Independent Reference Group

Background
Universal health coverage (UHC) is one prime target of the health-related Sustainable Development Goals (SDGs). The Government of Bangladesh has established a strong political commitment to achieve and ensure UHC and SDGs and a country-specific monitoring framework has been put in place. There are few challenges that have been identified in measuring progress of UHC: reliability of data, measuring effective coverage, and monitoring equity. Though Bangladesh is data rich – particularly in systematically producing and conducting national and sub-national surveys, there are gaps in producing valid and reliable estimates of health indicators for policy and planning. Establishing a standard tracking mechanism within the country and a platform for recommendations and agreement among the stakeholders can help monitoring and tracking health related indicators regularly.

With support of USAID’s Research for Decision Makers (RDM) Activity, Independent Reference Group (IRG) was formed for data handling, analysis, and modelling which can help in monitoring progress towards UHC and other health related SDG indicators in Bangladesh. icddr,b as the group secretariat has been working in close collaboration with academics, research evaluation specialists, research advisors, public health researchers from University of Dhaka, National Institute of Population Research and Training (NIPORT), a2i of Prime Minister’s Office, Health Economics Unit of MoHFW, Bangladesh Bureau of Statistics, MIS of Directorate General Health Services, Power and Participation Research Centre, WaterAid Bangladesh, WHO, UNFPA, UNICEF, The World Bank, Save the Children and USAID. Other active collaborators are independent researchers’, research consultant and policy makers under IRG. The primary objective of this group is to assess data and support policymakers to monitor, evaluate, and review the progress of the UHC indicators for Bangladesh. The group with its experts has been working on how to measure indicators of progress, assess data quality and also measure the effective coverage for each coverage indicator. Selected coverage indicators are also being analysed in light of equity. The IRG has been producing reports and sharing the relevant findings with the concerned stakeholders.

General Objective
To establish an independent platform for monitoring and tracking UHC and health-related SDGs indicators for Bangladesh as an information hub for all partners to discuss and review data sources and findings, and undertake required analysis.

  1. Specific Objectives
  2. a. Map all available data sources
    b. Create a data repository

  3. Data generation
  4. a. Analyse and produce valid and reliable estimates for policy makers and other potential entities, if required
    b. Measure the effective coverage for each selected coverage indicator

  5. Transmission and communications
  6. a. Produce research briefs for policy advice and feed into programmes
    b. Work as an information hub for national purpose

Activities
Bangladesh Framework for Monitoring Progress Towards Universal Health Coverage 2020
The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare (MOHFW) of Government of Bangladesh (GoB) developed a ‘Framework for Monitoring Progress towards Universal Health Coverage (UHC) in Bangladesh’ combining a set of 43 indicators in 2014. This framework was developed in Millennium Development Goals (MDGs) era. Considering the transitional context from MDGs to Sustainable Development Goals (SDGs) period and acknowledging the gaps in definition, data availability of the indicators in this framework, Independent Reference Group (IRG) coordinated a revision of this framework in collaboration with Health Economics Unit (HEU) and Quality Improvement Secretariat (QIS) of Ministry of Health and Family Welfare (MOHFW) and developed the ‘Bangladesh Framework for Monitoring Progress Towards Universal Health Coverage 2020’.

Data Quality Assessment of National Surveys and Surveillance
Rapid decline of estimates of mortality and fertility related indicators are evident in Bangladesh in the last two decades. However, discrepancies have been observed in the reported estimates of national surveys and surveillance for these indicators. To investigate the methodological aspects of these discrepancies, the IRG has conducted an assessment of the data quality of mortality and fertility related indicators for the national surveys and surveillance. The selected surveys and surveillance for data quality assessment are: Bangladesh Demographic Health Survey (BDHS), Sample Vital Registration System (SVRS), Multiple Indicator Cluster Survey (MICS), Bangladesh Maternal Mortality Survey (BMMS). The overall data quality assessment process was carried out by following six steps: (i) desk review, (ii) indicator identification, (iii) data source identification, (ⅳ) data quality assessment tool development, (ⅴ) interview the expert and (ⅵ) score comparison.
Data owner/focal person was identified to score different data sources according to the six dimension of data quality: (i) relevance, (ii) sound methodology, (iii) accuracy and reliability, (ⅳ) periodicity and timeliness, (ⅴ) consistency and (ⅵ) accessibility and clarity.

Quality assessment of health-related indicators through routine data source
District Health Information System (DHIS, version 2), a web-based routinely data collection system has been established by Director General of Health Services (DGHS), Ministry of Health and Family Welfare (MOHFW), Bangladesh for real time monitoring of health-related indicators. Independent Reference Group (IRG) took an initiative for assessing the data quality of the health-related indicators reported through DHIS2. The aim of this task was to assess the quality of the health related indicators reported for national tracking through DHIS2 and address the gap and challenges faced to obtain a national level estimate for the selected indicators.
The IRG has considered the Kangaroo Mother Care (KMC) and monthly Emergency Obstetric and Newborn Care (EmONC) dataset from DHIS2 for each month of 2019 for each division to assess data quality.
Experts recommendations and comments on the availability of relevant numerators and denominators of selected indicators in the reporting form of DHIS2 was gathered by arranging a workshop. Based on expert opinion, the data quality of DHIS2 is measured in terms of accuracy, completeness and timeliness.

Estimating financial risk protection indicators of Universal Health Coverage (UHC) in Bangladesh
Catastrophic health expenditure (CHE) and impoverishment due to out-of-pocket (OOP) payment are the key indicators of measuring Universal Health Coverage (UHC). IRG has undertaken an initiative to investigate the prevalence and impact of CHE related to OOP on poverty considering geographical variation in Bangladesh using data from Household Income and Expenditure Survey (HIES) 2016. The plausible reasons for geographical area specific changes of CHE and its impact on poverty have also been investigated through this work.

Effective coverage and equity analysis for selected health-related indicators
As one of the crucial parts of Universal Health Coverage (UHC) is to measure the service coverage of several specified indicators, IRG has taken the initiative to analyse effective coverage for some quality of care indicators. Antenatal care is a proven intervention in ensuring skilled attendance at birth and improving birth outcome for both mothers and babies. Quality of ANC is defined as woman receiving all of the basic components including weight and blood pressure measurements, urine and blood tests, and information on signs of possible complications along with four or more ANC visits, of which at least one is with a medically trained provider. The analysis under the IRG looked at the levels and determinants of quality of antenatal care in Bangladesh using data from Bangladesh Demographic Health Survey (BDHS) 2014 and 2017 by pooled analysis.

Another effective coverage analysis was conducted on utilisation of improved sanitation over the ten years in Bangladesh using data from BDHS 2007, 2011, 2014 and 2017-18. Associated determinates and inequity of utilisation of improved sanitation are also investigated in this study.

Workshops
IRG has organised several meeting and workshops with the government, academia, public health experts, development partners and other stakeholders. An inception meeting was organised with its all members to form the group start the activities in light of its objectives. Subsequently, a follow-up meeting was organised to proceed the planned activities. A number of consultation meeting held with the HEU and DGHS to revise the ‘Framework for Monitoring Progress towards Universal Health Coverage (UHC) in Bangladesh’. Moreover, two national level workshops were organised in collaboration with HEU for revision and finalization of Universal Health Coverage Monitoring Framework for Bangladesh. A discussion session was also held with HEU and Management Information System (MIS) on availability of routine data sources of selected health related indicators.

Documents
Indicator matrix
One of the prime tasks of IRG was to select and define the indicators necessary for monitoring and tracking progress towards UHC and other health-related SDGs for Bangladesh. The IRG has identified, and listed possible 81 indicators derived from Bangladesh UHC country monitoring framework and SDGs (Goal 2, 3, 4, 5, 6, 8, and 16) towards Bangladesh UHC perspective under 8 thematic group. The thematic groups were formed by the experts from IRG. The groups are: RMNCH-FP, Health workforce/Health system, Health Financing, Infectious diseases, Non-Communicable Diseases, Nutrition, Accident/Injury, Water and Sanitation. There are 19 indicators under the thematic group of RMNCH-FP, 19 indicators under Health workforce/Health system, 12 indicators under Health Financing, 8 indicators under infectious diseases, 11 indicators under Non-communicable diseases, 3 indicators under Nutrition, 5 indicators under Accident/Injury, 5 indicators under Water and Sanitation thematic group. There are also 27 indicators identified through the expert consultation for revised country monitoring framework for UHC in Bangladesh. Among the 27 indicators, 26 are service coverage indicators, 6 are health financing indicators, 4 are impact indicators and 1 is burden indicator. The detail of these works are summarised in the linked indicator matrix file. This indicator matrix is a living document and will be updated periodically in every six months.

Resources
Matrix for 81 Indicators
Reference Sheet for 27 Indicators