Role of spatial tools in public health policymaking of Bangladesh: opportunities and challenges

Our survey found that about 78 % of the respondents had geo-referenced maps or any
other kind of spatial data available in their organization. The spatial data include
administrative boundaries at different scales, road network, river network, and any
form of spatial data. Approximately 28 % of the respondents stated that they had geo-referenced
maps at the Upazilla level or the second administrative layer, while 26 % indicated
they had spatial layers available for all the administrative units, including wards
or the lowest administrative unit. With regard to technical capacity within their
organization for map creation, 55 % of the respondents indicated that their organization
was able to create maps to meet their own requirements, 61 % stated that their organization
used available maps, and 32 % stated that their organization sought help from an outside
agency to create maps for them.

Considering a high variability of map usage levels among the organizations depending
on its purpose, the survey also investigated the level of GIS and spatial tools by
the five categories of health policy agenda in Bangladesh, including identifying areas
with the shortage of community health worker, allocating drug supplies, locating health
facilities and service area, mapping communicable diseases, and assisting emergency
and obstetric care. Figure 1 demonstrates the variation in the map usage within each of the categories of health
policy and planning concerns. It is found that identifying areas with shortage of
community health workers emerged as the top most category in which maps were used
at a basic level mostly for visualization and descriptive purposes. The categories
that were ranked the highest in intermediate map usage were assistance in emergency
and obstetric services planning and allocation of drug supplies. In case of advanced
map usage, disease mapping emerged at the forefront. No significant difference was
found among the different types of organizations to which the respondents belong.

Fig. 1. The use level of maps and spatial models by health policy agenda

It is interesting to note that, as shown in Fig. 1, there exist a significant level of advanced use of spatial tool across many health
intervention sector, although uptake of these products for policymaking is limited.
This gap is partially due to the fact that knowledge of advanced use of spatial tools
is confined to and driven mostly by research-oriented scholars. In some instances
such as communicable disease mapping, it is also driven by those working in multilateral
organizations that work with the government closely. However, within the government
agencies, knowledge of advanced spatial tools for decision-making purpose is limited,
which was found to be one of the important barriers in Bangladesh, as shown in Fig. 2. Due to these factors, uptake in the application of advanced spatial tool for targeting
health interventions or decision-making purposes has been limited.

Fig. 2. Barriers to using of maps as a decision-making tool for health intervention

Figure 2 reports the mean scores for 11 barriers towards the adoption of maps and spatial
analysis as a decision-making tool for health intervention, along with standard error
bars to show the level of variability of the scores among 39 respondents. The lack
of inter-institutional collaboration was found to be the most important barrier mostly
due to the lack of sharing of spatial data among different agencies. This has led
to several agencies involved in generating the same kind of spatial data, ultimately
resulting in duplication of efforts. The lack of continuous availability of trained
personnel emerged as the second most important barrier. Some respondents felt that
even though staff training was quite prevalent in Bangladesh, there was a high turnover
of skilled staff to private high-paying jobs due to which knowledge was being lost
and the process of map creation and spatial analysis was not sustained after few fragmented
initiatives or efforts. In some cases, bureaucrats were assigned ad hoc roles and
responsibilities without having any prior educational background or experience in
that field, which in turn affected the level of acceptance and usage of these tools.
The lack of awareness on the use of GIS and spatial analysis as a decision-making
tool also emerged as a critical barrier because knowledge of spatial data creation
and its utility in analyzing health problems was confined mostly to GIS teams in those
organizations. In most cases, other people had very limited awareness on the use of
maps in their organization or its capability in analyzing and evaluating health programs,
which was observed by the researchers during the fieldwork. Besides, some respondents
remarked that budgetary allocation and statistical analysis still continue to be in
the domain of economists and statisticians, and sometimes they are not aware of the
capability of the GIS-based tools to inform decision-making.

As also seen in Fig. 2, the lack of financial power to the district health managers was also one of the
contributing factors due to which maps cannot be used for allocating financial resources
as these decisions were mostly guided by political compulsions. Some respondents viewed
the lack of spatial data as also a factor that made it less conducive to the use of
spatial tools as several agencies are currently in the process of generating spatial
data of various types and it would still take a few years before it can be linked
to existing statistical data to conduct any analysis. The lack of technical capacity,
lack of financial resources to outsource such tasks, lack of budget, attrition of
technical staff, and lack of time were found to be the lowest on the list of barriers.