While Bangladesh has made progress towards health system reform, bureaucratic inefficiencies, limited resources and social and economic inequities mean it still has a way to go before it is healthy and productive, Habib Zafarullah writes.
Bangladesh has made significant strides towards achieving the Millennium Development Goals relating to health, but the government still needs to do more to create a healthy population for increased economic productivity.
However, resource limitations, social and economic inequities and administrative inefficiencies prevent health-related programs from being effective. On top of that policy priorities and technical interventions remain trapped in bureaucratic inertia, formalities, and routines, and shielded from genuine stakeholder inputs into the policy cycle. Sketchy understanding of social, economic and technical dimensions of health-related issues force the political executive and legislators to bank on the bureaucracy, thereby causing health policies to be inside-initiated (the Health Ministry doing the routines with the help of committees) rather than outside-induced (stakeholder-driven). Even so, several non-state actors/institutions have been involved in varying degrees in running health programs.
Bangladesh’s public health system is controlled and managed by the Ministry of Health and Family Welfare and is mandated by the Constitution to provide healthcare to all citizens through an array of executive agencies and field offices at the subnational levels.
The Ministry of Health is also formally assigned with the task of policy development and strategy, regulating professional activities and standards, monitoring medical commerce, managing information storage, and retrieval, and facilitating non-state stakeholder participation in the health sector. Recently, several private providers in primary health care (PHC), emergency and ambulatory services, child immunisation, nutrition support and insurance schemes have come on board. Yet the health sector continues to suffer from inadequate facilities, poor management, resource constraints, and skills scarcity.
A National Health Policy (NHP) was designed in 2000, but it wasn’t until 2011 that the incumbent government put a new health policy into practice, and when they did so, it was without extensive stakeholder consultations. In Bangladesh, health governance has developed unsystematically, with the bureaucracy playing the key role, under partisan guidance of the governing leadership. Nonetheless, the new health policy aspires to achieve some vital objectives, principles and strategies– from providing primary health care and medical services at the grassroots to improving malnutrition among children, reducing infant and maternal mortality, ensuring availability of full-time medical practitioners and health personnel, expediting population control programs, arranging specialised health services, controlling drug administration, and regulating medical schools
The World Health Organzation has identified strategic policy frameworks, effective oversight, coalition-building, appropriate regulations and incentives, and transparency and accountability as key elements of health governance.
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Bangladesh’s public health system, though, suffers from management constraints, which can be attributed to the overall administrative structure. The Ministry seeks to maintain a linear chain of command and a single accountability channel between itself and executive agencies. In reality, this chain is often broken through communication breakdowns, rigid and indifferent application of rules and political interference at both national and local levels. The highly centralised structure strains the capacity to effectively implement policies, heightens coordination problems, and intensifies regulatory intrusion.
Additionally, strategic policy frameworks have been difficult to design, stakeholder participation has been sketchy at best, parliament is largely disengaged from the policy process and its committee system is inefficient in influencing policy formulation. Coalition-building in healthcare has never taken-off in Bangladesh, leaving the health system incoherent and disjointed. As civil society groups are disunited, policy networking has been limited and cannot contribute enough to policy development.
More specific guidelines and regulations covering state and non-state actors are vital for the NHP to work, and irregularities, corruption and extortion in the health sector need to be addressed. A robust surveillance system focusing on hospital management, physician practice behavior, healthcare fraud and abuses is needed to support policy implementation.
The huge shortage of human resources has been a deterrent to providing appropriate level of support and care to the people, especially the poor. Also, the high urban-rural disparity in access and availability of health care services causes inequities that further highlight inequities.
Inclusive health governance requires gender equity and purposeful stakeholder participation in the policy process. Performance must be complemented by conformance (precise application of rules and standards) to have a positive impact. Whatever gains have been achieved by successive governments in Bangladesh will need consolidation and further advancement for health services to reach the people effectively.