Quality of Care in Bangladesh
In Bangladesh, the Reproductive, Maternal, Newborn, Child and Adolescent Health (MNCAH) Quality Improvement Framework was developed in 2019. The National Health Care Quality Strategy (2021-2030) was developed and is planned to be disseminated nationally by end of 2022. Maternal and newborn health quality standards have been adopted and are being used to assess quality in selected health facilities. In 2021, UNICEF supported the adaptation, implementation and mainstreaming of the WHO standards for improving the quality of care for children and young adolescents in health facilities within UNICEF- supported districts.
Multiple quality MNCH projects are being implemented at district and facility level to support the achievement of the National Strategic Planning on Quality of Care for Health Service Delivery (2015) target which is to achieve Universal Health Coverage by 2032. Beginning in 2016, the Ministry of Health and Family Welfare, Bangladesh identified two districts – Kurigram and Narsingdhi as the first wave of learning districts for improving the quality for MNH. By 2022, quality MNH implementation has been scaled-up to 19 additional districts (6 districts supported by UNICEF and 13 by Mamoni MNCSP) in 304 facilities.
As part of ongoing efforts to improve the quality of care and address the underlying causes of maternal and perinatal death, workshop on Maternal and Perinatal Death Surveillance and Review (MPSDR) cause analysis was conducted in 2021 in 4 divisions of Bangladesh and a national technical meetings were held in 2021 and 2022 to revise the National Guidelines on Maternal and Perinatal Death Surveillance and Response and share the findings of this workshop at national level.
To ensure healthcare workers have the required knowledge and skills, quality improvement training and workshops on PDSA, 5S and MPDSR cause analysis are being conducted regularly. A national clinical mentorship program was introduced in 2021, and the National Clinical Mentorship Strategy and Guidelines are being developed in 2022 .
Strong leadership and accountability mechanisms for quality MNH have been built over the years. A systemwide focus on QI is gaining momentum and the Ministry of Health and Family Welfare has been aligning QI improvement initiatives at national level. Increased ownership is being observed in districts and facilities, which is helping significant scale-up within districts.
USAID’S Mamoni MNCSP project (2018-2023) is implementing clinical and operational intervention bundles along the MNH continuum of care in 232 facilities. Starting with the testing of this package of QI bundles in 1 district, MaMoni MNCSP has now scaled up to cover the 232 facilities in 13 districts.
Data is being collected against quality indicators and captured in DHIS2 in UNICEF-supported districts. With the support of UNICEF, experience of care data is being collected through questionnaires in the seven UNICEF learning districts (Patuakhali, Shirajgonj, Jamalpur, Coxes Bazar, Mowlovibazar, Kurigram, Rangamati); one-on-one interviews with mothers are conducted to assess the quality of service provided in facilities. There are also ongoing efforts to measure and monitor common QoC indicators related to the companion of choice and physical and verbal abuse. QI activities are monitored quarterly by QI teams using facility level indicators and a dedicated MNH focused QI Checklist.
In 2021, the Directorate General of Health Services (DGHS), Medical Education (DGME) and Family Planning (DGFP) and Quality Improvement Secretariat and UNICEF established a partnership with the National Institute of Preventive and Social Medicine (NIPSOM) for a nationally led learning system to document and share quality improvement learning. NIPSOM is working with regional Medical Colleges to design regional QI implementation plans. Each medical college begins by overseeing one district initially and acting as a clinical and quality improvement hub in the region. A focal person is identified for clinical mentorship and QI. Three medical colleges were initiated in 2021, and 4 in 2022 with clinical and QI coaching and mentoring in 55 facilities across 7 regions.
The Ministry of Health and Family Welfare is supporting and sustaining community engagement toward quality MNH services. Resources were committed to support the activation of Facility Management Committees and ownership of Local Government Institutes (LGIs), which are identified as the important pillar and gateway to engage the community with health systems and to establish social accountability at facility level. Existing facility committees and LGIs engage in data driven decentralized planning. District level advocacy meetings are being held and newly elected Union Parishads’ are being oriented on their roles to improve MNH. This mobilization of communities and Local Government Institutes (LGIs) secure the allocation of additional budget for Localized Investments in 2021. Linking the Ministry of Health and Family Welfare, local government and communities through a single platform maximized the potential for success. Local ownership is facilitating the increased utilization and improvement of MNCH services; 348 union level facilities were upgraded with the support of LGIs to provide MNH services including 24-7 delivery services. Further, MNH services have been initiated in 121 hard to reach and underserved areas where there was no previous service.
The WHO module Integrating Stakeholder and Community Engagement in Quality of Care Initiatives for Maternal, Newborn and Child Health was adopted into the local context , and trainings of service providers and health managers from learning facilities were conducted to engage communities in QoC for MNCH initiatives have been undertaken with the support of UNICEF. Mamoni MNCSP has supported community engagement at district and sub-district level through developing an integrated Model for Community Engagement for quality MNH and social accountability approaches with client feedback mechanisms (employing suggestion boxes, Help Desks and Citizen Charters).
A situational analysis on engaging the private sector for quality MNH care has been undertaken by MaMoni MNCSP. Between 2020-2021, the Ministry of Health and Family Welfare, Save the Children, Institute for Healthcare Improvement, and USAID conducted a situational analysis to explore mechanisms for private health sector engagement to improve maternal and newborn health outcomes. This work is ongoing and there are plans to host a multi-stakeholder dialogue to develop recommendations to take forward. The Quality Improvement Secretariat initiated consultative meetings with the private sector were initiated during 2022.
Photo: Sufia Khatun, 25, with her child at her home in Budhata Union, Ashashuni, Satkhira, Bangladesh, in April 2013. ©UNICEF/Haque