Consultancy on National Situation Analysis on Health Equity-Bangladesh

Introduction

Handicap International- Humanity & Inclusion (HI) is an independent and impartial international aid and development organization working in situations of poverty and exclusion, conflict and disaster. Working alongside people with disabilities and vulnerable groups, it takes action and provides testimony in order to meet their basic needs, improve their living conditions and promote respect for their dignity and their fundamental rights. Handicap International is a non-profit organization with no religious or political affiliation. It operates as a federation made up of a network of associations which provide human and financial resources, manage projects and implement its actions and campaigns. Handicap International is present in Bangladesh since 1997.

HI is a global actor recognized for its expertise on disability inclusion in the health sector. In line with the CRPD[1] and the SDGs, despite these international frameworks**, the right to health of persons with disabilities – representing about 16% of the world population – is consistently violated**[2]. Commonly, persons with disabilities encounter barriers to accessing health services, including physical, communication, attitudinal and institutional barriers and less health coverage, directly leading to worse health outcomes. For example, persons with disabilities are two to four times more likely to be denied health care, to be treated badly in the health care system, and to find health care providers’ skills and facilities inadequate to meet their health needs. As a result, persons with disabilities have 2.4-fold higher mortality rates than those without disabilities and are missing 10 to 20 years of life expectancy. The information available on barriers and facilitators to health care for persons with disabilities remain limited with scarce health related data disaggregated by disability, gender, and age[3]. When it comes to Sexual and Reproductive Health and Rights (SRHR) information and services, the rights of persons with disabilities and especially of women and girls continue to be violated due to deep-rooted discriminatory attitudes and practices, and a lack of law and policy enforcement. Denial of bodily autonomy and the right to informed consent, forced sterilization and contraception, forced pregnancy, coercive abortion and other forms of gender-based violence, denial of maternal, parenting and parental rights, denial of legal capacity and decision-making, lack of access to information and services, and a lack of access to justice are among the key rights violations’ women with disabilities face.

HI promotes the rights to access health, particularly focused on sexual and reproductive health information and services for all including persons with disabilities and vulnerable populations in development and fragile settings. HI is committed to universal access to health care services, integration of reproductive health into national strategies and program, and empowerment of persons with disabilities on advocacy, comprehensive sexual education, health literacy and social behavioral change communication. HI promotes an intersectional perspective aiming at applying a gender, age and disability lens to all actions. As a non-state actor in official relations status with WHO, HI builds on a long history of collaborating with the WHO in the health sector and contributes to supporting the rollout of the WHO Global Report on Health Equity for persons with disabilities. HI works on inclusive HSS in line with the six WHO Building blocks ((i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance)

Background

Links between health and development have long been acknowledged. It is generally recognized that securing a certain level of health-related development is a prerequisite for the overall economic development of a country. Over the last decades, particularly since the Millennium Declaration and formulation of the Millennium Development Goals (MDGs), development and health have increasingly converged. According to BDGH 2022, only 41% pregnant women received 4+ ANC visit and the percentage of deliveries attended by skilled health personnel is 70% which is lowest among the neighboring country like India, Nepal and Sri Lanka. Women in rural areas are less likely to have their deliveries assisted by medically trained providers than women in urban areas (65% versus 82%).

The sector of family planning, one of the major components of SRH is still lagging. According to BDHS 2022, the contraceptive prevalence rate (CPR) is 64%. 55% of women are using modern methods of contraception, while 9% rely on traditional methods. The 4th HPNSP[i] aims to reach a CPR of 75% by 2022[ii]. The same report shows that the total fertility rate (TFR) is 2.3 children per woman. The goal of the 4th Health, Population and Nutrition Sector Programme (4th HPNSP) is to achieve a TFR of 2.0 by 2023. However, the TFR has remained unchanged at 2.3 since 2011.10% of married women in Bangladesh have an unmet need for family planning whereas the percentage is 22 for women with disabilities[iii].

The need for health service information particularly the availability of quality accessible essential service delivery (ESD) focusing on child health care, safe motherhood, family planning, menstrual regulation, post-abortion care, and management of sexually transmitted infections, limited curative care and behavior change communication, Communicable diseases (including tuberculosis, malaria, others) and emerging noncommunicable diseases (diabetes, mental health conditions, cardiovascular diseases). As ESD is a combination of primary health care (Maternal and childcare, health education, accessibility of medicine, accessible treatment, local disease control, communicable and non-communicable diseases) and SRH-FP (maternal health and newborn care; adolescent reproductive health, safe abortion care; family planning; prevention and management of STIs/RTIs) , information and services related PHC and SRH-FP is more urgent for persons with disabilities, owing to their heightened vulnerability but persons with disabilities face multi-layered barriers in accessing basic health care services in comparison to others. Women and girls with disabilities are likely to experience unique obstacles and human rights abuses due to the intersection of their gender and disability which includes gender-based violence, abuse and marginalization. As a result, women with disabilities often face additional disadvantages compared to men with disabilities and women without disabilities. Women with disabilities are ten times more likely to be sexually assaulted than women without disabilities and they are mostly denied the right of decisions making on their reproductive and sexual health, which increases risks of unplanned pregnancy, unsafe abortion, and sexually transmitted infection as well as sexual violence.

The WHO Global Report on Health Equity for persons with disabilities analyses the factors that contribute to systemic health inequities for persons with disabilities and outlines important policy and programmatic actions and recommendations to reduce these inequities. The Global Report outlines ten strategic entry points for advancing health equity for persons with disabilities within national health systems:

Objectives of the Situation Analysis

To undertake national context situation assessment, analyzing policies and initiatives to set priorities and take action to promote equal access to services, quality, integration, and inclusiveness of health services, focusing on system strengthening, primary health care (PHC) including FP and SRH, especially with respect to the fulfilment of health rights of young and women with disabilities.

The specific objectives of the Study

• An up-to-date policy analysis with identification of gaps, strengths, challenges and opportunities within national policies related to health including different components of primary health care and sexual and reproductive health rights and family planning, particularly focusing on policies related to essential service delivery package.
• Conduct a mapping of government, private (Pharmacies) and civil society actors (NGOs, INGOs and DPOs) engaged in inclusive health, particularly essential service delivery package.
• An analysis of current situation of health equity in line with 4A1Q(Available, accessible, affordable, acceptable and quality) model of health service as well as the WHO building blocks using the 10 strategic entry points in the WHO on health equity for persons with disabilities as the key framework for analysis.
• Draw concrete recommendations to set or redefine the policy goals by supporting strategic planning, alignment of resources, interventions and to contribute to the local and global efforts to leave no one behind
• Propose a roadmap for the government; leverage domestic financing; identify where policy or legislation needs to be enacted or protected from regression to respond to critical health equity gaps.

More specifically, the study also addressed the following questions:

• What are the policy gaps, strengths, challenges and opportunities within national policies to promote equal access to services, quality, integration, and inclusiveness of primary health care and SRH focusing on essential service delivery package, especially for the young and women with disabilities?
• Who is engaged in providing disability inclusive essential service delivery package?
• What is the current situation of health equity in line with the WHO building blocks?
• What is the scenario considering the 10 strategic entry points mentioned in the WHO on health equity for persons with disabilities?
• What are key interventions needed to integrate disability in health system?
• Where policy or legislation needs to be enacted or protected from regression to respond to critical health equity gaps?
• What steps/actions need to be considered to address the WHO 10 strategic entry points?

The study also identified recommendations to set or redefine the policy goals by supporting strategic planning, alignment of resources, interventions and to contribute to the local and global efforts to leave no one behind. In terms of a forward-looking perspective, the study draws lessons learned and identified key operational experiences that may be used for future interventions.

Study Methodology

The consultant will use a mix of quantitative and qualitative methods of data collection, consisting of analyzing data based on the objectives. Statistical data derived from desk review, series of meetings including Key Informant Interview (KII), and Focus Group Discussions (FGDs) and the stakeholder workshop. The context analysis was based on these primary data and supported by the secondary data from other reports and secondary materials.

Expected Outputs

• A comprehensive report on situation analysis on health equity for persons with disabilities following the objectives

Timeline and expected duration:

• Final methodology including KII, FGD questions should be shared with HI at least 5 days before the field test.
• The assignment should be completed by 20 Nov 2024.
• Some report writing and other admin tasks can be added as per the need

Study Location: Countrywide study.

For details please see the Terms of Reference.