Shakeel Ahmed Ibne Mahmood*
Editor in Chief, Health Systems and Policy Research (HSPR)
Health care delivery is a daunting challenge area of the Bangladesh’s healthcare systems. This paper looks at factual evidence to describe the main challenges facing health care delivery in Bangladesh, including absenteeism, corruption, shortage of doctors/nurses, inefficiency and mismanagement. This paper concludes that good governance, including training and monitoring, allowing more non-governmental involvement and the needs of the informal healthcare service providers is important in ensuring effective health care delivery, and that returns to investments in health are low, where governance issues are not addressed.
Healthcare policy, shortage of doctors/nurses, informal healthcare service providers, good governance
An effectively performing health system is essential in improving the population’s health status, providing safeguard against health-related financial threat and enhancing the health sector’s responsiveness to customers needs. A health system consists of all organizations, people and actions, whose primary intent is to promote, restore or maintain health (Global Fund, 2011). Therefore health systems strengthening (HSS) is crucial for the successful scale up of disease control interventions (Coker et al. 2004; Barker et al. 2007; George Shakarishvil et al, 2012). Additional evidence (Travis et al. 2004: George Shakarishvil et al, 2012) also suggests that weak health systems are one of the main barriers in reaching the Health Millennium Development Goals (MDGs). Consequently, Health sector reform (HSR) is very much essential to advancement the performance of the any health systems. HSR a continued process of fundamental change in policy, regulation, financing, provision of health services, re-organization, management and institutional arrangements that is led by government, and designed to improve the performance of the health system for better health status of the population (Federal Ministry of Health, 2004). HSR is not only a health-related issue but also a development issue as health care systems account for 9% of global production and a significant portion of global empowerment. HSR implementation varies across different countries and regions of the world, indeed states within a country. This is because of differences in values, goals and priorities. (Saka M. J., et. all, JPAPR, 2012).
Bangladesh has made significant improvement in health sector, which make it an example for other developing countries even though being a resource poor country. Over the last decades key health indicators such as life expectancy and coverage of immunisation have improved notably, whilst infant mortality, maternal mortality and fertility rates have dropped significantly (Ferdous Arfina Osaman, 2008). Bangladesh stands out as a country that has taken giant steps in healthcare. Long before the emergence of contemporary global health initiatives, the government placed strong emphasis on the importance of childhood immunisation as a key mechanism for reducing childhood mortality. The Expanded Programme on Immunisation (EPI) in Bangladesh is consid- ered to be a health system success because of its remarkable progress over the last two decades. It provides almost universal access to vaccination services, as measured by the percentage of children under 1 year of age who receive BCG (a vaccine against tuberculosis). This increased from 2% in 1985 to 99% in 2009. Coverage of other vaccines has also improved substantially (Brac, 2009). However, poor access to services, low quality of care, high rate of maternal mortality and poor status of child health still remain as challenges of the health sector (Ferdous A. Osaman, 2008)
In Bangladesh, healthcare is offered either through government- run hospitals or through privately-run clinics. Bangladesh is still lagging in health care services for the poor as well as the affluent. In recent years, our neighbors, India and Thailand have forged ahead in respect of expertise and experience of doctors, advancement of healthcare technologies and high quality hospitals and health management organizations. To achieve this in our country, technological collaboration with technologically advanced hospitals are needed and follow health management organizations in the developed countries of Asia and the advanced nations of the West.
Human Resources, Nurses and Informal Health Care Providers
The most critical challenge faced by the health systems in Bangladesh is in the arena of human resources for health. The State of Health in Bangladesh 2007 report published by the civil society group- Bangladesh Health Watch makes for some alarming revelations, the report focused on human resources in the health care sector, the grim facts of the story are that Bangladesh is still running a staggering shortage of over 60,000 doctors (currently figure 31,000 physicians), and also have a deficit of almost 140,000 nurses. Moreover, Bangladesh has one of the worst nurse-physician ratios. In Bangladesh health sector, it has only one nurse per three physicians, while the ratio should have been the other way around, which is three nurses for one physician, a scenario inverse of the World Health Organisation’s (WHO) recommendation of having three nurses per doctor in a well-functioning healthcare system. Absenteeism of key health human resources (physicians) often make matters much worse. Lack of drugs, supplies and other facilities also plague the heath complexes. As a result, publicly funded health care system is used by only 25% of the population. Furthermore, this country has an acute shortage of medical technologists and allied health professionals and these are physiotherapists, laboratory assistants, x-ray technicians, etc. Human resources for health cannot be produced quickly.
The report’s conclusion was that roughly 80% of the country’s populations still seek their first line of care from informal healthcare providers that is traditional healers, faith healers and community health workers. Absenteeism, inefficiency and corruption are also seen common in current health infrastructure (Brac University, 2009; New Age, 2008). It is evident by the fact that 90% of children suffering from acute respiratory infection and/or diarrhoea. This is partly because of the lack of qualified health providers in rural areas. It is also because the Essential Services Package does not cover non-communicable and communicable diseases, environmental health risks, injury, mental health problems, and health providers are not trained to manage these conditions; consequently for these health issues, people routinely turn to unlicensed providers for treatment (Daily Star, 2012).
Health Systems Research
Considerable challenges remain in the forefronts in the efforts to improve the health status of the population, reduce health inequalities, improve the quality of care and public satisfaction with healthcare, and to increase the efficiency and sustainability of service-delivery agencies. These challenges point to the growing need for appropriate and applied research to enhance the knowledge about factors affecting the governance, provision, organization, financing and use of healthcare and health services as well as at the role of key multisectoral players within the healthcare system. Where resources are scare, it is vital that health system be strengthened so that every decision is the best decision. Health systems research can support that decision-making.
National Health Policy
It is apparent that the method of change needs to broaden beyond the redefinition of policy objectives and discussions of the ideological orientation of the health care system. Without institutional or structural change it is expected that existing organizational structures and management systems will be able to strengthening the weak and fragile National Health Care Delivery System and improving its performance. Health sector reform will therefore be concerned with defining priorities, refining policies and reforming the institutions through which those policies are implemented. As a result, the need for creative solutions to deal with urgent and intractable problems can easily get lost in discussions about the rights and wrongs of particular strategies. There is a need for rational debate and systematic analysis. In the first instance, this requirement must be addressed by descriptive information on reforms using a taxonomy that aids the analysis of the implementation and impact of reforms. Such a framework should allow a synthesis of the benefits and drawbacks of reforms that can assist each country’s attempts at producing better health from the level of investment within that country (Saka M. J., at. all, JPAPR, 2012)
In spite of such a fast growing private sector, Bangladesh does not have a comprehensive health policy with a vision for the totality of the health sector. As a steward for the health systems, the Ministry of Health and Family Welfare is yet to come up with an overarching strategic direction for the health sector as a whole encompassing both the public and the private sector (Brac University, 2009). The Constitution of Bangladesh, Article 15(a) and Article 18(1), has provided top priority to public health and nutrition as a state policy of governance. To implement the obligation of the constitution and expectation of the people at large, governments had taken initiatives in the past to prepare a pragmatic health policy for the nation. Accordingly, there were attempts to formulate an acceptable health policy in 1990, 2000, and 2006 to ensure quality medical care and services to citizens (Daily Star, 2008). To maintain consistency with the dramatic improvements in medical science, particularly in treatment and diagnosis, changes in global and environmental health, requirements of addressing occupation health and climatic health hazards, it was wisely felt essential to update the health policy.
Governance, political commitment and leadership
Apart from policy issue mentioned above, there should be good governance in health administration, both in the private and the public sector, for which political commitment should be transparent and all allocations should be demand based and balanced ones. There could be arrangements where civil society organisations and human right agencies can interact to ensure accountability and transparency in procurement, supply chain management, logistics so that well functioning services can be provided through access of quality medical products and technologies. A strong health financing structure is also important, which can ensure population’s protection from health related financial crises. In addition to these aspects, a well functioning information system is also vital, which would disseminate information timely on critical health outcomes. There should be also participation of health watch groups with regular inflow of information. Existing human resource development (HRD) plans need to be reconstructed to have long-term objective to improve the quality of healthcare services (clinical and managerial skills), and to address emerging health problems of Bangladesh. Funding on training is very much crucial for informal health providers, as well as funding for community systems that mobilize demand for services. In addition to that tailor made programmes need to be provided in line with local needs, so as delivering services to hard to reach, at–risk and vulnerable populations. There should be strategies for community engagement/involvement to increase awareness of, access to, and utilization of health services, and provision of appropriate services at the community level. Moreover, strong leadership (political, donor, and government) support & public accountability are essential to strengthen a sense of commitment & accountability of Bangladesh health care systems, especially in times when the government is exploring means of reform.
Public private partnership
Based on the failures in the state run health care system identified by the Bangladesh Health Watch report there will no doubt be a significant thrust to allow more private sector or non-governmental involvement in healthcare services. The report suggests that the potential benefits of harnessing the ubiquity and the influence of the informal healthcare providers could be massive, with training and monitoring. Bangladesh needs to improve ‘quality of nursing’ to develop health sector (New Age, 2008). More doctors, nurses and informal health care providers are also need to be recruited. This could be explored as a public-private partnership and can greatly reduce the existing pressure on the medical infrastructure run by the government.
The author concludes that good governance is important in ensuring effective health care delivery, and that returns to investments in health are low, where governance issues are not addressed. Strengthening the health system through better management and organization and effective use of resources can improve health conditions and enhance the quality of health care delivery in Bangladesh. Furthermore, more research is needed on health system reforms. However, Bangladesh can take references from the health policy, which was formulated in 1990 (chaired by the late General M R Choudhury along with Nobel Laureate Prof Yunus, and Magsaysay Award recipient Dr. Zafurullah) as it was highly appreciated by WHO. Above all Bangladesh should immediately translate its health policies into action to benefit the people of this country by ensuring humanity, equity, and poverty alleviation.