Health sector demonstrates the incredible power of the "system" By Professor Dr Abul Kalam Azad

The District Health Information System (DHIS2) used to collect and analyse aggregate data from health facilities; it also includes an individual record function which helps health workers to track pregnant women and children

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Abook published a decade ago by the United Nations (2005) titled “Public Enterprises: Unresolved challenges and new opportunities” stated that the performance of public enterprises is determined 80 percent by the system, 16 percent by the leadership and only four percent by rest of the staff. Before 2008, the eHealth and the health information infrastructure of Bangladesh's government healthcare network did not pay much attention to building a good system as well as providing appropriate leadership. Since mid 2008, the approach and design of the country's health information system (HIS) has been redefined, boosted by the extensive political support of Digital Bangladesh Vision 2021. The progress of eHealth and the electronic health information system of Bangladesh has drawn significant global attention; they are being recognised as models to follow in other countries.
The most recent recognition came from the German government through the formal launching of a book titled “A quiet revolution: Strengthening the routine health information system in Bangladesh” by its Federal Ministry of Economic Cooperation and Development in Berlin (November 26, 2014). The book summarises the results of HIS strengthening in Bangladesh into five broad categories, viz., i) dramatically reduced administrative burdens - and more time for patients - through digitisation of routine reporting; ii) use of individual health records improves patient care; iii) a national electronic repository signals the end of information silos; iv) better quality and more comprehensive routine information now available from the public sector; and v) improved capacity at Bangladesh's Ministry of Health and Family Welfare and growing international contributions in eHealth. In 2011, the Honorable Prime Minister Sheikh Hasina received the United Nations South-South Award for Digital Health. The Management Information System (MIS) of the Directorate General of Health Services (DGHS) under the MOHFW of Bangladesh could make this success happen in just a few years.
The background
In early 2008, the office building of the MIS department of DGHS doned a gloomy frustrating look due to poor maintenance for years at a stretch. There was no internet connectivity, not even in the head office. Work environment, in respect to light, ventilation, sitting arrangement, ICT resource, staff skill and motivation, was also very poor. Staffs were unskilled and frustrated due to the lack of career prospect. Data collection was conducted using paper forms and would take, on average, two months from the lowest level health facilities to the MIS department. Now things have changed and data flows instantaneously and electronically. There has been significant improvement in physical and ICT infrastructure, training, skill and staff motivation, monitoring, supervision, transparency and accountability, and data quality and information culture as a whole.
Motivation for change
The mandate, available strengths, weaknesses and opportunities of the MIS department were revisited in 2008. It was revealed that without the use of ICT, management and meaningful use of health data from across thousands of health facilities and organisations all over the country would not be possible. A blueprint was made for gradually building an ICT-based national HIS infrastructure and system to make the best use of health data. In 2009, the effort received enormous political support due to the government's Digital Bangladesh Vision 2021. An eHealth component was also added on top of the HIS. Today's progress is the result of the consistent effort to improve and implement the blueprint.
Full internet connectivity of health sector
The MOHFW of Bangladesh started connecting health organisations to the Internet in May 2009 and completed connectivity of the entire health sector by April 2014. The 24,000 rurally deployed frontline health workers engaged for home visits, about 13,000 community clinics, all the union health centers and all public hospitals, academic institutions and health administrative offices (all together about 1,000) now have tablet PCs, laptop computers, desktop computers or computer LANs, as appropriate. Connectivity, principally, is provided by broadband wireless modems (3G if available locally, otherwise 2G). A state-of-the-art data center in the MIS office in Dhaka and a disaster recovery system in the Khulna health office have been established. All MOHFW staffs, responsible for handling and using ICT, have been trained.
Software solution - eHealth enterprise architecture - citizens' lifetime electronic health records 
To enable health staffs with sufficient ICT skills to perform eHealth-related work better, use of too many softwares was discouraged. Only three web-based open source softwares, viz., DHIS2, OpenMRS and HRM, have been chosen for all kind of situations. The DHIS2 (District Health Information System, version 2), developed in the University of Oslo, Norway, is used for gathering data on preventive and public health services from all over the country and is being applied by both state and non-state healthcare providers OpenMRS (Open Medical Record System), a globally acclaimed software, has been chosen for hospital automation. The HRM (Human Resource Management) System has been developed in-house and is used for processing human resource information. Multimedia projectors have been provided to each upazila, district and divisional health manager's office to enable them hold monthly review meetings with the help of software-generated automated reports. Another breakthrough that will be introduced by the end of 2015 is the electronic shared health records (SHR) system. The SHR will be portable between healthcare providers and hospitals for real-time reference and updating. To take this implementation forward, the MIS has already collected electronic records of 98 million citizens. The SHR will integrate the DHIS2, OpenMRS and HRM in an eHealth enterprise architecture (eHEA), to exchange data through an electronic health information exchange (eHIE). MIS is also working with a multi-ministerial initiative led by the Cabinet Secretary to develop an electronic universal civil registration and vital statistics (CRVS) system to lead to an electronic national population register (NPR) with a view of making a national citizen registry with a core basic data set to authenticate each individual with unique identification and biometric data. The MIS has already made a rich data source for geo-locations, health organisations and health workforce in the form of electronic registries.
Citizens' grievance management system: complaint-suggestion box
In 800 public hospitals and organisations, there are display boards mounted on walls, which describe how to send complaints about the quality of services or suggestions for service improvement. Clients of the hospitals or health organisations text complaints or suggestions to a particular mobile number shown in the display board. According to the DGHS website, a web server located at MIS receives the texts and makes them available instantly for public viewing. The responsible staff members at MIS check the complaints and suggestions, talk to the SMS senders to find out more about the message, and undertake actions to solve the problem or work on the suggestion. The complaints and suggestions become publicly available in real time on the DGHS website.

Prime Minister Sheikh Hasina receiving UN Award for Digital Health in 2011 from ITU Secretary General Dr Hamdoun

Mobile phone health service
All upazila health complexes and district hospitals (a total of 482) provide medical consultation free of cost through mobile phones. Each of the hospitals has a mobile phone carried by an on-duty doctor. This phone is accessible for incoming calls round-the-clock. People living in the catchment areas call the number, if the need arises, and the doctor gives appropriate medical advice. The service has been extended to about 13,000 community clinics The mobile phone health service received the ICT4 Development Award in 2010 and special mention at the Manthan India Award in 2011.

Telemedicine

In 42 government hospitals, advanced telemedicine centers have been established. Equipped with different remote capture peripherals and dedicated bandwidth, these centers are providing referral specialist consultations to patients attending the peripheral hospitals. The community clinics in rural Bangladesh also take advantage of internet connectivity for patients who require direct medical advice from a qualified doctor working either at upazila or district hospitals. They communicate via video-conference over Skype to help link doctors and patients.

Office attendance monitoring from central point by fingerprint machines
Allegation about staff absenteeism particularly from remote health facilities is not uncommon. The MIS installed low cost fingerprint time attendance machines in all upazila and district hospitals. Staffs record their check-in and check-out times by touching the sensor of the respective machine. The office attendance data is then transferred to the central server via the Internet and becomes available for viewing from anywhere through a web portal. Daily, weekly, monthly and yearly staff attendance reports can be produced for national, subnational and local levels.
ICT and local health interventions - improving maternal and child health through COIA initiative
Under an initiative launched by the United Nations called COIA (Commission on Information and Accountability) for maternal and child health, the MIS started to electronically register and track every pregnant woman and under-five child, using 11 core indicators. All partner healthcare providers use a shared electronic online data collection form in DHIS2 for this purpose. Frontline health workers and community clinics register pregnant women and under-five children living in the respective community catchments by using this online form. A routine weekly meeting is held at the community clinic, where government, NGO health workers and members of the community clinic management committees jointly review, validate and clean collected data to measure and understand the local maternal and child health situation, make intervention plans and implement those in the next week(s), taking up shared responsibility. Automatically generated summary reports in the form of lists, tables, charts and maps from DHIS2 make the review simple and easy. Review by the higher authorities is also done and feedback is given. This routine “Monitor-Review-Act” cycle continues and thereby local communities take control of their own maternal and child health situation.
Interactive online health bulletins
An exciting work of the MIS is the introduction of an interactive web-based publication called the “local health bulletin” by each health organisation under DGHS. Local health bulletins have created an opportunity to obtain local health data on the upazila, district or hospital level; they are also helping to build local information culture. Over 500 government health organisations publish their own health bulletin using a web-based template provided by MIS. Each organisation prints hard copies of their own local health bulletin and organises a local annual publication ceremony before the national annual health MIS conference; at the national conference, local managers and allied staffs present and defend their respective local health bulletins. Such interventions help to improve the quality of data of local health bulletins and contribute to the strengthening of local information culture.
Multiple stakeholders sharing the same health data platform
The success of the MIS is owed to the creation of an environment which harbors the convergence of all vertical health programs and health stakeholders into one shared HIS resource (data center and DHIS2) for collection and use of health data. Vertical programs like community clinics, maternal and child health programs, etc., are all using the same resource. Development partners like the World Bank, GiZ, DFID, UNICEF, ICDDRB, USAID, JICA, SAVE, UNFPA, PLAN, CIDA, SIDA, BRAC, JHU, etc., are supporting and/or using the system.
The use of social media platforms
The web portal of MIS remains as a vibrant platform for health information dissemination. The website has been completely redesigned to accommodate new trends and tastes. Social media interfaces, viz. Facebook, Twitter, Google+, YouTube Channel, etc. are being successfully used to attract a wide range of audiences. Our social media platforms are attracting the largest number of audiences, about 500,000 each month.
Public-Private Partnership - mHealth for safe pregnancy and childcare
MIS is carrying out a partnership program with D.Net (supported by USAID) to provide a mHealth service called MAMA (Mobile Alliance for Maternal Action). The program uses a short telephone code (16227), which provides to pregnant and new mothers, lifesaving information and advice for newborn babies and children through SMS and IVRs. MIS is also working with WHO and Johns Hopkins University to develop and operate mCare (for pregnancy care), mTikka (for immunisation) and OpenSRP (for easy data entry by frontline workers).
Conclusion
The Bangladesh Ministry of Health and Family Welfare is enjoying the benefits of building a system rather than an ad hoc solution for health information and eHealth. The simple, low cost, yet effective solution has drawn remarkable global attention as an eHealth model. The eHealth system is generating evidence for decision-making, improving health system efficiency and quality, helping the ministry to reach the citizens with service, and bridging the urban-rural digital divide. The nationwide unified eHealth network has just started to reveal its incredible power to transform public health through mass empowerment, particularly that of grass-root actors.
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The writer is Additional Director General and Director of Management Information System (MIS), Directorate General of Health Services (DGHS)

Targeting higher hanging fruits By Mushtaque Chowdhury, PhD

BANGLADESH'S recent socio-economic progress has attracted wide attention globally. In an article, the editor of The Telegraph, India reflected on how Bangladesh has weathered all odds and is now able to proudly move forward. He compared Bangladesh's achievements to that of his native state, West Bengal and lamented how the latter was falling behind. A host of such writings and on how the rest of the world can learn from this is appearing regularly in global development literature. David Lewis, a professor at the London School of Economics,wrotein a recent book, “Once written off as a basket case, Bangladesh is now spoken of as a basket of innovation.” The prestigious British medical journal, Lancet, published a series on Bangladesh. In introducing the story, the editors termed the gains in Bangladesh as 'one of the great mysteries of global health.'
Over the past few decades we have successfully harvested the 'low hanging fruits' but addressing the unfinished agenda and future challenges, the 'high hanging fruits,' would require fresh commitment, innovative thinking, concrete efforts and higher investments. As Amartya Sen wrote, 'The key to Bangladesh's laudable success has been the avoidance of the twin dangers of inertia and smugness. The future will demand more from these virtues'. Withthe rightattention given to the issueshold us back, we can accelerate our gains many folds.
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Bangladesh indeed has done exceptionally well despite its perennial limitations. It is one of the few countries which are on track to achieve both MDGsfour and five. Life expectancy,which is the average number of years a person in a given societyis expected to live,has increased by 70 percent since independence. In 1971, the life expectancy was just over 40 years and now this reached to nearly 70 years. Interestingly, women have benefited more. Until the 1980s, Bangladesh unfortunately was one of the few countries in the world where women lived a shorter life than men. This has now been reversed, with women living longer than men. In terms of health, Bangladesh's record is exemplary. The country has reduced its infant mortality rate tremendously, from 150 in the early 1970s to less than 50 now. Similarly the maternal mortality ratio has decreased from about 600 to less than 200. This is quite remarkable since it challenges the conventional wisdom that maternal mortality is directly related to availability of skilled attendance and facility delivery - both of which are lacking in the country. Bangladesh's achievement in fertility control is even more dramatic. The total fertility rate has reduced from about 7.0 in the early 1970s to 2.3 in 2010. In some areas such as Khulna, the 'replacement level' has already been reached.

Bangladesh has accomplished some public health miracles. Take the case of immunisation. In mid-1980s only 2 percent of children were vaccinated. With the government's commitment, and engagement of civil society organisations, development partners and the media, this climbed to 70 percent in a mere five years, which prompted Unicef to call it a 'near miracle.' Diarrhoea was a major killer of children and oral rehydration therapy (ORT) - the treatment of choice - was not available to the people. BRAC, with technical support from ICDDR,B carried out a decade-long arduous campaign to teach mothers how to prepare itfrom salt and molasses. Due to such intensive effortsand subsequent involvement of the public and private sectors,the usage rate of ORT in Bangladesh is now the highest in the worldand has become a part of the local culture in the sense that mothers transmit the knowledge to their next generation. Our success in family planning is well known and is a cause of envy for many countries.

Bangladesh is a high burden tuberculosis country. The directly observed treatment - short course or DOTS - the recommended therapy for TB, has made impressive progress, exceeding the WHO target of both case detection and treatment completion. In Bangladesh the government and NGOs work very closely and the national TB programme is a perfect example. The above achievements make us proud. But what about the future? Keeping the momentum going will require a good understanding of the unfinished agenda and the future challenges. It is true that we have done well compared to some of our economically better-off neighbours. But we are still lagging behind Sri Lanka in terms of most indicators. Sri Lanka's maternal mortality ratio, for example, is less than 30. The challenges are many and formidable. The decline in some rates such as neonatal mortality has unfortunately been very modest. 

With many of the contagious diseases still persisting, we are faced with a double burden. The epidemiological and demographic transitions are bringing the non-communicable and life-style related diseases such as diabetes, hypertension and cancer into the fore which is further exacerbated by the ageing of the population. Threats from the newly emerging infectious diseases such as Ebola, Nipah virus, Bird-flu, etc. are real. Unfortunately our health system is hardly prepared for these. Human resource is an unending problem with shortages, misdistribution, skill imbalance and malfunction. Public investment in health is one of the lowest in the world here. 63 percent of the expenditure is out-of-pocket and limits a citizen's access to quality healthcare, and increases poverty. Lately, there have been some policy guidelines for achieving Universal Health Coverage by 2032,but no headway is in sight. Governance of the health sector is a continuing issue mired with raging corruption and wastage of resources. There has been a limited success in reducing malnutrition. Bangladesh has one of the fastest growing urban settlements and about a third of this lives in slums. But there is little attention given on how to deal with this. NGOs are also working in urban slums but there is hardly any co-ordination with the public sector or between themselves. Environmental pollution and climate change will likely worsen vulnerability, particularly that of the poor. Issues such as arsenic in drinking water, unfortunately, remain neglected or forgotten. The gains of the past years are considerablydue to gains in some of the social determinants of health. Poverty persists - about a quarter of Bangladeshis are still poor by any standard. Income inequality is high and is not reducing. Child marriage is rampant and a shamefully – 60 percentof girls are married off before the age of 18 - the highest in South Asia. Drowning and road accidents continue to add to the number of deaths and injuries but no effective strategy is in place to tackle them. 

The writer is Vice Chair of BRAC and Professor of Population and Family Health, Columbia University.

At your service

Today entrepreneurs see the difference between a one-time sale and an experience-induced customer loyalty to the business. This involves striking up a conversation with customers, offering them drinks or decent reading materials while wait, and just maintaining a peaceful ambience.

                      

Mehereen Aziz

Many businesses forget that human interaction is the foundation of all institutions. Individuals make a family unit which collectively creates a neighbourhood which then builds a town and so on and so forth till nations come into being forming the world that we inhabit today. Despite our technological advancements, there is no substitute for a basic personal connection, a fact that businesses tend to be short-sighted about.
Recently, however, there has been an upheaval in the service industry as entrepreneurs are emerging from the breed of customers who were frustrated by the status quo. The concept of customer service found popularity with Bangladeshi entrepreneurs who have lived abroad and have had firsthand experience of excellent customer service, thus both prioritising customer service in their local business, and recruiting and training employees who they believe can enhance the purchasing experience, not just facilitate it. These entrepreneurs see the difference between a one-time sale and an experience-induced customer loyalty to the business. Today, customer service involves striking up a conversation with customers, offering them drinks or decent reading materials (not torn magazines) while they are waiting, and just maintaining a peaceful ambience.
Excellent service became a benchmark in Bangladesh when Pizza Hut opened its doors in Dhaka in 2003. Suddenly, the dining experience was not just limited to good food. It also included a smiling waiter asking you what you needed, the whole restaurant singing for you on your birthday, and a chorus of “Thank you” when you left.
The service culture does not have to be a tedious process for businesses. A genuine desire to make a meaningful contribution to others' lives is all that is needed. Small actions, such as a warm greeting, a pleasant smile with eye contact, or a simple offer of food, books, entertainment, or just a good pair of listening ears, count towards an exceptional customer service.

Customer service professionals mostly work on an incentive basis, such as a sales commission or tips. For some, customer service is the forefront of their business and their incentive bonus makes up the majority of their income.
We must provide exceptional service on the phone in order to pursue people to sign up for credit cards or loans. If customers don't like our behaviour, they could simply hang up. For us, excellent customer service is the minimal,” explains Mahbub, manager of the telemarketing department of a bank.
Then there are cases where entrepreneurs invest in customer service in industries where a positive shopping experience can go a long way in increasing sales. “I recruit enthusiastic university students who need a part time job, because they know the trends and are motivated enough to provide good customer service” says Nazim, who owns a sportswear franchise and trains sales assistants before they are hired as permanent staff. Waiters and beauty parlour attendants also pay attention to service, because they have observed that providing good service can lead to rewarding tips. “I earn more from tips than from my daily parlour salary,” says Rehana, who works at a renowned parlour in Gulshan 2. “Besides, if they like your services, the regular parlour customers will always ask for you when they visit. It pays to be cordial,” she adds.

Of course, the concept of tipping has both good and bad effects. “Honestly speaking, I pay more attention to customers who come in a family and look well-off. When young people come, I don't provide my best service because they don't tip much,” admits Sojib, a Thai restaurant waiter in Uttara.

While some businesses take training and supervision seriously, other businesses might opt for on the job training of sales professionals to cut costs. This has led to many cases of customer service professionals who lack the basic service etiquette. “Most sales assistants stick to you and don't allow any personal space. I find it extremely uncomfortable and cannot browse for products, especially if the assistants are male,” complains university student Prema, regarding a large handicrafts retailer.

There is also an element of customer service from the business owner's part, which is yet to be improved upon in Bangladesh: After sales service. That is, the exchange, refund, or repair of a product after purchase.
“After sales service quality is sorely lacking. I own a luxury car and even then, I have to wait for months if any car parts need replacing. And let's not even mention the complete absence of after sales service in regular consumer goods,” remarks a multinational director.
Despite some drawbacks, on the whole the service culture is gearing towards the positive in the country. Mobile phones and the Internet have increased the direct interaction between customers and businesses. The small business sector is booming, both formal and informal. With a huge number of competitors, especially for those operating in the fashion, dining or media industry, making real and lasting connections with buyers at a personal level is integral to standing out.
As a country of more than 160 million people, we tend to undermine our own power. People are at the centre of every business transaction. If you are a business owner, the transaction that matters most is the transfer of a finished product or service from the seller to the buyer. This last transaction is what gives your business its credibility.
A buyer might just need one small push to buy three units instead of one. It is the job of the customer service professional to, as they say, “seal the deal”. Now that businesses are investing in their people skills, consumers can look forward to human interactions when procuring goods or services, and hope that after sales services also improve in the same proportions.
Photo: Shahrear Kabir Heemel
Location: Cafe Bazar, Pan Pacific Sonargaon; Khazana
Special thanks to Salman Kabir, Public Relations Manager, Pan Pacific Sonargaon and
Avishek Sinha, Khazana

The writer is is a Feature Writer and Monica Islam is a contributor for Star Lifestyle, The Daily Star.