School Health Record System: A Tool to Yield Demographic Dividend

It is estimated that out of almost 172 million people of Bangladesh, 34.3 percent are under 15, 61.1 percent are between 15- to 64-year-olds, and 4.7 percent are above 65. The median age in Bangladesh is 27.1 years.¹ The total number of people under 15 and over 64 are known to be the dependent part of the population who rely on the working population aged between 15-64. The dependency ratio in Bangladesh is 63.7 percent of which 56.1 percent is under 15 and only 7.6 percent are above 65. This ratio enumerates that the pressure on the working population that must cover their own, as well as the dependent population’s expenses, is very high.²

If a rough estimate is made, then more than half our population are school going children. The data explains why the term “demographic dividend” is frequently used in the context of Bangladesh and the fact that the country has a youthful population. However, to attain that dividend a lot of nurturing is required for the youths and the children. The social responsibility to ensure that the upcoming generation receives the right education, a stable environment, access to health, and equal opportunities in future depends on the current generation of policy makers and implementers.

Health is at the core of all human development. Health education, health seeking behaviour, prioritizing primary care, ensuring universal health coverage (UHC) are all integrated. The national agenda and Sustainable Development Goals are aligned with the vision to achieve universal health coverage by 2032.³ To that end more than 14,000 active community clinics are covering access to health as an additional layer in the health system, specifically designed for the rural people that constitute more than 60 percent of the population.^4,5

The country is still a long way off to achieve UHC, but smart strategies can bring everyone under either primary or secondary health care by leveraging the impressive gain in communication technology. The Directorate General of Health Services (DGHS) has already taken an initiative to automate the healthcare system by using a shared health record and bring 60 million people under health card system within the next five years. A common platform for health information system (HIS) will be designed by the Management Information System (MIS) department of DGHS.⁶

90 percent of the government health facilities, including the community clinics are already using District Health Information Software-2 (DHIS2) and Bangladesh is the largest implementers of DHIS2 globally, with an average reporting rate of 98%.⁷

This system compiles aggregated data that is useful in budget allocation for disbursing medicines, medical supplies, and hospital bed expenses.⁸

The new health ID card system aims to record more granular data of patients with full past medical history, diagnostics, and prescriptions. The project is the ideal solution to further manage the complexities of healthcare delivery systems. It will identify the trends in disease pattern and disease prevention that will ultimately help in formatting appropriate budget allocation for medicines and supplies. It will also indicate region-wise required postings of specialists based on disease prevalence. It is ambitious and for a country of over 170 million it will be a formidable task to build a system that secures privacy of patient information, is interoperable, can analyze and predict trends, and is able to generate information of health expenses.

Major population base as described in the country demography are the children under 15 in Bangladesh. A parallel approach to the unique health ID system can be a student health record system. The government of Bangladesh is already giving student IDs to 1.6 crore student in secondary and higher secondary level students which will be converted to National ID cards when the students turn 18.⁹ This same student ID can be used to record student health information from the elementary school level up until the higher secondary. The provision of basic health needs and collection of student health data from schools will be pivotal in developing a society that will truly yield a demographic dividend.

A Pilot Project for School Children

A School Health Record pilot project was launched in 2022 in Jashore based on the interoperable health information system principle. The project was a collaborative effort of the administration, local Member of Parliament, and Radiant Pharmaceuticals. A web platform was developed where student IDs were created and health record of 2006 school children from Madhusudan Taraprasanna (M.S.T.P) Girls School and College, and Jashore Collectorate School was documented by six local doctors for three months through health camps within the schools. M.S.T.P School was chosen as it is one of the 300 School of Future of Information and Communication Technology Division of the Government of Bangladesh and the Collectorate School was chosen as it is directly under the authority of the Jashore District Commissioner. Along with students’ information, parents’ information on having common noncommunicable diseases were also recorded.

Objectives of the Pilot Project:

1. Quick access to personal health information anywhere, anytime.
2. Instant information available to other health professionals outside school or regional network.
3. Tracking, managing, integrating, analyzing health data both long term and in real time (sudden rise in communicable diseases like dengue, Nipah, cholera or seasonal flu).
4. Care in continuum from school years.
5. Capture health trends- e.g prevalence of asthma, diarrhoea; compliance in immunization record; parents suffering from hypertension, diabetes, cerebrovascular diseases, kidney diseases, cancers, etc.
6. Cost cutting in the long run by going paperless and eco-friendly.
7. Flagging personal life-saving informationdrug allergy, food allergy, blood grouping.
8. Age specific growth monitoring and early disease detection for referral.
9. Promoting disease prevention by encouraging health seeking behavior, nutritional advice.
10. Mental health promotion and optimizing school attendance to avoid school dropouts.

International Standards of School Health System

As part of the national health systems in 53-member state of the European Union, World Health Organization (WHO) supports the development of school health system.¹⁰

School health record is a routine process in the USA and The Family Educational Rights and Privacy Act (FERPA) protects the privacy of all student education and health data.¹¹

In Singapore the school health services were established in 1921 with the belief that school is the starting point of the preventive medicine to build a healthy, productive population that would eventually benefit the nation.¹²

Malaysia provides school health services to all government and government-aided schools since 1975. Approximately 1.8 million primary and secondary school children in Malaysia benefit from school health services every year.¹³

Aligning with Global and National Agendas:

1. WHO’s Global School Health Initiative, launched in 1995, seeks to increase the number of schools that can truly be called “Health-Promoting Schools”.¹⁴
2. The United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Food Programme (WFP)’s renewed partnership aimed at strengthening health and nutrition programs for school children.¹⁵
3. Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages.¹⁶
4. Sustainable Development Goal 3.8 target aims to “achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”¹⁷
5. Bangladesh has a school health program since 1951.
6. Under Health Population Nutrition Sector Development Program (2011-2016), existing School Health program of DGHS expanded all over the country provides preventive and promotive health services through health education, screening (Eye, ENT, Dental health), First-Aid and referral etc.¹⁸
7. There are 23 School health clinics (SHC) functioning in the country out of which 21 are in district level and only two in upazila level.¹⁹

Why is it important to launch a pilot project?

Large scale projects that include participation of multiple stakeholders must be first tested in smaller scales to make necessary adjustments. The government of the United Kingdom invested in an overambitious £12.7 billion project of “nationwide implementation of EHRs National Programme for Information Technology (NPfIT)” in 2002 which was a colossal failure and was officially dismantled in 2011. It did not take into consideration the experience of the end-users, which was in this case the clinicians, it was a top-down approach, rigid non-adaptable system, insensitive to local circumstances and was maligned. Ideally a home-grown interoperable system is rendered more successful, cost effective, and can be scaled up upon successful implementation of a pilot project.²⁰

Basic Health Record

• High prevalence of c-sections. Western countries give higher rates for hospitals encouraging natural deliveries.
• At home delivery is negligible. Higher awareness of safe birth.

Findings

The pilot project disclosed unexpected but relevant information. More births are happening in healthcare settings and just like in metropolitan cities of Bangladesh, childbirth from caesarean section is 50.44% whereas childbirth from normal delivery is about 45.86% in the district urban locations. Sore throat and cough are more prevalent than diarrhea. Food allergies are prevalent in 30.35%. Except for Covid vaccines other immunization history is completed, however, the vaccine card could not be produced in 100 percent cases. Only 12 percent children know swimming, which is alarming considering drowning is a leading cause of death among children. Finally, upon taking family history a good number of parents were found to be diabetic and hypertensive.

Leveraging Information and Communication Technology for Impactful Solutions

The student health record system was a web platform, easily accessible and simple format where most of the answers could be chosen from ticking the menu bars. It generated a vibrancy within the school and among parents. Even from this short survey type pilot project, the data gathered gave directions to introduce some simple implementable measures for the region. For instance, swimming can be a community skill development program for children, and parents can be given disease prevention advice to control hypertension and diabetes. A low hanging fruit for DGHS that can be immediately designed is to develop a digital immunization record for all children. By duplicating the Covid shurokkha app, an immunization portal can be created that logs each and everyone’s vaccination record that can validate the well-established expanded program on immunization. Anyone can access their immunization record with one click.

The major idea for the project was to leverage the information and communication technology already well established in Bangladesh for an impactful outcome. Network Readiness Index (NRI) is a leading global index based on 58 indicators that measures the degree of readiness of countries to exploit information technology and assess its impact. Bangladesh was ranked 91st out of 134 countries in 2023 which was up from 95th position in 2021 and 105th in 2020.²¹ The scores indicated Bangladesh’s strength in ensuring access and usage of internet, mobile internet subscription, and digital payments impacting the quality of life.²¹ The trend suggests, Bangladesh has impressive network readiness given the income level but less utilization.²¹ Leveraging this readiness to roll out health system platforms that generates usable data is the most basic step to identify the tasks to improve the health care delivery in Bangladesh.