The key issues identified as the facilitating factors are as follows.
i) Upstream level decisions for integrating ICT and health
Strong upstream level commitments have been found in the policy landscape regarding the integration of ICT across all government departments including health. The government manifesto of “Digital Bangladesh”, formulated in 2009, advocates for ensuring an ICT-based society where all possible activities of the government, non-government and semi-government organizations will be performed using ICT network for ensuring equitable and comprehensive development by 2021 (27). Placing this “Vision 2021 Agenda” as a guiding principle of the government, all ministries of the government of Bangladesh began to thrive using digital platforms for providing need-based high quality services for all citizens of the country.
In addition, the Government of Bangladesh expressed commitment to achieve Universal Health Coverage (UHC) by 2032. With this aim, the ‘health care financing strategy’ was formulated by the Ministry of Health and Family Welfare (MOHFW) in 2012, that clearly acknowledges that, along with other factors, human resource development as well as proper utilization of ICT is imperative for achieving UHC goals (28). Bangladesh has signed the United Nations Sustainable Development Goals (SDGs), which obligates the Government of Bangladesh to make stronger investments for improving HRH management. All these upstream policy level commitments could create a conducive environment to integrate ICT for health systems strengthening which is evident in recent advancement in MOHFW – such as introduction of online DHIS2, Open MRS, HRIS etc. for ensuring ‘measurement and accountability’ and ‘data for decision making’ in the public sector health care delivery system.
ii) Commitments for ICT based HRM
The upstream level commitments have been reflected in the content of relevant policies and strategies of the Ministry of Health and Family Welfare (MOHFW). The National ICT Policy 2009 formulated by the Ministry of Science and Information & Communication Technology (MoSICT) is one of the prime examples. This policy was formulated to function as “binding guide” for adopting ICTs by all other ministries of the government to improve efficiency and effectiveness of government interventions. Giving emphasis on health system, the national ICT policy provided strategic guidance to improve the health care delivery system through introduction of e- and m-health. In addition, under the strategic theme 7.1, the ICT policy recommends developing, updating and using a comprehensive national database for all HRH including, doctors, nurses, paramedics as well as the alternative medical practitioners in the country. The policy particularly recommends that this comprehensive and dynamic database will be used for all kinds of HRH management activities including recruitment, posting, transfer, retention and retirement. Importantly, creation of this database was taken as priority short term task, mentioning as “need of the hour”, which was supposed to be implemented within 18 months of policy formulation. Therefore, the national ICT policy was the first impetus for building and using an ICT-based tool for improving HRH management in the government sector (29).
One of the main goals of The National Health Policy (2011) was to ensure the best utilization of ICT tool for improving overall health systems performance. Although there is no specific content in National Health Policy for integrating ICT in HRH management, its strategy#13 has clear and elaborate recommendations for establishing an integrated management information system using computer network for planning, implementation and monitoring of all health programmes in the public sector (30).
The Program Implementation Plan (PIP) of the “4th Health, Population and Nutrition Sector Development Programme (HPNSDP) 2011-16” is the first policy document in the health sector that took specific decisions to provide accurate and up-to-date HRH information to policy makers and all relevant stakeholders for better HRH planning and management. The operation plan (OP) on HRM of the 4th HPNSDP identified problems for not having a central information system on HRH and thus endorsed specific decision for establishing ICT based HRH information system for ensuring real-time data for management decision support and planning. In this policy, specific target was set to establish a central HRIS within 2014 and to utilize it for HRH management by mid-2016 (31). More importantly, there was clear recommendations for updating National Health Workforce Strategy for promoting evidence-based HRH planning and management. Based on this recommendation, ‘The Health Workforce Strategy 2015’ was formulated by MOHFW, in which “Health Workforce Information System (HRIS)” was taken as one of the five main thematic areas. Under HRIS thematic area, the major commitment was to establish a comprehensive central health workforce information system to promote evidence-based decision-making in HRH management (32). This was further enforced in the PIP of next health sector program ‘the Health Nutrition, and Population Sector Program (2017–2022) which has taken three major activities to be accomplished by 2022- i) Establishing one central HRIS that is linked to all agencies; ii) Capacity building from central to periphery level for institutionalization of the online HRIS and iii) Using HRIS data for evidence- based planning and decision-making, and all these activities are to be completed by 2022 (33). The PIP of HPNSP (2017–2021), has identified the DGHS as the first initiator and other departments within MOHFW have been advised to introduce HRIS for better HRH management.
iii) Budget allocation
The PIPs of 3rd and 4th health sector program has allocated adequate budget for establishing and utilizing comprehensive ICT-based HRH management tool. In PIP (2011-16), a total of 14747.00 lakhs (USD 17.393 million) was allocated for development and management of HRH. In this budget, specifically 670.00 lakhs (USD 0.790 million) was allotted for developing Human Resources Information System (HRIS) and automation of HR management process (posting, training and transfer) (31). In the next PIP (2017-21) a total of 9982.47 lakhs (USD 11.770 million) was allocated for overall improvement of HRH management. From this amount, 2193.00 lakhs (USD 2.587 million) was allocated for implementing and monitoring HRIS tool centrally. It is important to mention that, this policy mentioned the explicit allocation strategy of the budget over the period of 5 years, e.g. 62.00 lakhs (USD 0.073 million) was allotted for establishing one central HRIS that is linked to all agencies within MOHFW; 61.00 lakhs (USD 0.072 million) for establishing monitoring framework for implementation of Health Workforce Action Plan, 61.00 lakhs (USD 0.072 million) to ensure use of HRIS data for evidence-based planning and decision making, 1570.00 lakhs (USD 1.852 million) for research/ survey/ study and 439.00 lakhs (USD 0.518 million) for seminar/ conference/ training required for implementation of HWF (33).
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Lacunae in policy and scope of strengthening
i) Stakeholder engagement:
There are specific recommendations across the policies to engage different stakeholders for implementing the HRIS. In general, the government agencies, semi-government institutes and in some cases private sector organizations were identified as stakeholders to implement the HR related policies. However, there was no specific declaration about the role of the implementing bodies and there was limited information about the extent of engagement of other (than government) stakeholders. For example, according to the National ICT policy 2009, Bangladesh Computer Council or its successor organizations are identified as the implementing actors. But the specific role of each of the implementing bodies such as other ministries and departments were not explicitly mentioned in the policy. The policy also identified private sector as one of the primary actors to implement the HRH database (item#218, under Objective#7). However there is no clear role clarification on how the private sector players will be engaged in the planning and implementation process (29).
The 4th Health, Population and Nutrition Sector Programme (HPNSP 2011–2016) declared the importance of engaging multiple stakeholders in HRH management with their full involvement as per requirements. But there is no reflection about the scope of engagement multiple stakeholders for specific tasks. Similarly, ‘Bangladesh Health Workforce Strategy − 2015’ recommended some strategic intervention in short-term, mid-term and long-term for strengthening the health workforce information system. However, there is no budget attached with this strategy. In this regard, both government agencies and private sector actors were identified as key stakeholders. However, there is no clear guideline on how to integrate all these stakeholders for a comprehensive national database. Monitoring the private sector data of HRH has been identified as one of the major challenges in these policies.
ii) Implementation and Monitoring strategy
The 3rd HPNSDP (2011-16) recommended for developing and establishing a Central Human Resource Information System (CHRIS) encompassing all the directorates and departments of MOHFW by 2016. However, the subsequent 4th HNPSP (2017-22) mentioned that the HRH data was not made available in a single place from all over the country. There was no specific reason mentioned regarding how the establishment of a central HRIS for all directorates was impeded. This policy (PIP 2017-22) also mentioned that, in the initiative of establishing comprehensive HRIS under the 3rd sector programme, the ownership of MOHFW was not prominent. This is also reflected in the Logical Framework of the 4th PIP, as under the component-5 “Important Assumption” was taken as “Health Service Division of the MOHFW has control on CHRIS based at MIS department of DGHS”. This indicates that while the DGHS has a well-developed HRIS for capturing their countrywide HRH, there was a lack of implementation plan of other agencies within MOHFW.
The Health Workforce Strategy 2015 and the two PIPs (2011–2016 and 2017–2022) mentioned a long term plan for an assessment of the implementation, monitoring and reviewing of the HRIS. However, the other policies and strategies lack such strategy to evaluate the appropriateness of the design of the tool as well as the coordination mechanism among stakeholders in the implementation process. The National ICT Policy did not provide any clear idea about the budgetary allocation for developing and using the database for HRH management. Similarly, the Bangladesh Health Workforce Strategy 2015 recommended a step-wise approach for establishing and using the HRIS, but the action plans was designed without any specific budget.
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iii) Coordination among policies:
All these national level policies related to use of ICT in the management HRH were formulated gradually one after another over last 10–12 years. However, there are certain gaps with regards to coordination among these policies. For example, the National ICT policy enacted in 2009 had component on ‘update and database for management of human resources’ to be implemented as a short term task (within 18 months of policy formulation). However, the progress or implementation status of that policy was not reflected in the subsequent MOHFW policies such as PIPs of 3rd and 4th Health Sector Programme (31, 33) or Health Workforce Strategy 2015 (32). Even it was not explicitly mentioned in those policy documents.
Apart from inter-ministries policy coordination, there were also gaps in intra-ministry policies. For example, the MOHFW policies for transfer-posting of the employees necessitate involvement of multiple authorities in different tiers of health system. For example, DGHS is responsible for doing transfer and posting of staff within grade 7–9 (34). Whereas, the transfer and posting of 3-4th class employee is done under the Establishment Ministry (24), by sub-national level authorities at districts and division. Involvement of multiple authorities was clearly mentioned in those two policies; but none of these policies mentioned about the implication of HRIS tool in managing the database of HRH. Even, the latest, ‘Bangladesh Gazette 2018 for non-medical’ did not mention about the implication of ICT database upon management of this group of HRH (24, 34).