AFTER a long wait — more than 48 months, in fact — the health minister has finally delivered. A new national health policy received the endorsement of the legislature a few weeks ago and became the stated overarching vision of the health system. It is a milestone for the current government as it replaces the one introduced by the then Awami League government in the fag end of its mandate in September 2001. Although the Awami League lost power in the ensuing elections in late 2001, the incoming Bangladesh Nationalist Party-led government neither abrogated the national health policy nor declared its commitment to it. On the contrary, the incoming BNP government started to slowly but surely distort and dismantle some of the key provisions of the policy thereby significantly weakening the health system. One of these BNP ‘atrocities’ against the health system was that of dismantling the community clinics that were initiated by the previous government to bring healthcare services to the doorsteps of the vast rural population. Given the obvious critical role of the community clinics forming the last tier of the primary healthcare system at the most grassroots level, there was no logical rationale to dismantle or abandon them. Nevertheless, it was done with vengeance and consequently the health system and the people of Bangladesh suffered.
The present government must be congratulated for the fact that, even before formally announcing the national health policy, it started the work of establishing and/or revitalising the community clinics. Almost 14,000 of such community clinics right at the village level are already operational providing vital primary healthcare services to our village communities. Once they are in full strength (18,000 of them are planned across the country) and operational with adequate human and other resources, these community clinics could bring a revolutionary change in our health system bringing primary healthcare services to the doorsteps of the people and linking them to the rest of the health system. Health promotion and illness prevention through the provision of critical health information to the people and encouraging them to adopting a healthy lifestyle could — in the long term — help bring a paradigm shift in our health system whereby the emphasis is not primarily on providing services but equally (or more) on creating an environment that produces health. Such a paradigm shift is possible only when people at the community-level are mobilised and motivated to adopt a healthy lifestyle and at the same time protect and preserve their environment and its natural diversity. Community clinics could indeed play the most critical role in this respect. Let us hope that the present government will do its best in realising the full potential of community clinics. The newly announced national health policy, especially some of its bold declarations and initiatives could forcefully contribute to this goal.
Following the successful launching of the community clinics more than a year ago, there were great expectations that the national health policy would clearly articulate their role and the additional resources required to make them fully functional. According to the health ministry, currently 13,000 community clinics are operational and the target is to have 18,000 of them around the country. Also, there is a plan to have 8,000 multipurpose workers in 2,700 selected community clinics in 116 upazilas specifically to address child malnutrition issues. These are extremely important and timely initiatives. However, their effective implementation (and long-term sustainability) would require significant additional resources for the health system. Neither the policy nor the last budget tends to indicate that the government is committed to substantially increasing financial resource allocations to the health system. It remains to be seen whether the soon-to-be announced 2012/13 budget commits more resources for health care. It should be noted that the last two budgets (20010/11 and 2011/12) allocated only 5.9 per cent of their resources to the health sector.
The newly announced policy makes a good assessment of the health situation in Bangladesh (malnutrition, maternal and child health issues, continued heavy burden of communicable diseases, etc) and quite clearly identifies some of the major constraints faced by the health system (for example, lack of and mal-distribution of human resources for health, lack of access to the health care services in remote areas and for the poor, inadequate attention to some of the emerging issues including non-communicable diseases, etc). The policy declares to solve almost all the problems that the country’s health system is faced with. People in rural areas throughout Bangladesh, the policy assures us, will have easy access to health services. There will be adequate number of appropriately trained doctors and other health workers in all upazila health complexes and community clinics. There will be an efficient health information system; public-private partnership will be further expanded and strengthened to ensure better health care services. The policy notes that the government will take actions to ensure availability of trained birth attendants at the time of delivery in order to reduce maternal mortality. It talks about improving the referral system and also the hospitals (district hospitals as well as specialised hospitals and institutes based mostly in the capital city. The policy makes bold statements in improving the governance of the health system as well as strengthening monitoring and evaluation of the system’s performance. In short, there is hardly any area that escaped the attention of the policy and in almost all cases the policy assures us of action and good results. The policy itself is touted as a ‘weapon for ensuring good health’ and, consequently, covered almost all areas of the healthcare system.
Using the World Health Organisation’s classical statement to define health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,’ the policy sets three overarching goals for the health system. These are: (a) ensuring the availability and accessibility of primary health care and emergency health services for all; (b) to further improve and expand client-centred, quality health services based on the principle of equity; and (c) to make people aware of and encourage them to use illness prevention and health promotion services. The policy, thereafter, lists nineteen basic objectives. As noted earlier, these objectives seem to encompass almost all areas of the health system. For example, the objectives include improving the nutritional and health status of all Bangladeshis irrespective of their creed, caste, socio-economic status or location (rural or urban); ensuring accessibility of quality health care to all, especially for those in rural or remote areas and the urban poor; providing priority to availability of emergency health care; reducing maternal mortality ratio and the infant and under-5 mortality rates and try to bring them considerably down by 2021 — the fiftieth birth anniversary of Bangladesh. The objectives did not miss to note strengthening family planning services, reducing the total fertility rate (bringing it to replacement level by 2021), and improving the overall nutritional status of the people.
The policy has a few more enticing and ambitious objectives. Examples include ‘to ensure peoples’ right to health information’ (Objective 16); or to ‘ensure gender-equality in health services’ (Objective 9). Another objective is ‘to ensure easy availability of essential drugs and to control the cost of such drugs’ (Objective 17). Perhaps one of the most ambitious is the objective of ‘ensuring coordinated and unified actions of all ministries, departments, private sector agencies involved in public health and medical services’ (Objective 14). Needless to say, the policy also pledged ‘improving the educational standards of traditional/alternative medical systems like Unani, Ayurveda, and Homoeopathy’ (Objective 19).
The objectives, it must be said, are laudable. The ‘basic principles’ that followed are also easily understandable as they represent long-standing demands of various health system stakeholders and grassroots organisations. Some of these basic principles are universally accepted and flow from numerous United Nations declarations. For example, it must be appreciated that the policy pledges to make all Bangladeshi citizens irrespective of their ethnicity, religion, caste, creed, gender, income and geographic location aware of their rights to receive health information and services based on social justice and equity. It is important to note that the basic principles also include a pledge to bring greater collaboration and coordination among the family planning and healthcare services. At the same time the basic principles, to the relief of many health system stakeholders, declared the government’s desire to make every effort to coordinate and better integrate nutrition programmes with health initiatives. Lack of coordination between health and nutrition programmes was a common complaint of health professionals. It is widely believed that this lack of coordination is the root cause of the inefficiency and ineffectiveness of our nutrition programmes. It is hoped that such coordination will improve the efficiency and effectiveness of both the nutrition and health programmes.
The ‘basic principles’, as noted earlier, encompass the entire spectrum of the health systems identifying numerous areas for further strengthening and improvement. These include deployment of appropriately trained additional human resources for health (physicians, nurses, midwives, health technicians of various types, etc) at all levels of service delivery — from the upazila health complexes to community clinics, district hospitals and the tertiary care hospitals; updating the essential drugs list and making them available at all levels; further improving the health systems through introducing/expanding e-health and telemedicine; and preparing the health system for effectively facing the challenges of climate change and natural disasters.
The national health policy identifies two broad ‘challenges’ faced by the health system. These challenges are in the area of service delivery as well as that of demand for and utilisation of services. ‘Poor management’, ‘limited resources’ and ‘low quality of services’ are the challenges in the area of service delivery. On the other hand, in the area of demand for and use of services, the challenges include financial barrier in accessing health services, and lack of knowledge to adopt a healthy lifestyle. These are widely recognised challenges of our health system. For example, lack of financial (as well as human) resources is well documented. Bangladesh spends less of health care per capita than any other South Asian country and even less than many sub-Saharan countries. According to the World Bank, in 2009 Bhutan spent $98 per capita. The corresponding figures for India and Nepal were $45 and $25. On the other hand, in 2009 Bangladesh spent only $18 per capita on health care. Sri Lanka and Pakistan spent $84 and $23 per capita on health care in 2009. Even war-torn Afghanistan had a greater per capita expenditure ($51) on health in 2009 than Bangladesh. Figures of per capita health expenditure on health for some of the sub-Saharan African countries are also noticeably higher than that of Bangladesh ($18 in 2009). Corresponding figures for Chad ($42), Burkina Faso ($38) Djibouti ($84) Cote d’Ivoire ($55), and Ghana ($45) are noteworthy.
Why our spending on health care is so low? It should be noted that except India, all the other countries noted here have per capita gross national product similar to that of Bangladesh. Moreover, most of our health expenditure (65%) is borne by individuals and households as ‘out-of-pocket’ expense; only about one-third of the health expenditure ($6 out of the total $18) is from the public exchequer. The health policy admits that Bangladesh spends too little on health and promises to do more. Nevertheless, it does not provide any clear guideline on how and exactly to what extent out spending on health care will rise. Bangladesh currently spends about 5.9 per cent of its annual budget on health care. There is no clear indication whether we will see any substantial additional budget allocation for health care soon.
Moreover, the policy fails to identify a few more fundamental challenges faced by the contemporary health system in Bangladesh. Two of these most important challenges could be identified as the structure of the service delivery system itself, and the system’s lack of capability and inability to develop and enforce standards guiding the private sector healthcare services.
The health system in Bangladesh is essentially a centralised system with all power concentrated in Dhaka. The outlaying service delivery ‘posts’ (district hospitals, upazila health complexes, union health and family welfare centre, and community clinics) have extremely limited decision space; they are essentially meant to carry out whatever directions given by the health ministry or more appropriately the Director General of Health Services and the Director General of Family Planning Services based in Dhaka. Although the system is ‘decentralised’, it lacks ‘devolution’, providing greater flexibility/freedom to the local level to respond more effectively to local health needs. With a population of almost 160 million (and growing), it is imperative that Bangladesh seriously considers the value of a devolved health system. Sadly, the health policy fails to recognise the need for devolution with a view to better serve the diverse health needs of a growing population. It also fails to clearly articulate any institutional framework to develop and enforce quality of care standards across the board especially to regulate the fast growing private sector.
Nevertheless, it is the lack of clear commitment to additional financial resources (and also in better and more efficiently using existing resources) that stands out as the most glaring weakness of the policy. All the bold initiatives noted in the policy (for example, having one community clinic for 6,000 population or less whenever warranted, establishing a national health council with the prime minister as the chair to oversee the implementation of the policy, constituting an executive committee with the health minister as its chair comprising representatives from concerned ministries, departments, NGOs and health experts to review health issues and advice the Minister in resolving problems, and extending the Internship programme for newly graduated physicians from the current 1 to 2 years in order to ensure that one of those two years is spent in rural health facilities) would require substantial additional funding to implement. Alas, the policy fails to provide any clear commitment to such additional funding accept giving platitudes that funding will be made available. Without any clear roadmap of such additional funding it remains to be seen how and to what extent the NHP will be implemented.
Dr Anwar Islam is consultant and adjunct scientist, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).