEU, ii) MIS units of two directorates of MOHFW, iii) Funders (WHO, USAID, Unicef) and v) local NGOs. This initial introductory workshop was used to understand the policy direction and existing initiatives undertaken by the HEU in relation to voice and accountability, and introduce and discuss the RESPOND project with key project stakeholders.
Year(s) Of Engagement Activity 2017
 
Description Research communication and validation workshop in Dhaka, Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact On 14 March 2018, the RESPOND team in collaboration with Health Economics Unit (HEU) of the Bangladesh's Ministry of Health and Family Welfare organized a one-day research communication and validation workshop in Dhaka with key stakeholders working on voice and accountability issues. A total of 30 participants were represented at the event. Stakeholder groups represented include: i) policymakers at the HEU, ii) MIS units of two directorates of MOHFW, iii) Upazila Health Complexes, iv) Funders (WHO, USAID, Unicef) and v) local NGOs. The meeting was used to share initial findings of the RESPOND project with key project stakeholders for validation and subsequent discussion. This was the first of the two workshops planned by the project, with the second one planned in May 2018 which will aim to facilitate development of interventions to further strengthen the patient feedback system in Bangladesh.
Year(s) Of Engagement Activity 2018
 
Description Stakeholder workshop to develop interventions for improving patient feedback systems at the Ministry of Health and Family Welfare 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact In early-June 2018, the RESPOND team in collaboration with Health Economics Unit (HEU) of Bangladesh's Ministry of Health and Family Welfare organized a 0.5-day workshop in Dhaka with key stakeholders working on voice and accountability issues. A total of 36 participants attended the event, which was co-led by Dr Rumana Huque, RESPOND team leader in the ARK Foundation. Stakeholder groups represented included i) policymakers at the HEU, ii) MIS units of two directorates of MOHFW, iii) Funders (WHO, USAID, UNICEF, the World Bank) and v) local NGOs. The workshop drew on international evidence on strategies to improve patient feedback systems (including a published review by the RESPOND PI, Dr Tolib Mirzoev) to develop a comprehensive intervention to improve patient feedback systems in Bangladesh. Specific materials developed during and shortly after the workshop included: i) awareness leaflet and poster for service users; and ii) guidelines for addressing patient complaints
Year(s) Of Engagement Activity 2018