It would be naďve to expand the health care services and introduce community clinics at the village level without first and/or simultaneously addressing and resolving the problems faced by the upazila health complexes and the district hospitals,
writes Dr Anwar Islam

HOSPITAL care or inpatient care is an essential part of the continuum of care that any health system must ensure. Although primary health care – mainly ambulatory – is required by ninety per cent of the population ninety per cent of the time, some of us some of the time would require inpatient or hospital care. This applies to the ‘essential’ or non-elective inpatient care that is provided at the sub-district or district level as well as to more complicated inpatient care provided at the tertiary and/or specialised hospitals located in large urban centres. Upazila health complexes in Bangladesh provide the most basic primary healthcare services along with their multiple sub-centres scattered around the upazilas. Understandably, our upazila health complexes are primarily geared towards ensuring maternal, newborn and child health services – from health education to immunisation to antenatal, delivery and postnatal care. Ensuring emergency obstetric services for 10 to 15 per cent of pregnant women who require such services is also a critical responsibility of the upazila health complexes. Needless to say, all upazila health complexes are equipped with beds for such inpatient care. Almost 64 per cent of our 421 upazila health complexes have 31 beds, while the rest or 153 upazila health complexes have 50 beds each. Unfortunately and surprisingly, there is no relationship between the number of beds that a upazila health complex has and its population size. One should not assume that an upazila health complex with 50 beds has more population than the one with 31 beds. Similarly, the population size in upazila health complexes with 31 beds varies quite significantly – from around 150,000 to 250,000 or more (in some cases). It is difficult to find any logic in allocation of resources so uniformly without regard to two most critical factors – demographic (population size and its distribution across age and gender) and epidemiological (the nature and distribution of disease prevalence within the population) characteristics. Bangladesh is unique in this respect – ignoring the most fundamental variable in planning and allocation of scarce healthcare resources.
   There are more surprises. Since the beds are distributed without regard to demographic and epidemiological characteristics, financial resources attached to these beds are also egalitarian in nature. For each bed the upazila health complexes receive the same amount of money per year – approximately Tk 18,000. This translates to about $261 per bed per year. In other words, it is Tk 1,500 per bed per month or about $22 per bed per month. How much is that on a daily basis? Our health system allocates a full Tk 50 per bed per day or little over 0.72 cents. Tk 50 is supposed to cover all expenses related to keeping a patient in a bed – from upkeep and maintenance of the bed to essential supplies needed by a patient occupying the bed. Is it possible to do all these with Tk 50 a day? Here again, the allocation of financial resources has no connection with the most critical factor that determines bed cost – occupancy rate. Whether the bed or beds are occupied or not the upazila health complex would get the same yearly allocation. Is it logical? An occupied bed surely costs more than an unoccupied one. Clearly, our policymakers and planners are simple people with simple logic – distribute resources equally across the board. Why bother to engage in complex equations plugging in demographic and/or epidemiological variables? That will create a lot of work and lot of headache. Why make life complex?
   Stranger things happen within our health system. Each upazila health complex irrespective of its area population or case load has 9 physicians. That does not mean that there are nine physicians in each upazila health complex. That only means that there are nine sanctioned positions for physicians. One upazila health complex may have 3 physicians on board while another may have only one. A lucky one here and there might boast of 6 or 7 physicians on board (rarely there are nine physicians in any upazila health complex). However, that also does not mean that one will find 6 or 7 physicians present in any given day in those upazilas. A number of them could be practising in a nearby town (or in the capital Dhaka) while on the payroll of the upazila health complex. On the other hand, policymakers or planners do not take into consideration the caseload (or the area population size) of any upazila health complex in allocating physician resources. One would guess that average number of patients that come to an upazila health complex for services per day (or the number of patients served by the upazila health complex each day) would have a bearing on the number of physician resources allocated to the upazila health complex. Clearly those mundane considerations do not disturb the conscience of our health system.
   Fortunately, the upazila health complexes receive separate funds for medicines – Tk 600,000 or almost $8,700 per year. The drug budget covers the drug needs of both inpatients and outpatients. Again, there is no relationship between the drug funds and the number of patients served or the size of the area population covered by the upazila health complex. Drug costs usually accounts for almost 65 per cent of total healthcare costs. Is Tk 600,000 adequate to meet the needs of 150,000 to 250,000 people? Let us assume that a typical upazila health complex serves about 1,000 discrete patients a month or 12,000 a year and all of them would require some drugs. If so there would be Tk 50 for drugs for each of these patients throughout the year. If these discrete patients visit the upazila health complex four times per head during the year, each time requiring some drugs, funds available is miniscule indeed. Moreover, it is a common knowledge that inpatients require more drugs than outpatients. In other words, bed occupancy rate would have a direct bearing on funds required for drugs. Alas, our health system planners and policymakers are oblivious to these facts.
   Not surprisingly, the upazila health complexes are plagued with multiple problems. Physicians are seldom available, at least not in full force. In many instances, one may not find even the RMO – resident medical officer – in his/her chamber in the upazila health complex. The RMO, it may be recalled, is perhaps one of the most critical human resources for health in any given upazila health complex. In many upazila health complexes – some argue in almost 50 per cent of the upazila health complexes in any given day – either the gynaecologist and/or the anaesthetist are non available. Some critics even go further. They argue that it is rare to find both a gynaecologist and anaesthetist present in a given upazila health complex. As noted earlier, ensuring emergency obstetric services is one of the key functions of any upazila health complex. Obviously, one cannot provide emergency obstetric care without a gynaecologist and, at the same time, an anaesthetist. On the other hand, these human resources for health are needed not only for emergency obstetric care but also for normal delivery (and other maternal, newborn and child healthcare services). How can we ensure the presence of these human resources for health in every upazila health complex?
   One of the key problems faced by the upazila health complexes is non-functioning equipment. Rarely, one would come across an upazila health complex where all the essential equipments are in working order. If the X-ray machine is working, the ultrasound is not. On the other hand, even if the X-ray machine is fine, it could be that there are no x-ray films. If the ultrasound is in working order, one may not find a technician to operate it. In interviews, more than 40 per cent of service consumers – primarily poor rural peasants – say that they are required to buy needed x-ray films from outside to get an x-ray done at the upazila health complexes. The number of disgruntled consumers is much higher if the question involves the availability of drugs. Most patients argue that drugs are rarely available at the upazila health complexes. It is especially so if the drugs in question are costly. Moreover, not an insignificant number of patients note that they often buy the same drugs that were given by the government to the upazila health complexes at the nearby stores. In other words, drugs given by the government for free are sold on the open market. The quality of laboratory facilities available in any given upazila health complex is also questionable. Laboratory equipments are often non-functional. No less important is the fact that in many upazila health complexes gloves and other supplies critical for the safety of service providers as well as that service consumers are in short supply. Repeated use of a hand glove, even the ones used during surgery, is not uncommon compromising the safety of both the service provider and the consumer.
   It is difficult to give a comprehensive list of problems faced by the upazila health complexes. It is widely reported that as much as 65 per cent of the ambulances are idle at any given point of time. They are idle because there is no money to buy petrol or to carry out essential maintenance work or to change a dysfunctional tyre. On a visit to any upazila health complex or district hospital one would find not only rotten beds and/or bed sheets, floors and ceilings and an overflow of patients on the floors and corridors, but also an overwhelming lack of cleanliness throughout. Lack of cleanliness is so pronounced in most upazila health complexes and district hospital washrooms that one wonders whether our health system puts much value on the health of its clients. It seems that our public hospitals or inpatient facilities are yet to hear about infection control and quality assurance – two of the most critical concepts and practices of any modern health system. Quality of care should have been an integral part of all that we offer to the public. As a noted scholar said, ‘quality care is what happens at all the points of service along the continuum of care, and high quality care is a function of the system’s ability to produce care that will address the client’s needs in an effective, responsive and respectful manner…’ Our health system seems to have learned little in this respect and continues to produce, more often than not, nightmarish experiences for its clients thereby fulfilling the saying that ‘every system is perfectly designed to get exactly the results it gets.’
   One more problem confronting our inpatient health facilities must be noted – the nuisance of ‘dalals’ or agents whose business is to snatch unsuspecting prospective clients for the private clinics operating nearby – and often by the same physicians who are on the payroll of the public facility. District hospital premises are notorious for the patient-snatchers. The ‘disease’ seems to be spreading downwards. It would be nice to see how the new soon-to-be-introduced health policy addresses this reprehensible patient-snatching nuisance.
   It is apparent that our health system, quite understandably, puts greater emphasis on primary health care and on maternal, newborn and child health services. An analysis of the Health, Nutrition and Population Sector Programme spending pattern seems to support this conclusion. More than 40 per cent of the HNPSP budget is spent on reproductive health and family planning services; another 40 per cent is spent on child health services including immunisation. Only about 14 per cent of the HNPSP funds are spent on limited curative care consisting primarily of inpatient care. For Bangladesh it perfectly makes sense to spend more money on family planning, maternal, newborn and child health and other largely preventative community-based services. However, inpatient hospital/facility based services must also be viewed as an integral part of the continuum of care. The health system, like any other system, is composed of interdependent integrated parts where the whole is greater than its component parts. A system, on the other hand, works effectively and efficiently only when all its parts work collaboratively and coherently creating a balance or equilibrium. This equilibrium principle simultaneously dictates that a change in one part of the system necessitates corresponding changes in other parts. In other words, our primary health care services (or sub-system) cannot work efficiently and effectively unless the inpatient care or hospital care sub-system also functions effectively. Consequently, in allocating resources – human, financial and material – there must be a balance between these sub-systems. Similarly, it would be naďve to expand the health care services and introduce community clinics at the village level without first and/or simultaneously addressing and resolving the problems faced by the upazila health complexes and the district hospitals. It is time that our health system policymakers and planners fully comprehend and apply this systems view while allocating resources or establishing new layers of services. In short, a systems approach is critically needed to design, sustain and continuously improve our health system.
   Clearly, a systems approach is lacking in Bangladesh. It remains to be seen whether the new national health policy articulates and adopts a systems approach in addressing the myriad problems faced by the health system. A half-hearted piecemeal approach will further erode and compromise the central goal of our health system – protecting,
   promoting and further improving the health of the people of Bangladesh.
   Dr Anwar Islam is associate dean and director, James P Grant School of Public Health, BRAC University