Health sector progress
Bangladesh has achieved significant progress in health and population indicators over the last few years (due to increased access to health and family planning services) through a combination of community, and household level service provision strategies. The fertility transition is already underway in the country and the success of the immunization programme is most impressive, including a reduction in infant and child mortality. Bangladesh is on track to achieve some of the Sustainable Development Goals (SDGs). An example is child mortality, which has gone down dramatically in the last few years. Another is the Total Fertility Rate (TFR), which decreased to 2.7 in 2007 and the Bangladesh Maternal Mortality Survey suggests that the current rate is even lower.
The irony of the story: Abuses of medicare expenditures:
Despite all these achievements, abuses of medicare expenditures, facility utilization, and burden of treatments are alarmingly high and disgusting. Because of inadequate healthcare facilities in public health sectors people in need of healthcare are compelled to approach private sectors. Private hospitals, clinics, and diagnostic centres are growing fast in Bangladesh. These are available even at the union or village level with low-quality services and are ill-monitored as well. Besides very high-cost corporate private hospitals in major cities, most of the private clinics and diagnostic centres are not cost-effective for middle or lower-class people in Bangladesh. Many of the village doctors, quacks, and even qualified doctors are doing malpractice by prescribing unnecessary investigations and drugs. Poor people have to expend from their own pocket. Costs and qualities should be strongly monitored by local as well as higher government authorities. Most of the time government health departments are helpless to execute their duties or have no manpower to monitor. People have to suffer. Doctors in most private hospitals, clinics, and diagnostic centers including corporate hospitals in major cities write unnecessary investigations and drugs. But some doctors are doing honest and ethical practices in those centers. In a resource-poor country like Bangladesh, the government health department should fix the diagnostic and hospital costs at reasonable rates. Drug administration should monitor the prices of the drug. Drugs with the same generic name are being sold at different prices by different pharmaceutical companies. Quality control of dispensed drugs should essentially be monitored by the drug administration. Fake and adulterated drugs are also sold by some drug shops. Fraudulence in private healthcare is a common practice in Bangladesh. Helpless patients and their relatives are compelled to bear the costs at any cost. Poor people also suffer a lot because they find it difficult to access public health facilities
Access to public health facilities in Bangladesh
Instead of success in a few health sections, several challenges still remain unmet. The difference between the rich and the poor, between the urban and rural, between urban middle classes and urban slums, and between men and women are alarming. Even though Bangladesh has made remarkable progress in reducing infant and child mortality and improving life expectancy, there has not been desired progress in improving the nutritional situation of children and women, especially pregnant and lactating mothers. Hundreds of thousands of women and children in rural areas and people from the poorer strata, including those living in urban slums, have, no access to services that could decrease the severity of their illness. Though there are many notable successes in Bangladesh's health sector, there are also significant challenges in the areas of system losses, access, and quality of services.
When government resources for health are constrained, good management of health services is particularly important to sustain health care access for the poor. In Bangladesh, primary health care services, including maternal and child programmes, have been pursued mainly through supply-side interventions. However, although health services are free at public facilities, getting health services from semi-qualified or unqualified allopathic practitioners and traditional health care providers (ayurvedic, homeopathic, Unani/kabiraji, and others) are common and popular in rural areas leading to low utilization of public facilities. There are a number of factors that affect the health status of people. There are demand-side factors, such as income, assets, social and cultural practices, lifestyle, and supply-side factors such as the public health care delivery system, health expenditure, etc. There are also environmental factors and gender inequality-related factors that influence health status. Most of the time public health facilities are not accessible to poor people because qualified doctors are not available in upazila or union health centres, investigations and drugs are not available, capacity and behaviour of the healthcare workforce are not satisfactory. The sordid saga is that public health facilities are not well utilised or could not be utilised. There are lots of Dalals or middlemen who take poor patients to private clinics or diagnostic centres. Many of these clinics and diagnostic centres have no permission from the health department. They work everywhere including in the larger cities and cheat the patients. Here lies the lack of good governance and monitoring. Available evidence suggests that poor governance in the health sector is negatively influencing the service delivery mechanism in Bangladesh, which, in turn, results in low utilization of public facilities. Non-availability of drugs and commodities, discrimination against the poor, imposition of unofficial fees, lack of trained providers, weak referral, feedback and monitoring systems, unfavourable opening hours, and interdepartmental difficulties contribute to the low use of public facilities in Bangladesh. There are also extreme shortages of healthcare providers. There are also huge disparities in the distribution of providers between urban and rural areas, with only 16 percent of qualified doctors practicing in rural areas. Bangladesh has one of the lowest nurse ratios in the world and the capacity of the existing training institutions is insufficient to significantly increase these numbers in the near future. (Bangladesh Health Watch 2008).
Health Care Delivery System
Compared to many other developing countries, Bangladesh has a relatively developed public infrastructure of health facilities as well as a relatively extensive human resource base for the delivery of health and family planning services. There is an extensive network of hospitals, health centres, dispensaries and training centres in Bangladesh. This network at the district level and below comprises 64 district hospitals, 402 health complexes at the upazila level (UHCs), about 4,000 health and family welfare centres (HFWCs) at the union level and thousands of community clinics (11,000-13,000) at the ward level. But despite these, large segments of the population of Bangladesh have limited or no access to the health services at all and for many of the rest, the care they receive is inadequate.
Limitations in facility consumption
Facility consumption in public sectors is limited by many factors. The under-served majority is largely rural but also includes the urban poor. Efforts to improve health have had a modest impact on the health of the vast majority of the population in Bangladesh. This is commonly attributed to two main reasons. First, health activities have typically overemphasized sophisticated, hospital-based care, while neglecting preventive public and community-based activities. Second, even where health facilities have been geographically and economically accessible to the poor, deficiencies in logistics, staff absenteeism, poor supervision, informal payments and lack of social acceptability have often compromised the quality of the care they offer and limited their usefulness. Essentially, it is the poor and vulnerable members of society who are particularly prone to the largest burden of cost and poor service delivery
Availability and utilization of facilities: The factors underlying access and utilization are diverse. Income is only one factor that might explain access to health services in developing countries like Bangladesh. It is necessary but not sufficient-other factors such as institutional and non-economic factors (cultural and social constraints, gender, etc.) play an equally important role in determining access to health services and their utilization. The three aspects of health, such as status, access and utilization, are distinct though interrelated. Indicators of health status, e.g. mortality and morbidity rates, can reflect whether health services have had any impact on the health of the population. Greater availability of health services is obviously intended to improve health status and to reduce inequity in the distribution of health services. Availability of health facilities and services is the essential prerequisite for access to health care. Availability should also conform to the cultural perspectives and specific needs of the population such as availability of required number of doctors and nurses, female doctors, specialist doctors and paramedics. However, it is important to consider the actual utilisation of available health facilities since equity and access are likely to have an impact on health status only if these facilities are actually utilised.
Social prejudice and accessibility:
The three main aspects of physical accessibility are the distance from the health facility, travel time, and travel costs to arrive at the facility. Numerous studies have shown that physical access to health services is an important determinant of the utilization of public health facilities in Bangladesh. Location is one of the most important factors to determine access to health services. Getting permission to go to a health provider is found as a constraint to health service access. In addition, 49 per cent of women reported that finding someone to accompany them was a problem. Men who were sick were more likely than women to utilize modern qualified providers in rural Bangladesh. The gender bias may reflect beliefs that it may not be appropriate for women to be seen by a male provider. In addition to the longstanding cultural biases against women, the fact that the health providers available in rural Bangladesh are predominantly male suggests that the problem of women's access to care will not be easily solved.
Conclusions: Governance plays an important role in using healthcare facilities in both public and private sectors. If the health system is not governed well, health workers are absent, patients pay illegal fees, and basic inputs are stolen without any consequences for those who mismanage or corrupt the system, the performance of health services will be poor and health of the people will suffer. Many health systems rely on anecdotal evidence to guide policy. It is important to provide the evidence and outline the major challenges facing health systems, dealing with issues typically ignored or unaddressed. Better country-level data can help in diagnosing the problem and some of the experiments here may offer possible solutions. The second conclusion is that the returns on health investments may be very low where governance is not addressed. Third, a country's health system is the institution that must be engaged. Without bolstering the key institution for the sector, it is unlikely that the goals of reducing poverty, mortality, and morbidity can be achieved. The evidence here points to serious problems of governance across the globe in developing and transition countries, which thwart the goals. Finally, achieving the dramatic and permanent declines in mortality envisioned by the Sustainable Development Goals is doubtful unless governments shift their attention to the institutional factors that affect performance in the health sector. Funding without the necessary institutional strengthening could lead to perverse results, and assistance for both governance and financing will be needed in the health sector. Incentives that raise performance - ensuring appropriate, targeted training so health professionals are equipped to do their job; linking pay and performance; reviewing and auditing performance; improving recordkeeping, and upgrading logistics for drugs and supplies - need to be an integral part of health systems. Investments in institutions require these kinds of initiatives, and donors are in a position to foster such improvements with both funding and advice to oil the wheels of progress and support the emergence of strong institutions. Where public services are free or subsidized, with the intention to promote access and utilisation of vital health services, the abuses related to lack of drugs, staff absences, and informal payments undermine these objectives as well as the credibility and effectiveness of public services more generally. Without attention to these non-medical issues, clinical care quality and equity in access will be lost, leading to both lower health status and poorly spent public revenues. Because good governance promotes economic growth and effective public services, the health sector cannot afford to be sidelined on this agenda.
Professor Dr. Md. Shahidur Rahman (Retd), Physical Medicine and Rehabilitation Bangabandhu Sheikh Mujib Medical University.
shahidurpmrbd@gmail.com
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