Bangladesh Health Watch

The project Making Bangladeshs Healthcare Systems More Responsive and Participatory (2019-23) in its four-year life span undertook a large number and range of activities to achieve the stated project goal. The major achievements from these activities can be grouped into three categories: • Establishing a potentially sustainable model for generating local-level accountability • Bringing about improvements in health service delivery through indigenous local-level initiatives • Contribution to knowledge and understanding of specific issues in health • Strengthening BHWs capacity and image as a health sector advocate The Regional Chapters, through forums at district, upazila, and union levels along with the youth forums have emerged as a model for instituting local-level accountability of government health facilities. These forums, with well-capacitated members drawn from different segments of society and having a sizeable representation of women have by now developed processes to systematically review non-technical aspects of service delivery in their respective government facility, identify the priority problems and raise them with the local level facility management through periodic authority meetings to seek solutions to those issues. These meetings which bring together the facility managers and providers on one hand, and the healthcare users and forum members on the other, have emerged as a new collaborative way to work together to mitigate some of the problems. This project had taken a number of initiatives to instill sustainability: 1) A well-respected local NGO (host NGO) was selected for each of the forums to support the forum members in secretarial and organizational work; this NGO was paid only a token minimal honorarium to support the part-time payment of designated staff to support the forums. The NGO CEOs and focal points subsequently got involved in delegations to meet senior government officials the NGOs name appeared side by side with that of the forums and BHW, Increasing its credibility and reputation, and focal points were given different types of capacity-building inputs. These measures gave a degree of ownership of the local NGO to the forum activities. During evaluations and in conversations with third parties the NGOs have expressed their serious intent of continuing to work under this arrangement, as they see it as a contributor to their image and experience. 2) Selection of motivated members to increase voluntarism: The forum members give considerable time to the initiative and are not remunerated in any way. BHW introduced this arrangement to screen in individuals who were interested in bringing about changes, rather than being motivated by the allure of fees/honoraria. Over the years, the dropout rate of the members has remained at around 30 percent which is not a drastic fall; the members who remain in the forums continue to take on their responsibility with enthusiasm. 3) Developing ownership of the RCs among members: Members are given a lot of autonomy to develop their work plans by themselves. They actively participate in meetings with the health facility management and other local authorities which helps to elevate their social status. They are also provided with training, the topics of which are identified by the members themselves and vetted by BHW. All of these measures together create a sense of ownership for the initiative, as recognized by the members themselves. In addition, the reward of seeing some of their work positively impact service delivery provides a lot of satisfaction and encourages them to remain attached to the forums, as reported by forum members. 4) Bringing about improvements in health service delivery through indigenous local-level initiatives: Since the forum members are on the ground and constantly in touch with their centers, they can ensure that changes continue to hold, and are not lost soon afterward. Thus, in the concerned facilities, the additional chairs organized for waiting patients are still there, the solar panels and tube wells installed in two community clinics are working, separate ticket counters for males and females are functioning, and so on; some initiatives however require regular re-enforcement through the authority meetings, e.g. restricting the time of visit to facilities by medical representatives of pharmaceutical companies. There has been some impact of the forums work on hospital attendance of service providers- attendance of doctors in community clinics has been initiated and absenteeism has been reduced at least in one district hospital of Bagerhat District. 5) Contribution to knowledge and understanding of, and action on specific issues in health:The project made important contributions to existing knowledge through research and reviews. Thus quick research undertaken at the beginning of the Covid pandemic helped to raise the issue of low-quality PPE being provided to government doctors which kick-started a number of actions by the government to address the situation. The three cycles of budget analysis carried out under the project have helped to establish evidence that the health sector is massively under-budgeted and PHC. Strengthening BHWs capacity and image as a health sector advocate:Several initiatives taken under the project have helped BHW to emerge as a strong voice in the health sector: •Partnerships were established, e.g. with the local NGOs acting as Host Organizations, with individual organizations (e.g. BSMMUs Health Informatics Department, Health Economics Institute, Unnayan Sammanay) and individuals (CHT Zila Parishad Chair, District Commissioners and UNOs and other local government officials of the eight regions). • An important partnership with the journalists community also evolved in the course of the project which resulted in strong media coverage of most BHW events and a number of catalytic investigative stories by journalists. • BHW successfully promoted itself as a trusted health watch dog by updating its website, and social media presence- especially Facebook, YouTube, and twitter, press coverages of its events. Study on Linking the Voice of the Poor to the 5th Sector Program: Climate change impact on health: Recognizing the significant impact of the present emerging global and national climate situation on livelihoods and health, BHW commissioned a research assignment to collect the voices of climate-affected communities. The study highlighted health trends in various climate-vulnerable areas. These trends included an increase in stroke rates in river-erosion-prone areas and a heightened risk of preeclampsia among pregnant women in southern regions due to high salinity. Additionally, prevalent health issues such as skin diseases, fatigue, eyesight problems, reproductive health problems, diabetes, hypertension, jaundice, and diarrhea were identified. Study on Climate Change induced Mental Health Problems in the coastal area of Bangladesh: Several pieces of literature revealed that Bangladesh faces significant challenges from climate change due to its vulnerable location and socio-economic conditions. Climate-related health issues are increasing, including heat-related mortality and mental health disorders. The project conducted a mid term review and BHW also conducted an end evaluation aimed to evaluate the project with five specific objectives. Recommendations from the end of project evaluation was brought into the next phase 2024-2025.

BHW, through this proposed project, will attain the following change (outcome/purpose):- A more responsive healthcare system that delivers better quality, more transparent and equitable healthcare for all being informed by peoples participation and voice. The above outcome will contribute to health of all citizens, especially marginalized, hard-to-reach, poor, populations particularly women and young girls. The following outputs will lead to the aforementioned outcome: i. Civil society platforms/individual voices enabled to hold government (and other actors) accountable to major health sector commitments ii. Changes in policy/practices as a result of evidence based advocacy carried out to improve the situation related to quality of care, transparency and equity iii. Understanding of duty bearers on quality of care, transparency and equity enhanced. In order to achieve the above three outputs, three main sets of activities, will be carried out:  a) Planned advocacy to enable civil society platforms/individual voices to hold the government accountable to major health sector commitments b) Evidence based, topical advocacy on situation of quality of care, transparency and equity in the health sector c) A multi-pronged approach to improve awareness and understanding of duty-bearers on quality of care, accountability and equity. The following assumptions will apply to the Theory of Change: From Activities to Outputs - CSOs will participate in BHW activities and share necessary information - Government officials at all levels will be supportive to bring civil society inputs to improving performance of the sector - Government officials will be open to constructive criticism From Outputs to Outcome - Government will remain committed to universal health coverage and SDGs - Government will continue to prioritise Quality of Care, equity and accountability issues - Government will remain committed to peoples participation and engagement - Government will continue taking evidence based policy decisions