A critical look at synergies and fragmentations of universal health coverage, global health security, and health promotion in delivery of frontline health care services: A case study of Bangladesh

Summary

Universal Health Coverage (UHC) and Global Health Security (GHS) activities encompass mitigation of risks to health and well-being rights posed by infectious disease outbreaks and facilitated by health promotion (HP) activities. This case study investigated Bangladesh's readiness and capacity to ‘prevent, detect and respond’ to such outbreaks of an epidemic/pandemic nature. A rapid review of relevant documents, key informant interviews with policymakers/practitioners, and a deliberative dialogue with a crisscross of stakeholders were used to identify challenges and opportunities for ‘synergy’ among these streams of activities. Findings reveal conceptual ambiguity among respondents about the scope of the three `agendas and their inter-linkages. They perceived the synergy between UHC and GHS superfluous and were obsessed with losing their respective constituencies and resources. Poor coordination among the focal agencies in field activities, lack of supporting infrastructure, and shortage of human and financial resources posed additional challenges for better pandemic/epidemic preparation in future.

Funding

This study, “Researching the UHC-GHS-HP Triangle in Bangladesh,” was funded by the Wellcome Trust, UK

Introduction

The COVID-19 pandemic has laid bare the fragile health systems of the LMICs like Bangladesh with all its weaknesses and vulnerabilities.1, 2, 3 It also reiterated the importance of tried-and-tested necessary public health measures to contain infectious disease outbreaks in LMICs.⁴

Universal Health Coverage (UHC) became the center of global health discourse mainly in the last decade, evolving from and addressing the shortcomings of the concept of primary health care as ‘the most efficient and cost-effective way to achieve universal health coverage around the world.’5, 6, 7 Besides curative care, the health system has another arm, Health Promotion (HP) and disease prevention; thus, both are required.⁸

The concept of Global Health Security (GHS) evolved from concerns arising out of global health emergencies, such as those from outbreaks of SARS (2003), H1N1 influenza (2009), Ebola (2014), and Zika (2016). These experiences have exposed the fragmentation in global health.⁹ To achieve the Sustainable Development Goals (SDGs) targets, an integrated approach for implementing UHC, HP, and GHS-related activities is crucial. However, the three areas' priorities and agendas are often fragmented, especially for GHS and UHC.

Despite these differences, UHC and GHS are often considered to have a ‘marriage of convenience’ where the marriage arguably offers mutual benefits. Both UHC and GHS encompass risks to health and human rights posed by epidemic outbreaks, and one can help advance the other.¹⁰ UHC can progress GHS efforts when the absence of a financial barrier facilitates the early detection of infectious diseases. On the other hand, GHS can help advance UHC as the former incorporates both ‘collective’ security (from the trans-border spread of diseases) and ‘individual’ security through access to safe and effective health services, products, and technologies are broadly aligned with UHC. Thus, a strategic and effective partnership between the two can strengthen systems and be achieved by ‘embedding GHS into UHC,’ paving the way for developing an integrated health system that includes public health interventions.¹⁰ Unfortunately, COVID-19 revealed that UHC does not thrive in times of high GHS demand. In the current context of COVID-19, the health securities of countries are under scrutiny as the disease has crossed borders and traveled fast all over the world.

The importance of ensuring synergy among UHC, GHS, and HP in the current COVID-19 epidemic is felt more than ever, particularly in Bangladesh, which has seen epidemic outbreaks of the bird-flu virus, Nipah virus, and SARS virus in the recent past¹¹ and is presently in the midst of the COVID-19 pandemic crisis.

With a high political commitment to achieve UHC by 2030, a reality check of the existing scenarios related to the triangle of the agendas, UHC, GHS, and HP, in Bangladesh is essential to identify the synergies and gaps to align these agendas better in terms of their efforts. This study is expected to fill these knowledge gaps and inform decision-makers in reforming and re-building a ‘resilient’ health system that can prepare for and respond to outbreaks and ensure universal health coverage.

Methods

The current case study is nested in the larger project “Lancet Commission on Synergies between Universal Health Coverage, Health Security, and Health Promotion” and was conducted in three steps. The first step was a rapid review of the literature to understand the concepts and their possible synergies, inform the key informants of the policy landscape, action plans, and strategies in the country and identify critical points of the three concepts for discussion following the qualitative step. The qualitative part was designed comprising Key informant interviews (KIIs) with policymakers and practitioners in the three areas in Bangladesh. Data was triangulated to identify the key emerging themes based on which conclusions and recommendations were made. Knowledge gained from the above two steps was shared in a stakeholder meeting with a subset of the same KII sample. Each method applied in the three steps has been described in detail below.

Step 1: rapid review

We conducted a Rapid Review (RR) to summarize evidence for policymakers and programmatic actions on the “synergies and fragmentations of Universal Health Coverage (UHC), Global Health Security (GHS), and Health Promotion (HP) in delivery of frontline health care services in Bangladesh,” following WHO guidelines.¹² According to the WHO, RR involves a type of knowledge synthesis in which systematic review process is accelerated and methods are streamlined to complete the review within a shorter span of time than is the case for typical systematic reviews. This method has emerged as a streamlined approach ‘to synthesis evidence in a timely manner typically for the purpose of informing emergent decisions faced by decision makers in health care settings’.¹³ We chose this method for reviewing existing literature on the above concepts to meet our purpose within our time constraint, quintessential to rapid review.

Once the objective(s) was finalized through discussion among the research team, we developed a Rapid Review protocol that specified the study objectives, set eligibility criteria, data sources/search engines to be used, and key search terms, following WHO guidelines (Table 1). Our choice of the number of sources and extent of the search was limited by time, strategy detailed in Table 2. Thus, we used ‘Google Scholar and PubMed’ for peer-reviewed publications and ‘Google’ for grey materials. We preserved all records for PubMed and Google search, but limited Google scholar search results to the first 100 entries for inclusion in the screening phase. The exact key terms are provided for PubMed in Table 3. We hand-searched government websites for relevant policy, strategy, and/or planning documents which are listed in Appendix-1. The search terms were fixed across all databases, but varied by different Boolean operators, and the documentation process by limitations of the databases/search engines. Two reviewers (STA and PH) searched and screened the relevant articles. One researcher (STA) extracted data using a matrix in an Excel spreadsheet, predeveloped for charting and analysis of the screened data. Any confusion or disagreement was resolved within the group at the screening and data extraction stage upon discussion. A subset of extracted data was checked by a third reviewer (MS) for quality assessment of included studies. Two researchers (MS and STA) performed a thematic analysis based on the major themes of the review. We developed a brief narrative synthesis specifically to inform the respondents who participated in the next step. No ethical approval was obtained for this step as we worked with secondary data. The step-by-step inclusion of the relevant articles are shown in Figure 1. In total, 19 peer-reviewed journal articles and 11 policy documents were included for the review, which are presented in Appendix-1 & 2.

Table 1.

Rapid review protocol.

Search strategy	Inclusion criteria	Peer-reviewed articles that include either of, in combination of two or all of the three concepts; HP, UHC and GHS (i.e. articles that discuss HP only, HP and GHS, or HP, UHC and GHS).
		Policy documents in Bangladesh in light of either of, in combination of two or all of the concepts in concern (HP, UHC and GHS)
	Exclusion criteria	•Articles that do not cover either of the concepts •Policy documents not based in Bangladesh
Time frame		Any
Language		English
Study/article type		Any
Data source	Peer-reviewed journal	PubMed, Google Scholar
	Grey literature	Google
	Institutional website	Official websites of the Government of the people's republic of Bangladesh (See Appendix-1 in the Appendices)

Table 2.

Search strategy.

Health Promotion (a)	Universal Health Coverage (b)	Global Health Security (c)	Context (d)	Geographic location (e)
Health promotion Health communication Behaviour change communication Community health Public health interventions Preventive health care services	Universal health coverage Health insurance schemes Equitable healthcare coverage and access Out of pocket expenditure Social safety net Healthcare service providers	Global health security Antimicrobial resistance Zoonotic disease Immunization Health information system Biosafety and biosecurity Surveillance National laboratory systems Emergency response Outbreak response and disease containment	Health system Community Facilities Governance Policy Strategic plan Action plan	Bangladesh

*Thematic area a, b, and c combined with the Boolean operator ‘OR’ and d & e combined with ‘AND’.

Table 3.

Key search terms for PubMed.

Sl.	Remarks	Key Search term	PubMed results
1	(HP OR UHC OR GHS) AND Bangladesh	((((Health Promotion) OR (health communication) OR (behavior change communication) OR (Community health) OR (preventive health care services) OR (Public health intervention)) OR ((Universal health coverage) OR (Health insurance schemes) OR ((Equitable healthcare) AND (coverage OR access)) OR (Out-of-pocket expenditure) OR (Social safety net) OR (Healthcare service providers)) OR ((Global health security) OR (Antimicrobial resistance) OR (Zoonotic disease) OR (Immunization) OR (Health information system) OR (Biosafety) OR (biosecurity) OR (Surveillance) OR (National laboratory systems) OR (Emergency response) OR (Outbreak response) OR (disease containment))) AND (Bangladesh)) AND ((Health system) OR (Community) OR (Facilities) OR (Governance) OR (Policy) OR (Strategic plan) OR (Action plan))	8,821
2	(HP AND UHC) AND Bangladesh	(((((Health Promotion) OR (health communication) OR (behavior change communication) OR (Community health) OR (preventive health care services) OR (Public health intervention)) AND ((Universal health coverage) OR (Health insurance schemes) OR ((Equitable healthcare) AND (coverage OR access)) OR (Out-of-pocket expenditure) OR (Social safety net) OR (Healthcare service providers)))) AND (Bangladesh)) AND ((Health system) OR (Community) OR (Facilities) OR (Governance) OR (Policy) OR (Strategic plan) OR (Action plan))	992
3	(UHC AND GHS) AND Bangladesh	(((((Universal health coverage) OR (Health insurance schemes) OR ((Equitable healthcare) AND (coverage OR access)) OR (Out-of-pocket expenditure) OR (Social safety net) OR (Healthcare service providers))) AND (((Global health security) OR (Antimicrobial resistance) OR (Zoonotic disease) OR (Immunization) OR (Health information system) OR (Biosafety) OR (biosecurity) OR (Surveillance) OR (National laboratory systems) OR (Emergency response) OR (Outbreak response) OR (disease containment)))) AND (Bangladesh)) AND ((Health system) OR (Community) OR (Facilities) OR (Governance) OR (Policy) OR (Strategic plan) OR (Action plan))	516
4	(HP AND GHS) AND Bangladesh	(((((Health Promotion) OR (health communication) OR (behavior change communication) OR (Community health) OR (preventive health care services) OR (Public health intervention))) AND (((Global health security) OR (Antimicrobial resistance) OR (Zoonotic disease) OR (Immunization) OR (Health information system) OR (Biosafety) OR (biosecurity) OR (Surveillance) OR (National laboratory systems) OR (Emergency response) OR (Outbreak response) OR (disease containment)))) AND (Bangladesh)) AND ((Health system) OR (Community) OR (Facilities) OR (Governance) OR (Policy) OR (Strategic plan) OR (Action plan))	4,745
5	(HP AND UHC AND GHS) AND Bangladesh	((((((Health Promotion) OR (health communication) OR (behavior change communication) OR (Community health) OR (preventive health care services) OR (Public health intervention))) AND (((Universal health coverage) OR (Health insurance schemes) OR ((Equitable healthcare) AND (coverage OR access)) OR (Out-of-pocket expenditure) OR (Social safety net) OR (Healthcare service providers)))) AND (((Global health security) OR (Antimicrobial resistance) OR (Zoonotic disease) OR (Immunization) OR (Health information system) OR (Biosafety) OR (biosecurity) OR (Surveillance) OR (National laboratory systems) OR (Emergency response) OR (Outbreak response) OR (disease containment)))) AND (Bangladesh)) AND ((Health system) OR (Community) OR (Facilities) OR (Governance) OR (Policy) OR (Strategic plan) OR (Action plan))	488

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart of included studies.

Step 2: qualitative component

The Rapid Review findings informed the development of guidelines for key informant interviews (KIIs) in the second stage. The purpose of the qualitative phase was to understand health system governance at the national level around these concepts and the perception of policymakers and practitioners about these concepts in advancing UHC in the country by 2030 and improve resilience to face future epidemic/pandemics (e.g., like COVID-19). We reached out to purposively selected government professionals dispersed across various levels of planning and implementation of the relevant programs of UHC, GHS, and HP under the Ministry of Health and Family Welfare (MoHFW). From the primary list prepared from our existing networks, 11 agreed and finally took part in the face-to-face interviews after informed consent. In the KIIs, we explored the following key themes: i) perceptions and understanding of the three concepts (UHC, HS, and HP) in the context of Bangladesh, relevant policy and practices, and alignment (‘synergies’) and gaps (‘fragmentation’) among the three concepts, including underlying reasons; ii) challenges of overcoming the gaps to build synergy and reaching a consensus; and iii) way forward to develop a health system which is people centered, equitable, fair (financially protected) and resilient (e.g., to infectious disease threats and AMR).¹⁴ For KII guideline, please see Appendix-3.

Informed written and verbal consent, including consent to audio recording, was taken before commencing the interview which lasted about 45 minutes on average. Data were transcribed verbatim directly into Bangla from the audios. The transcripts were uploaded on Atlas.ti (version 8) for analysis. The transcripts were read and coded by a team of three researchers who read the transcripts several times for familiarisation. Next, we divided the text into smaller units and labelled them with codes. Both deductive and inductive approaches were applied for coding. For the former, a list of codes was already made from the guideline and literature review such as perception, synergy, and fragmentation. This made up the codebook. During coding, these codes were applied to respective texts. However, whenever new codes emerged, the new codes were added to the codebook and existing codes were modified whenever necessary. This process was inductive. The codes were finalised based on several discussion in the team. Moreover, each transcript was coded by at least two team members to check for agreements and disagreements. The codes were also discussed with senior researchers in the larger team for their expert opinions. This peer-debriefing process also improved the trustworthiness and rigour of the findings. All these steps helped to ensure the reliability and quality of coding. Then, codes that were related to one other were categorized which were further discussed upon for consensus. Patterns and connections between the categories were determined and linked to the overarching themes. Overall, the coding and categorization took place in tandem. The team also prepared a data display matrix to present sub-themes/themes used and relevant codes and used it to identify patterns and themes.

Step 3: stakeholder deliberative meeting

Knowledge gained from the above two stages was shared in a stakeholder meeting with eight policymakers selected from the pool of participants in the KIIs. The deliberative meeting was held to discuss, debate, and reach a consensus on the scope and barriers of achieving synergy and how to overcome the obstacles. The purpose was to re-align the three streams of activities to prepare the health system to ‘prevent, detect and respond’ to emerging and re-emerging cross-border epidemics, including the emergence of antimicrobial resistance (AMR). The meeting was recorded upon approval from all participants, coded, and analyzed in the same way as step 2. Participants taking part in KIIs and stakeholder meetings were high officials from the Planning and Health services divisions of the Ministry of Health and Family Welfare (MoHFW), several Line Directors from the Directorate General of Health Services, DGHS, MoHFW, icddr,b and IEDCR.

The project received ethical clearance from the Institutional Review Board of BRAC James P Grant School of Public Health, BRAC University (Reference No: 2019-010-IR). The participants were the senior policymakers at the MoHFW, and to keep their identity anonymous, we have not included the organizational link in the quotes.

Role of the funding source

The funder had no role in the study design, data collection, analysis, interpretation of data, or writing the manuscript.

Results

Information collected through three sources (Rapid Review, KIIs, and stakeholder meeting) were triangulated to identify the key emerging themes. Findings are presented below according to these themes.

UHC, HP and GHS: conceptual clarity

To be able to implement the activities under UHC, GHS, and HP, conceptual clarity is important, which was not evident in the interviews. According to the rapid review, the three concepts, e.g., UHC (delivering services), HP (preventive and promotive health), and GHS (epidemic preparedness), have different agendas, focal agencies, and roles and responsibilities with few measures to coordinate and consolidate activities. Interestingly, all the implementing agencies are housed within the same ministry, i.e., MoHFW and the activities are tailored from its planning wing. The relevant activities are implemented through the existing Primary Health Care (PHC) infrastructure at the front lines. UHC targets the population at an individual level for equitable access to quality health care. In the case of GHS, the focus is mostly on preventing, detecting, and controlling infectious diseases and targets people in the community. Although in our rapid review, the policy analysis of the 4th health sector plan revealed partial alignment between UHC and GHS (e.g., related to early notifications of outbreaks from the field), in practice, coordination hardly exists as indicated in the stakeholder meetings with the KIIs. Prior to implementation, the synergy between UHC and GHS is not reflected in the policies or practices.

GHS was the least familiar concept among the three except for those working in infectious diseases, such as in the IEDCR and Communicable Disease Control (CDC) unit of the Directorate General of Health Service (DGHS). Most KII participants had adequate knowledge of their respective UHC and HP programs' most relevant concepts to perceive HP as an integral part of GHS and UHC independently. However, they rarely reported conceptualizing synergy with GHS. Some respondents were unclear about the GHS concepts, including its purpose and activities, and were not concerned about the utility of linking the two concepts. Quoting financing as the only component of UHC, one respondent believed fragmentation could not be helped as there is little or no connection between GHS and UHC. This complacency and the tendency to stick to their respective 'comfort zone' can be reflected in the following quotes.

“The focus of Global Health Security is infectious disease…the reason it is about global security is that communicable diseases can easily cross borders. This is a global issue. That's why it cannot be easily linked to Universal Health Coverage which is about finances…”

- KII #1, CDC, DGHS, MoHFW

Another respondent was of the opinion that GHS has a specialized focus and should be dealt with by people/Department(s) who have the requisite skills:

“Not all departments and programs have to be equally concerned [about all the three areas]. All must know about and work for universal health coverage and health promotion. But the work of global security is focused on which has different regulations and measures and is the responsibility of a specific department whose sole responsibility is to take care of it. Not everyone's job is security.”

- KII # 2, Secretariat, MoHFW

Similarly, another respondent who worked mainly for UHC said:

“We only look after the responsibilities related to Universal Health Coverage. But, we are not that concerned about Health Security or Health Promotion activities. And, since IEDCR takes care of the activities related to Health Security, I think it is natural to think that the IEDCR should take the lead.”

- KII# 3, DGHS, MoHFW

Thus, a lack of conceptual clarity about the themes was evident, pointing to the participants’ compartmentalized mindset and tendency to stick to their respective disciplines.

UHC, HP and GHS: fragmentation and synergies

Our rapid review suggests that certain synergies can be drawn theoretically, but our findings from the KIIs provide a reality check to these superficial synergies. The respondents understood fragmentation as a division of tasks or responsibilities. They viewed it as beneficial, the same way synergy is required. For example, one respondent mentioned,

All three are complementary to each other… […]…our ultimate goal should be universal health coverage. Part of that entails ensuring health security; otherwise, there will not be universal health coverage. What if a disease comes from a neighboring country and there is an outbreak? If we do not have proper regulations, then there is a problem. Similarly, if we do not promote health, there will be diseases. We will need more clinical services, which might be unaffordable. That is why health promotion and health security are fundamental measures to progress toward achieving universal health coverage.

-KII#2, Secretariat, MoHFW

From the rapid review, we learned that the Health Economics Unit (HEU) of the MoHFW, the focal agency for UHC, tested a pilot ‘health financing scheme’ for improving access to services for poor people. In operationalizing this, HEU had to depend upon the DGHS as the latter is the primary implementing agency for delivering services on the ground. UHC activities cannot be scaled up by HEU alone. On the other hand, IEDCR is the focal agency for GHS and is funded by and works with the CDC/DGHS to implement IHR 2005 regulations. According to the review, it has ‘Rapid Response Teams’ at national, district, and sub-district levels to identify outbreaks of viruses or other disease-transmitting agents. However, one of our KII respondents commented that such teams ‘exists only in writing’ and are not integrated into the mainstream health system. For example, it can be mentioned here that three committees currently exist for implementing the IHR 2005: National Coordination Committee of MoHFW, National Technical Committee of DGHS, and Core Committee of CDC/DGHS.

When the respondents were asked what they thought of the fragmentation and synergies while aligning these concepts, they provided some examples from their practical experiences. For example, they mentioned the role of HP in GHS, such as building awareness, evidence-based advocacy, and risk communication for emergency preparedness, over and above behavior change communication towards achieving UHC. Still, some believed that fragmentation could not be helped as there is little or no connection between GHS and UHC.

“I think working in a fragmented manner is beneficial. How is it possible for one department to perform all the tasks related to UHC and GHS?”

- KII# 4, CDC, MoHFW

Fortunately, there were opposing views as well:

“All three agendas complement each other… we have to ensure health security; otherwise, there will be no universal health coverage. Similarly, if we do not promote health, there would be more diseases and more need for clinical services, which may be unaffordable… health promotion and health security are fundamental measures to progress towards achieving universal health coverage.”

- KII # 2, Secretariat, MoHFW

Perceived causes of fragmentation (or lack of synergies)

The respondents mentioned several issues for the lack of synergies among the three concepts and relevant activities at different levels.

Administrative complexity at the national level

The lack of conceptual clarity and poor coordination are compounded by the administrative division of MoHFW. Many respondents believed that the major cause of fragmentation is the division of the MoHFW into two wings, the Director-General of Health Services (DGHS) and Directorate General of Family Planning (DGFP) run independently and vertically. This division is historical and has been in place since the inception of the nation in 1971. After the liberation war, family planning became a major issue in the war-torn, famine-stricken country. There was a severe need to control the population expansion, and a separate line of the administrative body (DG Family Planning) under the ministry with distinct human resources and finances sought to do just that. This was never retracted once the purpose was served, and to date, the two directorates continue to operate separately, creating two different channels of supply chain and procurement, the duplicity of data collection and generation. One of our respondents remarked about the consequences,

“The division is irrational…it is creating confusion. At the community level, there are healthcare services and family planning. Both run similar activities (e.g., are ANC and PNC), but separately…there is no synergy. So now what's happening is that the same data that is being generated is coming from two different channels, and there is hardly any coordination.”

- KII# 6, icddr,b

All respondents seemed well aware of the issue, and when asked, one respondent revealed the subtle reason. In his/her words,

“Maybe we are not considering these two (DGHS and DGFP) as one. Maybe we are considering them as different. Those who are in the Administration decide these things. Those who are in policy-making, maybe we (people) are being made to think that way by them. Suppose, if we do things this way, maybe it will benefit us to get money from the donor and spending the money! If (you) have the authority to spend and get the money, you may have more opportunities to enjoy benefits from other sources.”

- KII# 7, DGHS, MoHFW

Similar bifurcation exists in catering health services in the urban and rural areas, this time by different ministries. This situation emerged because urban primary health care services are not being provided by the MoHFW but by the local government ministry (MoLGRD). This poses a clear disparity across geographical locations as quality of services may not be up to the same standard. Hereby, a separate governance mechanism for urban health care was identified as a significant reason for poor synergy.

One KII respondent stated this as a ‘confusion at the policy level’, which may resonate with the similar context of such divisions within the Ministry into DGHS and DGFP. S/he responded,

“There is fragmentation in that the MoHFW has a set of responsibilities that are different from those of the local government (MoLGRD). There is confusion at the policy level… […]…there is a lack of infrastructure below the tertiary level in the urban cities… […]… the services [provided by private sectors and NGOs in the urban areas] are not sustainable.”

- KII # 8, PPRC

Besides lack of coordination and duplication of data, other related challenges include overlapping services and, therefore, not being cost-effective in the process. One respondent mentioned:

“If both the divisions worked together, the quality and service coverage would have been better. The overlapping could have been avoided; the cost would have been reduced, and the shortage of human resources could have been tackled.”

- KII# 7, DGHS, MoHFW

Thus, the bifurcation itself discourages coordination and consolidation of activities of the MoHFW, including those related to UHC (focal agency residing in the ministry) and GHS (focal agency run by independent governance, management and accountability structure).

Lack of coordination and communication between public and private sectors

Some respondents perceived a lack of coordination in delivering services in private and public sectors to drive fragmentation in the health system that could ultimately affect attempts at the synergy of the UHC-GHS-HP. One of the participants mentioned,

“Fragmentation happens when the government does not recognize the priorities of the local initiatives that are happening at the micro-level, which as a result, get less support [from the government]”

- KII# 5, Secretariat, MoHFW

Another respondent expressed similar concern but from a slightly different perspective:

“All infectious cases are supposed to be in the infectious disease hospital, but that's not the case. There are numerous private services and lack of coordination with the Government and lack of infrastructure.”

- KII# 9, IEDCR

Development partners pursue and prioritize their agendas

Several participants identified the role of development partners in contributing to the fragmentation as well:

“Fragmentation extends to the development partners because, let's say the EU is supporting urban health initiatives in the local government division, and the World Bank is supporting the Ministry of Health for the same… the donors are then pushing their respective agendas instead of the national agenda.”

- KII# 5, Secretariat, MoHFW

According to the respondent, different development partners are running multiple projects simultaneously that seek similar outcomes; hence, there is overlapping and duplication of work. Thus, various governing bodies and donor agendas also drive fragmentation and complicate the achievement of synergy. Concerning this, they expected a more assertive role of the Government to discourage and prevent fragmentation by aligning the donors' interests. A respondent echoes this,

“If the ministry within the government can play a strong role in making synergy, if there is good leadership, it is possible (to achieve synergy).”

- KII# 3, DGHS, MoHFW

Epidemiological transition

The epidemiological transition from communicable to a mix of non-communicable and infectious diseases (‘double burden’) has given rise to a situation when more preventive services for lifestyle changes are needed. It also precipitates fragmentation as the current health system, plausibly, is oriented towards providing curative services to a greater extent. According to some respondents, focusing on the curative approach while the prevalence of non-communicable diseases rises also drives fragmentation. It causes challenges in allocating funds and human resources and hinders improved health outcomes in the country. To quote a respondent:

“The challenge is that people at the policy level are more focused on clinical services rather than prevention. We put in a lot of effort… but if you talk to a minister, he would first want to know the cancer treatment. He is not interested in antimicrobial resistance or any use of its surveillance.”

- KII# 9, IEDCR

Resource constraints

The insufficient fund was reported as a barrier to achieving synergy. To this, one policymaker said,

“If you talk about health financing, our per capita health expenditure is at the moment 37 USD. WHO is saying it needs to be a minimum 60 USD. So, to reduce this gap is very challenging”.

- KII# 3, DGHS, MoHFW

The respondents also cited weak infrastructure and insufficient skilled human resources as common barriers to achieving synergy. One respondent who worked in Health Promotion said:

“Our infrastructure is not that strong…there is a shortage of human resources in health. We do not have good laboratories. If you want the correct results related to virology, you must send that sample to Delhi, right? So, we have to improve the infrastructure. But before that, we need to train more people who are going to work in these labs.”

- KII# 9, IEDCR

He further stressed the importance of having more human resources:

“Expansion of the health workforce is not proportional to the expansion of facilities. Suppose there is a hospital with 500 beds, but the workforce is for 50 beds only…so there are buildings but no service. So, this has to be taken care of in the future.”

- KII# 7, DGHS, MoHFW

The shortage of human resources especially at the front lines was also a finding from the rapid review; whatever is available is plagued with low retention and frequent absenteeism.¹⁵ The front-line health workforce (community health workers, paramedics, doctors, and nurses at PHC) are supposed to implement these additional HP and GHS activities related to behavior and lifestyle changes and health security, respectively, at the community level and above delivering health care services. Besides, as the strategies for the three agendas encompass different activities, the current approaches do not specify how this can be done efficiently and effectively with the available resources.^15,16 Nevertheless, several respondents emphasized the scope for some synergy at the field level since the community health workers provide preventive and essential curative services for common illnesses and become involved in GHS activities during an outbreak/health emergency.

Discussion

This study explored the level and extent of synergies (or fragmentation) among UHC, GHS, and HP, perceived underlying reasons, and challenges and opportunities for aligning the three agendas. In doing so, this paper also presents the conceptual understanding of the UHC, GHS, and HP agenda by those at high levels of policy and practice in the public sector and an investigation of responses to infectious disease outbreaks. A review of available documents, in-depth interviews of the key informants, and output from a stakeholder deliberative meeting were used to consolidate and analyze relevant data. The findings reveal interesting insights into the three agendas, and the implications of these for building a resilient health system are discussed.

The existence of fragmentations more than synergies was evident among the UHC, GHS, and HP agendas in Bangladesh in policy and practice, not unlike in other countries.^17,18 Fragmentation of health systems limits our capacity to respond to epidemics/pandemics, especially COVID-19, effectively and efficiently. It is reflected during the management of the COVID-19 pandemic.¹⁹

One significant finding was that most respondents possessed less conceptual clarity about the three agendas and their inter-linkages, especially in the GHS agenda, as this was better understood only by those working in the infectious disease sector directly involved in related activities. Originating from this conceptual obscurity, most respondents perceived that the synergy between UHC and GHS is superfluous and, what is more alarming, not even needed. They were worried that synergy would lead to a shift in priority from their respective agendas depending on where the fund is available or the priority of policymakers.

The tension arising from this convergence in countries with an understaffed and underfunded health system, where priorities between UHC and GHS may differ, is plausible.⁹ For example, between improving laboratories (for GHS) or increasing the workforce (for UHC), a choice would have to be made, which is a challenge in implementing measures for GHS.^20,21 The findings of this study indicate that doing so will not be accessible due to a lack of coordination among the focal agencies to deliver integrated services in the field. Besides, there are also health system challenges, e.g., lack of appropriate infrastructure (e.g., labs and trained technicians), inadequate human resources, and limited financial resources to complicate the matter. Thus, the only way to ensure synergy between GHS and UHC may be to embed GHS-related activities into UHC activities, as suggested in recent literature.¹⁴ However, all relevant stakeholders must be at the same level conceptually for this to happen so that a successful synergy can occur.

On a more practical note, findings also reveal several unrealized points of convergence that may facilitate synergy.²² First, all the focal agencies are within the MoHFW, which can play a substantial role in coordinating activities towards synergy. The MoHFW can and should better coordinate with the donors to align the three agendas and prevent duplication of work and inefficient use of resources. Second, all three components have a strong prevention focus, i.e., UHC, GHS, and HP. It means HP can easily integrate into the system and bring synergy between UHC and GHS. The respondents perceived HP as a potential element of synergy binding the two other agendas, UHC and GHS. However, HP's activities should go beyond individual behavior change and be more active in incorporating messages related to health services and emergency outbreaks, among others. Third, the Essential Service Package (ESP) under UHC provides an excellent opportunity for synergy. Activities related to ‘infection prevention and control’ already fall under the infectious disease component of ESP. Therefore, outbreak notification, investigation and initiation of response to contain the infection can be integrated with GHS efforts. Finally, the common problem of shortage of skilled health workforce. Almost all the respondents in the three areas reported this problem. If there is coordination between the programs, the health workforce could be shared, and when tasks are not duplicated, the work burden will reduce, enabling effective and efficient service delivery.

Findings indicate that synergy is possible if political commitment and mobilization of resources, and coordination of activities within and beyond the health sector towards a common goal can be made. Bangladesh's outstanding successes exemplify this in instances such as the Expanded Program of Immunization (EPI),²³ The Global Polio Eradication Initiative (GPEI), and controlling emerging and re-emerging infectious diseases like Zika, Nipa Virus, H5N1 (Avian Influenza) outbreak. More recently, stakeholders in the human, animal and environmental sectors came together to promote the concept of 'One Health' in Bangladesh and tackle the epidemic of antimicrobial resistance. Ultimately, a One Health Secretariat was established at the IEDCR with staff from three ministries (human health, animal health, and environment) and support from the development partners.²⁴

A well-functioning health system increases efficiency when UHC, GHS, and HP efforts are integrated. These can be optimally utilized in limited-resource settings to achieve the different agendas' multiple objectives. Based upon the findings discussed above, we propose the following recommendations to facilitate the much-needed synergy among the three concepts, especially after COVID-19. First and foremost, awareness of these three agendas, including relevant activities, must be built among the key stakeholders in policy and practice in the public, private, and non-profit sectors. It can be followed by mapping activities that can be synergistic related to UHC, HP, and GHS. Second, a specific strategy is needed to assert the leadership of MoHFW to advance epidemic preparedness through coordination of activities under the three different agendas at the ministry level and provide supportive supervision. Third, the gaps should be identified through a critical review of the implementation of recommendations made by the Joint External Evaluation (JEE) survey. Fourth, consolidated actions from the ministry level should be instigated to overcome the barriers.²⁰ Finally, measures to address resource (physical, human, finance) constraints for the implementation of UHC, GHS, and HP should be ensured. The COVID-19 pandemic confirms the necessity of a comprehensive and inclusive UHC for individual and collective health security. Inadequate investment, fragmentation, and privatization weaken national health systems and expose them to severe crises in times of emergency.²⁵ In the post-COVID-19 era, we should seize the 'window of opportunity’ to push forward the structural reforms that have been long due.²⁶

Strengths and weaknesses

It is the first time the synergy and fragmentation among three global agendas, UHC, GHS, and HP, have been critically investigated in Bangladesh. The findings will benefit the policymakers in undertaking essential steps. However, the study was limited to exploring senior policymakers' views and experiences. Understanding the midlevel and front-line workers engaged in carrying the three agendas would have illuminated further reality necessary for implementing the policies.

Although under the same umbrella, the coordination among UHC, GHS, and HP is not a strong suit for the health ministry (MoHFW) in Bangladesh. There are more fragmentations than synergies among the UHC, GHS, and HP agendas in policy and practice. Fragmentation of health systems limits our capacity to respond to epidemics/pandemics of the extent of COVID-19 effectively and efficiently. The current COVID, 19 pandemic response of the country, also showed that UHC does not thrive in times of high GHS demand, and that the priority of GHS overrides UHC. Therefore, strengthening UHC (and HP) through synergy with GHS is essential to build resilience and ensure access to essential health services that would improve health security.²⁷

Contributors

The study was conceptualized by MS and SMA. The methodology was selected by MS. The rapid review was conducted by PH, IS, STA. The qualitative interviews were conducted by MB, PH, MS, and IS. The transcripts were coded by MB, PH, and IS. The first draft was written by MS. All authors read and contributed to the writing. SMA has overseen the study process and made the final revision.

Data sharing statement

De-identified transcripts will be shared upon request to the corresponding author.

Declaration of interests

All authors confirm that there are no conflicts of interest.