Assessing facility performance to improve health service delivery towards Universal Health Coverage in Bangladesh
In 2014, the government of Bangladesh launched the yearly assessment of public health facility performance using four methods developed by WHO: Physical assessments of facilities by a visiting team of assessors; Patient satisfaction surveys covering several topics like dignity, communication, confidentiality and quality of basic amenities, among the others; On-site monitoring tools applied monthly by health managers to review and report on the performance of their health facilities and community health services under their jurisdiction; The online monitoring tool, based on routine health information for each health facility.
This initiative aims at improving and ensuring the quality of health services delivery in the public sector in Bangladesh. By strengthening good governance practices and leadership skills, the World Health Organization Office in Bangladesh is closely collaborating with the government to increase the accessibility of public health services. To leave no one behind and meet the universal coverage enshrined as SDG 3.8, the initiative aims towards the highest quality and safety standards of public health services and facilities reaching all citizens, especially the country’s vulnerable population.
The government of Bangladesh has undertaken a core initiative to support SDG 3.8 Universal Health Coverage. The annual facility performance assessment initiative is to ensure effective, quality and standard delivery of an Essential Service Package (ESP) that the government commits to its citizens to advance UHC in Bangladesh.
WHO provided technical support to the government to develop a web-based dashboard for monitoring health facilities performance using routine health information. In collaboration with other partners, the WHO has developed the health facility assessment tools and trained several assessors to assess the country’s health facilities. On an yearly basis, the assessors visit the health facilities across the country and evaluate their performance. Field health managers also conduct monthly reporting of the services and facilities under their jurisdiction through an online measurement and scoring system. The system shows real-time data on a dashboard open for consultation to all the field health managers in Bangladesh, setting a virtuous competition and constant monitoring of their performances. The initiative also contributes to enhancing good governance, as it allows the monitoring of the investments made in the national public health sector. Over 500 public health facilities, including public and specialized hospitals and medical colleges, from the Upazila to the tertiary level, in Bangladesh, have been assessed every year since 2014. A great incentive to participate in this performance evaluation initiative is the Health Minister’s National Award, awarded to the best performing participating health facilities. The assessment measures the health facilities' fit-for-service delivery capacity, including cleanliness, staff punctuality, placement of appropriate display boards and patient guidance signs, improvement of laboratory services, waste management, and many others. Patient satisfaction with the quality of services is also assessed.
A comparative analysis of the results of health facilities that were consistently assessed from 2017 to 2019 demonstrates a sharp increase in the utilization of services across all facility levels. There has been a 74% increase in antenatal care consultations (ANC), with the sharpest rises at Medical College Hospitals in this period (160%). Postnatal care consultations (PNC) has witnessed a growth in service utilization; there has been an increase in standard delivery by 12% between 2018 and 2019 at the Upazila Health Complexes (UHCs). The patient satisfaction surveys demonstrate that waiting times for treatment have reduced from an average of 13.5 minutes in 2017 to 10 minutes in 2019. There is a 90% satisfaction rate with the treatment provided by a sample of 1123 respondents at 30 facilities. Most patients demonstrated their satisfaction with health care costs, although costs for investigations have risen by 68% since 2017 and for medicines by 25%.
The enabling factors are: the available funding and technical support from WHO, the political commitment of the Health Minister, the real-time data generated by the DHIS2 system readily available to access the facility performance using routine health indicators, and the joint commitment from DGHS, WHO and other partners to continue this activity on an annual basis. Some of the constraints are the shortage of human resources, the increase in workloads at the primary health facilities, and the gaps in the supply of essential medicines and diagnostic facilities
This practice is sustainable because it builds on the national actors’ capacities to assess the public health facility performances. The initiative strengthens the country’s good governance through the availability of real-time data on the shared dashboard, accessible to all field health managers and decision-makers. The dashboard allows monitoring the status and progress of public health facility performance and identifying the priority areas of intervention that need to be addressed. By covering all the country’s regions and all tiers of health systems structure, the practice ensures improvement in health service delivery, leaving no one behind. The initiative is replicable in countries with similar health systems structure. The award’s motivational and inspirational aspect is also a replicable component of the activity and contributes to sustainability.
The 2020 annual performance assessment, planned in November 2020, was postponed due to COVID-19. The assessment tools have been revised now to capture the impact of COVD-19 on the delivery of essential health services and the facility readiness for COVID-19 vaccination. The facility assessment findings in 2021 will guide the national policy actions towards health service recovery. They will also offer a lead to build a resilient health service delivery system to guarantee essential health service delivery during future pandemics and emergencies.
Deliverables & Timeline
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This assessment covers all public health facilities from upazila health complex (sub national level) to district and tertiary health facilities in Bangladesh