Number of nurses per hospital bed! Number of doctors per hospital bed! Ratio of average salary of government health worker e. Generic drug expenditure as a percent of total drug expenditure!
Percent of government recurrent health budget spent on public health services! Primary health care expenditure as a percent of recurrent costs! Percent of total government drug expenditures allocated to primary care facilities! Average length of hospital inpatient stay! Hospital bed occupancy rate! Percent of insured enrolled in plans which use copayments and deductibles, managed care plans, or plans subject to global budgeting 49 Financial sustainability refers to the capacity of the health system to replace withdrawn donor funds with funds from other, usually domestic, sources.
Institutional sustainability refers to the capacity of the system, if suitably financed, to assemble and manage the necessary non-financial resources to successfully carry on its normal activities. Percent of total health system financed by tax revenue! Percent of government health system financed by tax revenue! Government health expenditure as percent of total government budget! Government health expenditure as percent of GDP! Percent of total health spending financed by donors!
Percent of government health spending financed by donors 53 Percent of government recurrent health spending financed by donors! Percent of government health expenditure directed to primary care! Percent of government health expenditure directed to preventive care! Percent of government health expenditure directed to MCH services 54 Foreign doctors as a percent of all doctors! Number of months of foreign technical assistance funded by donors! Donor expenditures on technical assistance as a percent of all donor health expenditures 55 Comprehensiveness: A comprehensive range of health services is provided, appropriate to the needs of the target population, including preventative, curative, palliative and rehabilitative services and health promotion activities.
Accessibility: Services are directly and permanently accessible with no undue barriers of cost, language, culture, or geography. Health services are close to the people, with a routine point of entry to the service network at primary care level not at the specialist or hospital level. Services may be provided in the home, the community, the workplace, or health facilities as appropriate. Coverage: Service delivery is designed so that all people in a defined target population are covered, i.
Continuity Service delivery is organized to provide an individual with continuity of care across the network of services, health conditions, levels of care, and over the life-cycle. Quality: Health services are of high quality, i. Person-centredness: Services are organized around the person, not the disease or the financing. Users perceive health services to be responsive and acceptable to them. There is participation from the target population in service delivery design and assessment.
People are partners in their own health care. Coordination also takes place with other sectors e. Is the indicator clearly and unambiguously defined? Is the indicator available on an annual basis and without undue delay? Can the indicator be used to compare health systems meaningfully across countries? Can the indicator be readily and meaningfully applied to sub-regions and to population sub-groups e. Does a higher or lower value of the indicator consistently imply that a health system performs better?
Is the cost manageable? There is often an unavoidable tradeoff between cost, on the one hand, and validity, reliability, and timeliness, on the other hand. Special Initiatives Report No. October Margaret El. Kruk and Lynn P. Having explored these resources, if you still have questions, please be in touch with us — we are there to help and we often find that it is the students who ask questions about their studies and make demands who succeed best.
All the contact information that you may need is contained in this introduction. As we see you as a vital player in programme improvement, we ask you to give us feedback on your experience of this module.
An evaluation form will be sent to you on completion of your final assignment. Monitoring and evaluation Introduction. Monitoring and evaluation Unit 1. Monitoring and evaluation Unit 2.
Monitoring and evaluation Unit 3. Wasting prevalence falls as the age of children increases. However, UHS revealed a U-shaped relationship between wasting and age of children that might be associated with feeding practices — a recent phenomenon for children under-five [ 20 ]. Still, malnutrition in Bangladesh is complex and factors range from poverty and hunger, low rates of exclusive breastfeeding, inadequate complementary feeding, and recurrent infections [ 21 ].
The discrepancy could be due to seasonal effects in the timing of data collection. The reduction of 3. BCCM provided technical assistance to NGOs in knowledge dissemination on proper hygiene, sanitation, and proper treatment of diarrhea [ 17 ].
Treatment of diarrhea in Bangladesh by oral rehydration therapy is common and people are used to buying oral rehydration saline from pharmacies and shops. Available data show use of oral rehydration therapy is universal, although there is limited supply of oral rehydration salts from health facilities since diarrhea incidence declined substantially.
The project had a significant effect on increasing at least three ANC visits by 4. The unexpected result for PNC implies that the project was less effective in following-up post-delivery care possibly due traditional norms where the mother and newborn generally stay in the home after childbirth. Prevalence of ever breastfed children was reduced which may be due to emerging economic opportunities in the urban areas where traditional breastfeeding practices are interrupted. In spite of this, breastfeeding of infant within 1 day of birth had an increasing trend.
The project also increased contraceptive prevalence rate by 4. Pill, condom, and injectables are widely used modern methods of family planning. Subsidized social marketing and commercial sources are leading providers of these methods in urban areas.
The trend in urban TFR between baseline and endline is unexpected. Urban TFR increased from 2. This could be due to a sizable migration flow as around Rapid urbanization, mostly by migration of rural households with large household size, could have increased TFR in project areas. These migrants mostly belong to the poorest quintile and TFR among the poor is about one child more than that of the richest quintile [ 20 ].
The effectiveness of the project was also supported by a BCCM component which organized orientation for slum leaders, members of the ward PHC coordination committees, and local female leaders fighting violence against women; advocacy meetings for female ward commissioners and other influential women leaders; conferences for local stakeholders; and workshops for project NGOs [ 16 ]. Television advertisements and other promotional materials regarding the health services were also found to be effective modalities of information, but need to be improved as The endline evaluation of the BCCM component reports that there was an increase in the visiting patterns of adults to UPHCP-II health facilities, which shows awareness of the program and heightened initiative of seeking health services [ 17 ].
There was development in pregnancy-related knowledge, prenatal and postnatal child care, vaccination, acute respiratory infection, prevention of sexually transmitted infections and improved awareness that treatment is available for such diseases.
Adults who visited the health facilities had positive feedback on the quality of the service delivery, and advised their neighbors and relatives to visit the health facilities for services. The project was found to be effective in delivering health services with positive impact on various health indicators examined in terms of reduced diarrhea and acute respiratory infection in children, which could explain the downward trend in child mortality rate.
The increase of antenatal care coverage, improvement in breastfeeding practices of women, decrease in diarrhea and acute respiratory infection prevalence, and increase in skilled birth attendance could explain the reduction of U5MR and other indicators of child mortality in project areas, and improvement in the overall nutritional health of children. Still, malnutrition in Bangladesh is complex and remains persistent with factors ranging from poverty and hunger, low rates of exclusive breastfeeding, inadequate complementary feeding, and recurrent infections [ 21 ].
Effectiveness of the project was also seen through improved quality of care as a result of a quality assurance supervisory mechanism, capacity-building activities, and health facilities established in close proximity to beneficiaries. The pro-poor delivery of health services was found to be effective due to a behavior change campaign that reduced health inequalities across wealth classes. Wide campaign coverage coupled with effective and efficient delivery of health service increased the receptivity of the beneficiary population and enhanced the impact of the project.
Moreover, previous studies observed improved satisfaction of clients to the project. The patients expressed satisfaction with the UPHCP-II because of the close proximity of the strategically positioned health facilities to maximize accessibility. The patients also highlighted the good quality of service as another reason for their satisfaction with the project [ 25 ].
The total number of health services provided by the NGOs increased over time. It was initially observed that the cost per service was relatively high, but had decreased toward the end of the project implementation period as NGOs began to become accustomed and recognized by the community in their respective project areas [ 25 ]. Moreover, the capacity of NGOs increased as measured by the availability of staff, training, management of equipment and drugs, infection prevention, waste disposal, and use of registers [ 16 ].
These observations imply that the NGOs were becoming efficient in service delivery over time as a result of increased skill of the health personnel through capacity building and added innovations in management and implementation. However, continuous efforts should be invested further to improve the nutritional status of children to reduce the prevalence of wasting.
Safeguards should be set in place to actively mitigate the acute effects of malnutrition due to sudden economic shocks or political turmoil, and natural calamities. Behavior change communication and marketing activities could still be improved to increase breastfeeding practices despite the emerging economic opportunities available for women. Furthermore, PNC coverage and skilled birth attendance could still be improved, which would further reduce neonatal and infant mortality.
This could be achieved by improving post-delivery health seeking behavior, quality of care, and by making sure that health services are easily accessible by the beneficiaries, particularly urban poor and mobile populations. For instance, the informal private-for-profit providers located in poor slum settlements fill an important gap in coverage where formal provision is largely absent and limited to a few NGOs providing primary care on specific days and hours of the week.
Formal service delivery efforts can learn from successful strategies and prioritize the provision of affordable and quality care close to where the poor reside and at hours convenient to the working population [ 26 ]. A system of accounting all the target beneficiaries and their health status would also be vital in ensuring that the essential needs of the individual or household are provided regardless of the NGO providing the health services. This issue arises due to the mobility of project beneficiaries who transfer to or from a project area, and it could be addressed by providing each beneficiary a unique identification.
The identification system could build on the existing structure of the health entitlement cards. Such a system would allow the monitoring of health status and health care utilization across different facilities in different geographic areas.
It could also enable the measurement of project impact from the national or community level down to the individual or household level. Furthermore, several primary health care projects are simultaneously present in urban Bangladesh. Increased harmonization across these projects is essential to maximize collective impact towards distributing benefits equitably across the population. Amidst rapid urbanization, new approaches to sustainable financing, efficient governance, and enhanced engagement of partners which are responsive to the dynamic conditions of the urban poor are crucial to assure greater effective coverage of comprehensive and continuous essential health services [ 27 ].
The coordination among donor institutions should include dialogue in setting clear delineation of program areas to minimize redundancy of benefits, and to fully optimize the delivery of health services.
Forming an interoperable data platform across all urban health facilities from various projects would be beneficial for monitoring the health status of urban population. With this platform, improved measures of project effects can be generated as well as evidence for informing urban health policies and guiding responses to changing primary health care needs.
Lessons learned from the UPHCP-II experience and this impact evaluation study are aimed at enhancing effective design, implementation, management, and delivery of health services in ongoing and future urban health interventions to achieve effective and sustainable universal health coverage. The data that support the findings of this study are available from NIPORT but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.
Dhaka; United Nations. Department of Economic and Social Affairs, population division. Google Scholar. Afsana K, Wahid SS. Health care for poor people in the urban slums of Bangladesh. Article Google Scholar. Bangladesh demographic and health survey Bangladesh Bureau of Statistics. Report on the household income and expenditure survey Harpham T. Urban health in developing countries: what do we know and where do we go? Health Place. Asian Development Bank. Manila; Contracting urban primary healthcare services in Bangladesh—effect on use, efficiency, equity and quality of care.
Tropical Med Int Health. Loevinsohn B. Performance-based contracting for health Services in Developing Countries. Book Google Scholar. Lagarde M, Palmer N. The impact of contracting out on health outcomes and use of health services in low and middle income countries.
Cochrane Libr. Harnessing pluralism for better health in Bangladesh. Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh. A case study of outsourced primary healthcare services in Sindh, Pakistan: is this a real reform? Completion report: Bangladesh second urban primary health care project. End-line household survey under second urban primary health care project — Dhaka City corporation.
Todd, P. Paul Schultz and Strauss, John A. Handbook of Development Economics. Amsterdam: Elsevier; The Bangladesh paradox: exceptional health achievement despite economic poverty.
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