Health service delivery still not properly managed

Health service delivery is one of the six major components of the health system in Bangladesh. There are six building blocks which strengthen the health system in a country. These include health service delivery, workforce, information, products, financing and stewardship.
Since independence, Bangladesh has made significant progress in health outcomes. The country has made important gains in providing primary health care and most of the health indicators show steady gains and the health status of the population has improved. Health services are provided both through public and non-public sectors. Non-public sector includes Non-Government Organisations (NGOs) and private sector facilities.
 Despite Bangladesh's significant achievement in health sector, the country has failed to cater to the needs of the majority population due to failure to rein in anarchy and establish good governance in the sector. Although adequate healthcare facilities are available in villages, unions, upazilas, districts, and divisional headquarters, including Dhaka, still 43.1 per cent people receive treatment and advice from the drug store operators or a person without any formal degree or qualification in medical science.
Access to healthcare services has remained a dream as poor and lower middle class do not have access to quality services as private sector dominates the sector.    
The World Health Organisation (WHO) defines service delivery as the way inputs are combined to allow the delivery of a series of interventions or health actions (WHO 2001b). The service provision function [of the health system] is the most familiar; the entire health system is often identified with just service delivery. Service provision, or service delivery is the chief function the health system needs to perform (WHO 2000).
The Ministry of Health and Family Welfare (MoHFW) is responsible for planning and management of curative, preventive and promotive health services to the population of the country with two exceptions. In urban areas, delivery of health services including Primary Health Care services is mandated to the Ministry of Local Government, Rural Development and Cooperatives (LGRD) while for the three hill districts in Chittagong, the mandate is given to the Hill District Councils. Besides, almost all the ministries have their own hospitals. For example: Combined Military Hospital (CMH) under ministry of defence, Railway Hospital under ministry of Railway, Border Guard Bangladesh (BGB) Hospital, Police Hospital and Jail Hospital under the ministry of Home Affairs, Government Employees Hospital under Ministry of Public Administration, Labour hospital under ministry of Labour and University Health Centres under ministry of Education etc.        
According to data, there are 459 hospitals at upazila and union levels, 124 hospitals including district, division and capital where the number of beds is 41,655. The government has 21 medical college hospitals, and 11,816 community clinics. There are 2966 private registered hospitals and clinics and a large number of unregistered hospitals and clinics across the country. The informal sector service providers including quacks, village doctors (VDs) and traditional birth attendants (TBAs) meet 80 per cent of the total healthcare needs. According to a study of Health Education Bureau, 23.4 per cent people receive health services from the drug stores, 19.7 per cent from VDs, 16.2 per cent go to the MBBS or specialist doctors personally, 9.0 per cent people go to the private clinics during any health problem. Drug stores cannot be called pharmacies as no qualified pharmacist provides any service there. On the other hand, 12.1 per cent people go to upazila hospitals, 9.0 per cent people go to district hospitals or medical college hospitals while 4.1 per cent people go to community clinics or union health centres. According to another research carried out by the ICDDR,B, 85 per cent people receive treatment from quacks and 15 per cent people go to the qualified physicians. This presents a rather gloomy picture regarding the overall healthcare scenario.
The public sector is largely used for out-patient, in-patient and preventive care, while the private sector is used largely for outpatient and in-patient curative care. For improving effectiveness of the public sector interventions and for providing services responsive to the needs and demands of the population, the Government of Bangladesh, since 1998, has been pursuing a sector-wide approach (SWAp). The initial Health and Population Sector Programme (HPSP) of he period 1998 - 2003 was replaced later by Health, Nutrition and Population Sector Programme (HNPSP) in 2003- 2010. The MOHFW designed the Programme Implementation Plan (PIP) for HNPSP which covers 38 Operational Plans (OP) to be implemented by 38 Line Directors.
The present government has taken steps to revitalize PHC services by making the community clinics operational. These community clinics, one for every 6000 rural populations, were constructed in 2000-2001; but were not used for service delivery during the previous governments. An assessment of the community clinics, supported by WHO in 2009, showed that with the expansion of the health-care facilities to the peripheral level the distribution of health-care inputs and their utilization became more equitable and the utilization rate of these facilities was almost universal. Yet the effectiveness of these clinics has come under question as the community health care providers (CHCP) who receive a two-month training with an educational qualification of HSC, prescribe various drugs including six anti-biotics which puts public health at risk.  
In the public sector, upazila health complexes, and district hospitals, are providing curative care at primary and secondary levels respectively. Tertiary- level curative care is mostly provided at national and divisional levels through large hospitals affiliated with medical teaching institutions. While curative, preventive, promotive and rehabilitative services are rendered by public sector facilities and institutions, the private sector facilities, now gradually taking a big share of services at all levels, are mostly providing for-profit curative services. There are private clinics at upazila or below upazila level and their number is growing fast. Besides, unauthorised drug stores have sprung up almost everywhere. The private sector health services of the country is in a mess in the absence of a regulatory mechanism. This has contributed to the exploitation of people as they have to buy the same service at varying prices. Besides there is a wide gap in health service delivered to the rich and to the poor, and the rural and the urban people.  
There is another issue related to health service delivery which deserves attention. That is, the investment in health sector by the government. More than 70 per cent of the total health budget is spent on salary and other benefits, 10-15 per cent of the budget is spent on infrastructure and maintenance and the rest amount is spent on the patients. At present there is a total of 92,927 personnel employed in the public health sector and 12,991 CHCPs in the community clinics. There are about 16,000 doctors in the country against the need for 22,000. The number of doctors, nurse, technicians and other staffs may be inadequate for a third world country with a huge population like Bangladesh. But most of the medical personnel stay in the capital. It is hard to find any doctor in a village or a remote hard-to-reach area. It has kept the poor people living in rural areas out of the public health services and created scope for the quacks and other informal health service providers to dominate the health sector.          
Health has become a commodity more than a right although health is recognized as a right in the health policy. There is wide range of criticism regarding the government's failure to improve the present disorderly situation and serve the poor best as they are more interested in constructing infrastructure and purchasing equipment than to put the existing ones to use. There is lack of skilled and qualified technicians to operate various medical equipment and work in laboratories and diagnostic centres. Many equipment procured long ago are yet to be used at many public health facilities. There are upazila health complexes where there are ambulances but no drivers. In some cases there are drivers but not ambulances.
The health sector faces a tough challenging to make available better health services to the poor and low-income people.