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A problem of service
delivery or culture?

The failure to significantly improve nutritional standards compared to say simple medical deliveries like immunization is interesting. Nutrition is considered useful when measuring economic denial and developing projects out of that but not when detecting the goals of public health

Afsan Chowdhury

The problem and solution regarding the maladies of public health are both in the sources of governance but one wonders if it’s possible to link the two. As long as the ruling elite fails to find direction that creates space for public services undertaking as well as their natural right to appropriate, every public service sector actions will be diminished as they are doing here. Perhaps it’s failing a little more elaborately here because the rules of engagement between the elites -local, national and international- have not been fully set. Nor have been the rules of collaboration between the original sponsors of our existing governance system who are still critically influential in many sectors including providing quality funding for public health.

   In a curious way, the public administrative model that has emerged through Hegelian dialectics of Westernity as applied in the East was dominantly located in the failed experiment areas of command economy. However, not only has the Soviet system failed and the Chinese system run away but the pure Western model in the Europe and the USA are also almost strangled in providing free social service to the less privileged. In the face of such conceptual failures, the implementers in the East are stuck with installing a system which doesn’t have too many examples of success and they can’t/won’t provide their own models either.

   Development activities and employment generation

   One of the attractions of this model of course is the opportunity for the command bureaucracy –birthed in colonial times- to expand their clout without carrying the ideological baggage which their socialist cousins had to. It would appear that some of the inspiration for public service comes for a widely distributed multi-layered bureaucracy in its role as livelihood provider which in the absence of accelerated job opportunities is doing what micro-credit aspires to do for the poor. Both may be linked to the shortage of capital needed for employment generation. Hence public service is more rooted in the need for the middling class’s livelihood crisis rather than providing services as part of the State responsibility. The State in fact is no longer a traditional State given that nearly 40% live outside any livelihood or other connections with the State apparatus.

   While one may find some of the roots of martial laws/non-representative regime of the developing world in the contradictions of expanding economies with traditional societies-political and cultural- there are new contradictions in the existing models of governance which seems to be severely delinked from its given responsibility of service providing. This means its location is confusing and modernist elite do play certain roles which the present elite seem to be unable or unwilling to do so. Public health system is probably the best example.

   Colonialism’s philosophical journey to the East

   One of the major problems of public policy analysis is its refusal or inability to deal with the intrinsic philosophical issues of governance, whether in its disabled or flourishing shape. Possibly the weakness of the problem is compounded by the world view of the analysis, mostly products of Westernity whose attempts to establish western governing systems in Eastern spaces lead to not just failures or poor performances but well intentioned denials of services and decapitation of traditions.

   It’s useful to remember that that colonialism is also a philosophical journey for the West where it tested its moral products in captive social markets. The belief that agricultural capitalism cold be introduced in Bengal through a feudal system like the Permanent Settlement by the British colonialist should not be read as some Marxists do as an exploitative aspect of colonization but more as an example of the historical impossibility of applying Western historical methods to Eastern spaces. It was not just a failure in Universality but also a lesson in the primary difference between the East and the West. It should also be read as a need for convergence between the two especially in public policy making including in applied public health.

   Public health is in a crisis and one doesn’t need data to prove that but the sector has wider implications beyond treatment of patients of preventive medical practices which is more at home in preventive public medicine. The image of health is one of medical services delivery through static health centres. This is where the western imagination has intervened to create a sustainable source of arguments to bolster the case for medical intervention as a substitute for health. For example, few are linking the public health sector with nutrition management which is perhaps the most critical index of its health.

   The failure to significantly improve nutritional standards compared to say simple medical deliveries like immunization is interesting. One is not sure what the actual nutritional situation is and much happens based on estimates than actual data or delivery. Nutrition is considered useful when measuring economic denial and developing projects out of that but not when detecting the goals of public health. Command politics seem to have better success in convincing that the notion of public health is an end in itself and its failure is inevitable. Essentially, it’s an indicator of the State’s intent and a measure of its ability. It’s this conundrum that seems to weigh heavily on the health of the health sector.

   Poverty alleviation is very much part of this but can our efforts be enough ?

   Most data points to a poverty alleviation sum of around 0.5% per year to 1% depending on the allowed quantum of optimism. If one goes by the required targets including that mentioned in the PRSP and other contemporary cannons, we note that it pre-supposes a much higher reduction rate per annum, perhaps around 3 % or more. However, we are not sure by which process we are expected to assume success.

   The process of validating thus aspiration has also been scrutinized and while such exercises have validity in a more structured environment, one wonders if the failures of poverty alleviation have cultural links or not and if this aspect has been explored. Whether the failure to reach targets set by us and our friends have created a crisis because the actions have led to more institutionalized poverty than before. Are we enabled to battle poverty everything remaining largely the same and the possibilities of quality engagement at all the levels, internally and externally-still as weak as before?

   Are we entering a new world where language has to be adjusted to describe fresh versions and more extreme versions of poverty? The tools to battle this tide have all been designed by experts both local and foreign and one must pick up the courage after three decades of birth and loudly ask if Western born and West trained economists can address issues of Eastern poverty?

   South East Asia: East –West convergence the future

   Even in SE Asia where one may say that the West had more fruitful contact, its wealth generation is no longer explainable through western economic experiences and its inevitable cultural logic which Hegelians assume to automatically follow... In fact these are much better at being well constructed “convergent spaces’, a space constructed through engagement of two elite classes which occurred during a special period in history. However, this imposed inter-action, partly resulting from the military needs of the Indo-China war is not at its end and nor has it always been a peaceful partnership.

   For one thing the rise of the Islamic extremism as well as the much more violent threat of the avian flu virus that could wipe out a quarter of the world population as a result of small scale chicken farming by villagers who have been outsidered by the advanced aspects of new economy in the convergence based economic planning are causing acute concerns. Thus, this example too has been contested which was once considered an unquestionable triumph of Westernity. Public policy making process in such zones now demands greater scrutiny. The economic meltdown, the cause and the management of the SARS virus as well as possible global livelihood impact due to cultural alienation of a large militant section of people and possible global epidemic caused by accelerated economic policies executed by manipulating the nature and the environment have challenged conventional wisdom. While the colonial experience has been different especially the experience of serial colonialism in South Asia the impact has been quite huge.

   Need for an efficient system of subservience

   This argument doesn’t constitute any sort of rejection of Westernity but establishing a philosophical process through which the convergent spaces may be established. One may argue that such spaces are not necessarily positive but one needs to argue that the present East is in no position to argue either and hasn’t shown any intention too. Evidence suggests that if some improvement is going to happen, it will happen by establishing a more efficient system of subservience.

   The West is in a hurry, is not in the practice of listening and a bit nervous as well. It can understand the East only in terms of subjugation because that has been the dominant form of contact in history so it has never had an opportunity to learn. The West is in general not philosophically constructed to engage with the East and it has already constructed and imagined Easternity, first as it suited it and then as the East tried to assimilate with the West rather than converge.

   This has not benefited the East/developing world much and a major reason has been the absence of an East with which the West could engage. The East has paid attention in becoming bureaucrats and managers rather than thinkers and prefer to put on their thinking caps only when on scholarships or paid by dad and in western universities or labs and in the hope of assimilating in Westernity. The East wants to be the West and in doing so has created problems for both.

   It’s this vacuum that has lead to a philosophical crisis of communication. At this point of time, the only option is to construct Easternity in clear contours to be obviously observed by the West and encourage it to engage with this obvious and aspire for convergence.

   There are evidences to suggest that infrastructural development is important and in this development agencies have played a major role.

   Good. Good. One must congratulate this aspect of development but they fall far short of the promises made by development and it’s more of what we hold as basically incremental progress in bureaucratic planning and management. The rise of “roundtables” in Bangladesh is not accidental. It basically a system of producing consensus amongst this elite which runs Bangladesh as the politicians are proving increasingly unable to fulfill their role or not willing to.

   Public policy has become a subject of endorsement in a roundtable discussion meet and participation has become a subject of funded pursuit for an objective endorsed by the same bureaucracy. This division between public policy making and bureaucratic policy making illustrates the situation most acutely.

   The situation has been presented by several summations of development policies in Bangladesh where policy making has been questioned as a system of elimination of the more difficult to the easiest attainable rather than the necessary. Perhaps the weakness is most obvious as the space between administrators and development specialists have shrunk and the two are unrecognizable because the function of both has become the same.

   Policies are perceived as production of agencies and not as a result of an interaction between any given development outfit – government, NGO or donors- and of the unspeaking people, the consumers. Hence public health issues like human rights issues have become a subject of internal concern of agencies involved and also linked through livelihood.

   The risk of having a disengaged elite

   Westernity has exerted its will as it saw fit and as a superior or more powerful cultural source have imagined not just the ‘most desirable but also the process of achieving the same. Hence, we have situations of servility replacing independent choices. This reality must be factored in and in case of public health a chart has to be drawn which allows inter-action in this area of engagement albeit a limited one. As the responsibility of representation has been denied by the State and it is now distinctly reduced to bureaucratic functions in a limited scale, manifested by the bureaucracy and its subservient intermediary, the internal development agencies also known as NGOs, the functional aspects of development needs to be relocated.

   The international development agencies who are creating operating spaces for public policy making and application essentially engage with institutions that are not in engagement with the people. This creates a large gap and accounts for this vacuum in public health sector.

   It could have been met had the legislative apparatus been active but as part of the command politics structure, they are more aligned in power transactions of very different nature making the situation even more difficult for the international agencies who have assumed agency whether by choice or default to pay for and monitor functioning public policy.

   The case of the absent public in public policy making

   It’s the absence of the notion of the public that has crated a situation where the ruling elite have no need to be accountable to sustain their elite position in order to rule. Since elections have no link with governance and the parliament has to compete with the street as a political space of continuity, validity and legitimacy policy makers do not articulate policies because this is not their task anymore. And by not doing so, they are unable to participate in the construction of Easternity leaving the State to be managed by livelihood seekers who have no responsibility or can’t /or doesn’t have to have any responsibility thereby shrinking the already shriveled public space.

   It’s this collective inability to be culturally appropriate by the very people who are supposed to ensure its proper construction that is forcing the West to design the world as it sees fit. Its attitude towards climate change is a good example where it simply has turned to denial rather than face the harsh logic of nature and possible end. The argument obviously in their mind is that the West will survive global environmental catastrophe but the east certainly will not but given the economic and environmental abuse the east is heaping on itself, there is no space to converge.

   The collective inability of the local elite has created a crisis for the non-elite – the rest of the people- who are the primary recipients of public health measures. There re no discreet policy sectors like public health and public nutrition but there is a common link to a better public life. Unfortunately, they require a public policy making which is absent. The problem of existing policy making is that it has failed to produce many documents that fulfill much beyond the funder’s need but the funding West doesn’t see that such weak documents fail to deliver and such failures lead to greater complication for the West in future. And even when documents are made, the policy implementers ignore them because the documents may threaten their livelihood. Thus the GO-NGO- think tank alliance are circling their philosophical nightmare unable to find a way out and discover that they must contribute to create convergence so that West can engage with the East. The West doesn’t understand this very well because convergence and syncretism are not familiar concepts and thus the circle of denial keeps getting repeated.

   We are not understanding that we are in the midst of an internally generated colonialism which has responsibilities but which we deny and cause problems for all including recipients of public health demands. It’s as much a problem of culture as of weak service delivery.

A systematic dismantling
of the safety-net

Even a cursory glance at all available (and costly) research done so far, especially by internationally-run agencies, has been directed towards ‘micronutrients’ rather than ensuring adequate food (or ‘macronutrients’)

Dr Naila Zaman Khan

Many will say that Bangladesh has made remarkable progress in its health parameters since its independence. Policy-makers and development professionals, in fact, quote these successes as exemplary within less developed countries. It is ironic that we mention these statistics for self-glorification worldwide while millions are disenfranchised from even the minimal requirements of a healthy life today. In a country which fought for its liberty and democratic rights it should have been a given fact that we would improve on some factors such as infant and child mortality rates in the thirty four odd years of our existence. And, indeed, we have evidences of this claim (figure 1).

   Independence of any country is not only about the free voices of the people to be heard but also their survival with decent living standards, the absolute minimum of which would include two square nutritious meals a day, a fairly safe housing, adequate clothing, and recourse to minimum health services during sickness. The last condition has, unfortunately, become a curse for the majority, ie the poor.

   The bottom-line scenario

   Of the estimated 140 million population of Bangladesh, 35 per cent belong to the low income group, i.e. they manage to eke out a living and two meals a day. 20 per cent belong to the poorest of the poor (or the ‘hard-core poor’) whose monthly income is less than Tk3000 per month, an amount which rich people in the city spend a day to eat out or buy clothes. With an average family size of 3.5 to feed it is unimaginable and unthinkable what is eaten by a majority of our voting polity. So, what happens when these barely-surviving people fall sick? Only about an estimated 15 per cent avail government facilities; even so, in one service evaluation of the Shishu Bikash Network, it was found that compared to autonomous hospitals (eg. Dhaka Shishu Hospital, Institute of Child and Mother Health, or Chittagong Ma O Shishu Hospital) government hospitals (eg. Dhaka Medical College Hospital) provided services to a larger proportion of the poor, i.e. 20 per cent in autonomous hospitals versus 60 per cent in a government hospital. A closer look will reveal that these government hospitals, starting from the thana level to the divisional level in major cities are being systematically disbanded with poor investigation facilities, dismal administrative costs and practically no human resource development.

   When this safety-net of facilities within government hospitals is pulled out, it marginalises the poor further. Studies show that any major illness in a family is leading an estimated 27 per cent, who were living barely above the poverty line, into further indigence (Sen, Begum, 2001). Everyday major hospitals in the city witness cases where the family has sold most of its assets e.g. land, homestead or cattle to pay for treatment costs. When one MRI costs 8000 taka, which is more than two months earnings for a family, the ground reality is put into perspective. The irony of the matter is when one realizes that, most of these body scans and a whole list of blood tests and what-have-you requested by mercenary doctors is unnecessary and usually done at the behest of diagnostic labs in exchange of heavy commissions. Lack of any TORT laws or malpractice commissions, the latter usually set up by medical associations leave the general public with no scope to protest. There is no recourse for them but to either let the patient die or fall back on the village doctor for help and solace.

   Healers, herbs and fakirs….

   Fortunately, for the majority of the Bangladeshi poor traditional healers, fakirs, ojhas, shamans and their likes are still around to see to the needs of most of the common ailments and even when seriously ill. No thanks are forthcoming to the policy-makers and health planners as most of the traditional medicines, including herbal hamdards, ayurvedic medicine and homeopathy have been abandoned or are limping ahead simply because the vast majority cannot afford allopathic treatment; or because many truly believe in their efficacy. Although the health policy of Bangladesh mentions these alternative medicines (homeopathy, unani and ayurvedic medicine) the ground reality is that meager resources are allocated for their development. This policy is in direct contrast to the resources made available by government health ministries for the development of ayurvedic medicine in India and herbal medicine and acupuncture in China; and statistics even from the US now says that a majority of the public are resorting to alternative medicine.

   Lack of food: the slow killer

   Meanwhile, the general health of the population continues to deteriorate. Endemic malnutrition is the all-encompassing slow killer. 60 per cent of children have some degree of malnutrition. In a nutrition survey carried out in 2002 in villages in Kishoreganj 56 per cent of children were stunted and 64 per cent were underweight with strong evidences of chronic malnutrition. Almost no child or mother from the lowest income families had had milk, eggs, fish or pulses with their food in the past week. Where the ideal proportion of carbohydrate, protein and fat is 60 per cent, 20 per cent and 20 per cent respectively, the food consumed was calculated to be carbohydrate-based with nominal content of protein or fat (figure 2). As per research evidences from several current publications this scenario is endemic to all regions and the victims are the vulnerable populations of the country, in both urban and rural areas.

   The debilitating effects of chronic lack of food cannot be over-emphasised. Evidences from research demonstrate clearly their correlation with significantly poor intelligence and learning difficulties in children; short stature amongst women and children (and men, too, as boys at an early age are being affected) and depressed immunity to infections in most populations. There are evidences that a large proportion of adolescent girls sitting cramped from dawn to midnight without adequate food in garments factories are short and with low body mass index (BMI).

   The effects of lack of food (and caring) on older adults and the elderly, in both men and women, cannot be overemphasized. The resurgence of pulmonary tuberculosis is a prime example of what happens when the old, who are the most obvious ‘open’ carriers of the germ are pushed off from the receiving end of health care services.

   ‘Questioning the solution’

   As David Werner very succinctly puts it, we need to question the solution too. This is because a more pro-active approach with people’s initiatives has been shown to go a long way in restoring good health within communities. Unfortunately, our health planners have decided to put all their eggs into commercial baskets. A cursory look at the Ministry of Health headed and World Bank funded Health, Nutrition and Population Sector Planning (HNPSP) will demonstrate how commercial interests have overtaken programmes in primary health care (table 1).

   A few explanations are warranted on how the little resources allocated for health services could have been better utilized.

   A ‘micro’ solution to a ‘macro’ need

   One does not send children to school ‘fortifying’ them with zinc, iron or calcium tablets. A hearty breakfast of eggs, bread, milk, banana or what have you is the given norm; unfortunately it’s not so for the poor. The Ministry of Health’s solution for them is food fortification (eg. with iron), supplementation (eg. high potency vitamin A capsules) or nothing. Even a cursory glance at all available (and costly) research done so far, especially by internationally-run agencies, has been directed towards ‘micronutrients’ rather than ensuring adequate food (or ‘macronutrients’). A simple analysis of a person’s diet, given the poor intake of quality food will show that it is deficient in micronutrients too. A sustainable solution would have been community mobilization to increase the ‘common food’ of the poor eg. fish in ponds, rivers and other water bodies, together with leafy vegetables, tubers and roots. The pumping of pesticides and fertilisers into tillable land and the import of powder milk to the detriment of our dairy farmers etc. are inter-sectoral and inter-ministerial and local government responsibilities which should have been mobilized by the health ministry. This seems to be a long way off, in the absence of a vision for the future or a concerted political will.

   Ulterior political motives, too, sometimes push well-intentioned programs into oblivion.

   A prime example of misplaced intentions is the ‘Food for Education’ program. To state a fact, every school in more developed countries ensures that every child has at least one proper meal (usually lunch) within the school premises. This meal is well supervised and its dietary content balanced and adequate. In Bangladesh, the program fell into political a quagmire when ‘food’ was replaced by ‘wheat’ (or gom) to be given to the guardian of the child who then sold it in the market to use the money obtained towards the ‘child’s interests’. One can well imagine how the much-needed balanced diet got thrown out of the window!

   Bangladeshi children are thus left to the vagaries of international researchers and their respective corporate interests in pumping millions of dollars worth of zinc or any other ‘micro-nutrient’ into the blood streams of a grossly nutritionally denuded population, with no real food in sight in the near future.

   When children are having children, how safe is motherhood?

   Easily, over 85 per cent of Bangladeshi babies are delivered at home. Although the infant mortality rates have been reduced significantly they still remain high in the first month of life and also in mothers. The plateauing of maternal mortality rate (MMR) to an estimated 3.8 to 4 per 1000 is a sore point for the government. On the other hand, reasons for these high rates of death can be easily understood if one sees the state of health and development of adolescent girls.

   The age of marriage still being 17.5 years, approximately 45 per cent girls have given birth to their first child by 18 years of age. MMR is highest within this age group and it is reported that a majority of deaths during pregnancy in adolescent girls is due to violence within the family. So here is a catch-twenty situation for well-meaning but poorly-advised parents. They think that by marrying off their adolescent daughter at 14 they are ‘protecting’ her and providing her a ‘safe haven’ in her husband’s home; what is not thought about is that these are young persons whose development, emotional physical and sexual, is yet to be completed; and that pregnancy will steal whatever little reserves her body had. The resultant death by pregnancy (of the ‘child’ who was having a ‘child’), therefore, is easily understandable as is the necessity to counter such tragedies.

   Here, too, one cannot but reflect that the solution of the health ministry has more commercial motivations rather than socio-cultural ones. For starters, antenatal care (ie. regular check-ups during pregnancy for checking blood pressure, height of the baby within the womb etc) has been abandoned, as only about 25 per cent pregnant mothers are ever seen by any health professional during pregnancy. The resources, meagre at best, have been put into more technologically advanced and expensive Emergency Obstetric Care (EOC). As a result, millions of dollars worth of equipment is lying in thana and district hospitals today while birthing continues to be conducted by local dais whom the government has deemed too useless to provide training or any medical know-how.

   This is not to say that the initiatives of the people are not showing positive results; in a Safe Motherhood Programme run by the Johural Islam Medical College Hospital the mortality rate in about 20 villages has been brought down to 0.23 per 1000 by just providing regular antenatal

   checkups.

   Adolescence: big-time money for drug cartels

   The government talks about HIV AIDS prevention and seminars abound with the need for its prevention amongst commercial sex workers etc but one UNAID data shows that over 90 per cent of 15-year school children in Bangladesh don’t know how to prevent the infection. What is not said is how little sex education we impart to these school children.

   In a study of children from class 7 from both English and Bangla medium schools, it was found that a majority had very little information about their own bodies or the normal course of sexual development (FRAT, 2000). One biology teacher from an English medium school said he could not ‘look boys and girls in the eye’ and talk about these issues. Most Bangla-medium children asked why they were not taught these issues in class. Incidentally, there is only one chapter related to reproductive health in class 8 and, as alleged by the school children, most teachers asked them to ‘read the chapter at home’ with no scope for any discussion within the classroom. It is no wonder that adolescent boys and girls learn about their bodies through pornographic literature, blue films or from other informal, and usually dubious, sources.

   What the school curriculum also fails to address is how increasing numbers of children aged 12 or 13, in class 6 or 7 are beginning to smoke their first cigarette, which is paving the way for drug usage. (figure 3). Instead of imparting life-skills to these children (eg. how to counter boredom, or how to cope with stress, or how to say ‘no’ to peers) our schools are deeming it safer to ignore the issues, leaving this population vulnerable to the most open sale of cheap heroin, or what have you, in every child’s closest neighbourhood.

   So what’s the solution?

   Do we send off appeals to the health, social welfare, women’s and children’s, education, youth and other related ministries? That would seem fair enough as they are supposed to be manned by ministers who are the elected representatives of the people of Bangladesh. But then all these ministries have vested interests in corporate finance, donor funds, commercial bodies, and other overt and covert businesses to protect and promote. What these ministers and ministries cannot prevent is the free flow of information and knowledge to the general public.

   Health activism is something that has not yet come of age in Bangladesh. No thanks to professional bodies such as the Bangladesh Medical Association whose interest for existence seems to lie elsewhere; yet, things do happen when public opinions are mobilized. The banning of leaded petrol within two weeks of a press conference providing evidences of lead encephalopathy in children, is one example of how policies can be changed for the better. Some issues take longer, more concerted efforts and long term planning. But the process of health vigilance must remain a continuous one. That is how, maybe, we can ensure a healthy life for the majority of people in dire need of services today. Till then, we, the educated polity, remain guilty for simply ‘looking the other way’.

Not by health services alone

A health system that is unable or unwilling to demand and secure full public or professional accountability, ethical conduct, and acceptable standards of quality and safety, be it publicly funded or privately owned health facilities, is failing in its basic tasks and responsibilities to the public it serves

Dr Zakir Husain

Health by definition (as defined by the World health Organization) is a condition of complete physical, mental and social well being and not mere absence of illness or infirmity. Health care is more than medical care when ill; in fact treatment of illness is only a small part of health care; with other components such as health promotion and disease prevention, reduction of disability and rehabilitation of the disabled making for totality of care.

   Though it is a popular belief that hospitals and clinics produce health, these are adjuncts. Other major determinants like food and nutrition, hygiene and sanitation, healthy lifestyles and health-promoting behaviour and reduction of environmental health hazards are equally if not more important to health.

   Myth and reality

   The popular belief in hospitals and clinics puts excessive pressure on government to create an infrastructure for which it cannot fully pay and eventually, diverts limited resources away from what government has higher duty to provide, namely population based public health. Excessive or almost exclusive faith in hospitals and clinics may be good for the medical industry vending equipment, appliances and drugs but it is not necessarily good for public health. But good public health care not only produces high health status but also increases economic and social productivity of individuals, communities and the nation; the reality is, health of the population is not secured by medical or even health services alone.

   Bangladesh is a country with a heavy burden of population, heavier burden of diseases and disabilities, much of which is avoidable. With a large population with low education, skills, and productivity, the level of poverty is high. Poverty and ill health work as a vicious cycle in which one reinforces the other. Good public health is critical not just on heath grounds but also for the economic and social progress of Bangladesh.

   Health system uniquely challenged?

   It is in the above context that the health system in Bangladesh in uniquely challenged. The same condition also opens unique opportunity to embrace a policy, strategy and programme redesign - an overhaul of the health system to free it from internal contradictions. Just as health is the product of multiple determinants (of which medical care is only one and a minor one), health system is more than a set of defined health services. Health system reaches beyond health ministry into several other ministries and sectors, extending into health beliefs and behaviours of individuals, families and communities.

   Population health (good public health) will remain a goal not reached by some achievements of specific time bound ‘health’ projects. In fact, and ironically too, continuing failure to address population health through a comprehensive health system build up diverts attention, action and resources away from the system into fragmented projects which allow dramatic demonstration of ‘success’ without significant health improvement of population as a whole. This is not to decry or deny the success of few projects that consumed heavy funds but to draw attention to the fact that without strengthening of the system as a whole the gains made will not be sustained nor will there be significant impact on population health status.

   Only a socialist (now defunct) economy claimed to give health care to the people without regard to their ability to pay and as Bangladesh embraced a market economy such commitments sound hollow. But there is talk of taking health care ‘to the doorsteps’ of the people - a commitment is neither technically and financially feasible nor expected by the people. Unrealistic and unnecessary commitments remain more a rhetoric rather than a reality, undermining the credibility of the health system. But more to the point, such commitment diverts scarce resources into politically expedient ‘projects’ that are slow to complete and are chronically under funded and under performing.

   Closing the gap between rhetoric and reality

   Rather than promise of doorstep care, the state (public sector) can and should invest preferentially into a health system that puts essential public health functions (EPHF) first in its order of priority. Some examples of EPHF are safe drinking water, basic sanitation, safe and nutritious food and food products; other elements of EPHF are care of women and children, including reproductive and child health and for safe pregnancy and childbirth, public information and education on personal health and healthy behaviour, health protection by immunization and reduction of health hazards resulting from unsafe environment. These EPHF when performed well give a high aggregate as well as local health return with much higher cost effectiveness. Also, these services benefit the entire population and not the few who might be able to buy these services. As government does not command and control all the resources, it should selectively invest in areas leaving the market and people as individuals to take the right and responsibility they have.

   A health system that supports expensive infrastructure from within its limited resources but does not make best use of those, fail to run efficiently, provide little access to certain sections of population (the poor, remote, or marginalized) and their needs.

   A health system that is unable or unwilling to demand and secure full public or professional accountability, ethical conduct, and acceptable standards of quality and safety, be it publicly funded or privately owned health facilities, is failing in its basic tasks and responsibilities to the public it serves.

   Public funds are meant to bring good results for the people and with transparency; and it is equally obligatory on private care to give public service within prescribed rules and regulations.

   Unfortunately, much remains to be done as confirmed by frequent reports of negligence, corruption, and poor management of facilities and funds. True or not, health system is also notoriously reputed (not an enviable one) for its waste and indifference. Therefore, the sooner health system brings both public and private facilities and personnel within the scope of rules and regulations by regular inspections, granting or withholding accreditations, voluntary self- discipline and medical audit, the better the health system in the future.

   The emerging market and public health

   With emergence and dominance of the ‘free market’ regime, the public sector has come under greater scrutiny and competition; the state has effectively retreated from many public good and welfare oriented past undertakings and the health sector is no exception. In the past, health system was not sensitive to cost consideration. But now it is. Yet, there has not been enough systematic analysis of costs, cost centers and cost benefit in health system. Thus, it has been difficult to produce and present reliable cost analysis or cost benefit analysis to inform the staff within the system or policy makers outside or even raise public awareness on the subject.

   Time is now to carry out cost analysis and related studies of health outcome at alternative costs. Unit costs of service outputs have to be determined leading to some accepted standards for comparison of efficiency across facilities countrywide. Moreover, unit costs could also help new tool of budget allocation by determining departmental and even hospital allocations calculated upon performance and outputs – undoubtedly a more rational and fair method of allocation. Another area waiting to be explored is some kind of limited in scope social health insurance for which unit costs are helpful.

   Cost analysis though not always perfect, will help macro policy formulation based on evidence rather than on intuition or subjective considerations In general, it will help more informed and rational allocation of scarce resources and help formulate alternative strategy to mobilize additional resources for the health system. Notably, such analysis will help highlight the cost of health impact of policies and progammes in non-health sectors and benefits of health related actions as well. Thus, the inter- and multi-sectoiral dimensions of heath system will be more transparent and perhaps more compelling, something that has been conspicuously lacking so far.

   It is a historical fact that peoples’ health condition improved remarkably in Britain, Europe and in America more due to better nutrition, sanitation and living standards than due to better medical care. Inter - sectoral actions and contributions are key to better health of people. This is one essential element that strongly underpinned the primary health care as a key approach to Health for all as adopted universally in the Declaration of Alma Ata (Kazakhstan, former Soviet Union) in 1978. Those principles remain as valid today as then.

   How public health is influenced by policies and practices outside the health sector (health ministries to be specific) is well recognized though not always extensively documented. For example, take Food and Agriculture sector. Proper food and nutrition is an essential precondition for a healthy population and this is particularly crucial for growing children and adolescents. Unadulterated foods of high nutritive value are essential for health. Yet, even a casual observation of young school children shows how many of them are plainly and markedly obese (overweight) and this is because they have become fond of, if not addicted to, a life style based upon fast foods, (often loaded with sugar and salt giving ‘empty calories’ but little by way of nutrition) and bottled beverages. To make things worse they are getting little or no exercise. While indulgent parents may look upon their children as being ‘healthy’, childhood obesity is potentially a health disaster later in adult life likely to be seen in hypertension, diabetes and other metabolic disorders.

   Unless, ‘commitments’ to inter-sectoral collaboration are moved from committees and conferences to the operational level little tangible improvement will come out of paper initiatives and intentions. Health ministry can give technical information or guidelines but need not necessarily be tempted to assume the leadership role. Above all, effective inter-sectoral collaboration requires a new culture where sectoral ‘ownership’ or ‘turf’ is not something to be zealously guarded and this is true especially at the local level where the best results are often shown when other (than health) personnel are leaders and prime movers. The same is true at the central level where best inter-sectoral dialogues and decisions are often the result of leadership by experts, thinkers, analysts who are not necessarily led by health officials. This may be a lesson hard to learn but without some detour from the trodden path, nothing new might be struck.

   That vexed subject of autonomy

   Much has been talked about autonomy to be given to hospitals - a very good and timely move that gave promise of much better management and productivity. Yet, this has remained a vexed subject followed through by half heated measures. There is this tussle between devolution with loss of control and trust in local capacity. Indeed, autonomy of hospitals cannot be exercised in vacuum and cannot be implemented without carefully framed by laws that provide means and mechanisms, defines the functions and jurisdictions of governing bodies and its subsidiary bodies, describe the self governing medical discipline and audit procedures and many other essentials. No half-baked measures filled with doubts and reservations will do; it might even harm. Hospital governing bodies can govern using model by laws, medical staff committees for better clinical care and audit, making budgets and approving expenditures, raising local revenues and improving public accountability.

   The subject of autonomy is not isolated from other areas of decentralization and a notable instance is the transfer of ownership and management responsibility of government health activities to the local bodies elected or otherwise such as Union Parishads or District Councils. Something like a health system can benefit a great deal from genuine local contribution (community involvement- also a pillar on which primary health care stands). Local level planning for health has best promise in local debate led by local stakeholders and informed by health professionals (not excluding those drawn from the academia). A genuine process of locally debated and determined (health) actions might not all belong to health, (as understood by health officials at district or above) yet, if accepted might give higher health outcomes as perceived by the community.

   Community Clinics (under the previous HPSP) represent a well meaning but insufficiently examined local initiative and a community clinic owned by the local body run by a fully trained (say two years) resident community midwife, paid and supervised locally by beneficiary clients can make a difference in health for women and children. The difference is in availability of good primary obstetric care and childcare leading to the reduction of the present high mortality of mothers. Locally managed small drug stores are another micro enterprise eminently suitable and sustainable.

   The existing rules of business, regulations, the management culture or mere convenience may work against a serious search for change but that alone is hardly acceptable. Health system, by its high relevance and stake in the people whom it is mandated to serve has also by definition the greater need to be decentralized and devolved. Indeed, there are very good examples throughout the country and the region. Self managed primary health care works can mobilize local will and resources to complement government budget, generate employment and income locally and can generate health that is sustainable.

   A brief recapitulation: health cannot be delivered by health services alone; health system supported by collaboration by responsible sectors can improve health.

   Government has the right and duty to perform countrywide essential public health functions as priority and share the burden of personal medical care with private and non-government providers while ensuring quality and public safety and supporting a health safety net for the underprivileged.

   Government can effectively devolve resources and tasks to local communities by taking unconventional measures, giving local autonomy to local management and providing essential technical guidelines and subsidies where needed. Accounting for costs and cost effectiveness must be introduced to generate evidence and criteria for allocation of resources guided by performance and health outcomes rather than by assumed entitlement.

   A national health intelligence center with high quality surveillance and analysis is imperative for national (and population) security. In addition, there are newly emerging (viral epidemics, HIV/AIDS) public health threats and the re-emerging threats like tuberculosis, malaria will demand high vigilance combined with rapid response; the health system of the twenty-first century is much more than a self-contained assembly of hospitals, clinics and laboratories.

Focus on inequities in health

In the last decade the national averages of mortality, morbidity, nutrition and life expectancy have improved considerably in Bangladesh. However, disparities in access to health care services and health as an outcome exist among different socioeconomic groups

Simeen Mahmud, Rowen Aziz and Tania Wahed

Bangladesh has, over the last two decades, witnessed large declines in mortality and improvement in health despite economic hardship and inadequate health services. There is no evidence to show that these improvements in health have reached the most disenfranchised, neglected and vulnerable groups of people. Gains experienced differently by different groups of people indicate that socio-economic inequities in increased risk, utilization and accessibility of healthcare services also exist. Inequitable resource allocation and expenditure on health care services call for scrutiny from an equity perspective and existing poverty alleviation and other development programmes also need critical assessment in terms of their equity impact.

   The Bangladesh Health Equity Watch (BHEW) is a Bangladeshi initiative established to determine whether the health situation in the country is improving and if these improvements are equitable. BHEW is a collaborative enterprise of four organizations: the Bangladesh Bureau of Statistics (BBS), Bangladesh Institute of Development Studies (BIDS), BRAC, and ICDDRB: Centre for Health and Population Research. The impetus for BHEW came from the Global Health Equity Initiative (GHEI), which was started, by a small group of researchers from various countries, including Bangladesh, who were concerned by the growing inequities in health within and between countries. GHEI led to the Global Equity Gauge Alliance (GEGA), which is the umbrella organization with 11 country gauges (including BHEW) as members.

   The objectives and activities of BHEW and all other equity gauges are based on the three-pillar principle of Measurement and Monitoring, Advocacy, and Community Empowerment, all of which collectively lead to action and change and the three-pillar approach was developed by the Global Equity Gauge Alliance (GEGA) to be the guiding principle of how an equity gauge operates. At the recent ‘International Workshop on Health Systems and Health Equity’ held in Bangladesh on 29-31 May, 2005, Antoinette Ntuli, Chair of GEGA emphasised on the role of an Equity Gauge as an agent of change. She stated that an Equity Gauge functions as a catalyst for equity and strengthens the work of existing groups by providing evidence of inequities. It also strengthens community voices and links between community groups and decision makers and directly supports the role of decision makers through the mechanisms mentioned. Ms. Ntuli elaborated on the three pillars used by equity gauges to move research into action. The Assessment and Monitoring pillar provides evidence of the current dimensions of health inequity, as well as changes over time, using quantitative (including primary and secondary data) and qualitative (participative; stories; focus groups, etc.) data. The tools used should be responsive to new policies and programmes. The Advocacy pillar advocates for health equity through evidence-based policy recommendations, raising public awareness and mass mobilization. Its job is to inform stakeholders, shape public discourse, sensitise organizations, foster coalitions, influence decision makers through an ‘expert role’ and influence decision makers through a campaign or by social action. The Community Empowerment pillar actively supports community empowerment in developing projects, advocacy campaigns and interventions, works responsively and collaboratively with those who are affected by inequities, makes information (from measurement and monitoring) available and accessible, utilises community media (e.g. Community radio stations) and partners with communities in advocating equitable change.

   Speaking at the recent workshop on health systems and health equity, Professor Paula Braveman of GEGA emphasised that understanding the difference between health inequalities and health inequities is crucial. Both concepts refer to disparities, differences or variations between groups of people. But health inequities are a subset of health inequalities that refer to differences that are particularly unfair or unjust. Deciding what is fair or just can be based on the following approaches: Varying ideas of justice (e.g. perspectives on women’s status, caste, class, and racial/ ethnic/ tribal/ religious differences), the Utilitarian approach of maximizing average health regardless of distribution, the Egalitarian view of equal opportunities for all to be as healthy as possible, Rawls: ‘veil of ignorance’, maximizing conditions for those with the least and need for a universal criteria to guide policies. Dr. Braveman indicated that the International Human Rights Principles provide guidance for the understanding of inequities present in various populations and countries. These refer to economic, social and cultural rights, civil and political rights, rights to health, education, water, food, shelter, living standards and the benefits of progress. Almost all countries have signed a human rights agreement and governments are obligated to progressively remove obstacles to realise all rights for everyone and particularly for groups with more obstacles or discrimination.

   Antoinette Ntuli indicated in her address that it is important to remember that ‘pro-poor policies’ and ‘pro-equity policies’ can be contrasting strategies. Pro-poor policies target the poor by creating separate programmes, benefits, structures and processes and respond to poverty while the respective pro-equity policies work to build a single, fair society, rather than create mechanisms that perpetuate rich/poor divides, single out poor or marginalized groups and prevent groups from falling into poverty. Welfare programmes, food subsidisation aid, creating vertical health programmes are examples of pro-poor activities, while policies that increase the economically active sector and support fair wages, fair agricultural policies/subsidies and strengthening health systems architectures are examples of pro-equity initiatives. BHEW’s role is to monitor, assess and facilitate solutions to inequities in health. Although the current focus of BHEW is on health, the scope of the organisation may be broadened in the future to development issues such as poverty and human rights.

   BHEW has worked on incorporating equity dimensions, such as socioeconomic groups, geographical location, gender, health outcome and healthcare utilization variables and the like in the existing data collection systems in various organizations (including assessment of the impact of the poverty alleviation and community development oriented health programmes in reducing health inequity); it has been instrumental in establishing a new system of data collection in health equity monitoring, in disseminating findings among the policy makers, researchers, NGO leaders and members of civil society in a regular fashion to facilitate actions to minimize inequity.

   In the last decade the national averages of mortality, morbidity, nutrition and life expectancy have improved considerably in Bangladesh. However, disparities in access to health care services and health as an outcome exist among different socioeconomic groups.

   The analysis presented below is an example of how BHEW uses existing data sets to illustrate the inequitable situation prevailing in the health sector of Bangladesh. The data used come from the 2000 household income and expenditure survey (HIES) conducted by the Bangladesh Bureau of Statistics. The analysis examines the importance of factors such as location of residence (rural/urban), gender and household socioeconomic status as determinants of health status and health seeking behaviour. The dependent variables are defined as follows:

   Indicators of health status:

   1. Percentage of population suffering from chronic illness

   2. Percentage of population suffering a recent (in the last 30 days) illness

   Indicators of health seeking behaviour:

   1. Percentage of population who have received treatment from any public/government or private facility.

   2. Percentage of children 1-4 years of age who have been immunized with 8 doses.

   Graph 1 shows the health status and health seeking behaviour of the population by residence. Health status of the population is poorer in rural compared to urban areas in terms of prevalence of both chronic and recent illnesses. The rural-urban difference is more pronounced for recent illnesses. Meanwhie, health seeking behaviour also varies by residence. Rural children are less likely to be immunized and the sick living in rural areas are less likely to receive treatment when ill. The urban advantage is more evident for immunization behaviour.

   Gender inequalities are also clearly visible (Graph 2). For both health status and health seeking behavior indicators there is a visible gender bias in favour of males. Women are more likely to be both recently and chronically ill compared to men in all areas, and women/girls are less likely to receive treatment when ill or to be immunized than men/boys. Women’s relatively higher probability of experiencing illness, both recent and chronic, is observed in urban as well as rural areas and it is interesting to note that although the level of illness is greater in rural areas the male advantage in health status is smaller in rural than in urban areas (Graph 3).

   The next graphs present health status and health seeking behaviour by the level of schooling of the household head’s wife which is a proxy for household socio economic status. The probability of suffering a chronic or recent illness has an inverse relationship with the education level of head’s wife (Graph 5). Also, the probability of the sick receiving treatment when ill and children between 1-4 years of age being immunised rises with the number of years of schooling of the head’s wife (Graph 5). The positive education effect on the probability of receiving treatment, however, is visible only when the head’s wife has attained SSC or higher schooling level. The positive effect of education of the head’s wife is much stronger on the probability of children being immunised.

   Graph 6 illustrates gender differences with respect to wife’s education level. As before, irrespective of head’s wife’s schooling level women are more likely to suffer both chronic and recent illness compared to men. Interestingly, the negative education effect on the probability of suffering from a recent illness, seen in Graph 5, does not hold for women and is enjoyed only by men.

   With respect to the probability of a sick person receiving treatment the general male advantage diminishes as the education level rises. In fact, in the category between 5-9 years of schooling for the head’s wife the bias is reversed and females were more likely to receive treatment than their male counterparts. With respect to children’s immunisation the male advantage persists at all education levels, although the gender gap is somewhat reduced when wives have an education level of SSC or higher.

   These data are from a nationally representative sample and collected by a government agency, hence they can be taken to be fairly credible. They provide evidence of inequities in health status and health seeking behaviour with respect to gender, residence and socio economic status, all of which are unacceptable in a democratic society and avoidable given a government committed to a just and poverty free society.

Secrets and lies; shame and denial

As a practicing psychiatrist educated and trained in the US and coming back to practice in Bangladesh after almost thirty years, I am struck by how similar the mental health issues are in Dhaka to those I helped treat in Boston, while at Harvard Medical School

Dr Omar Rahman

Mental Health in Bangladesh remains a largely neglected, unexplored, underserved and an underfinanced arena, the step child of a health system which focuses primarily on physical illness and even that, very haphazardly. The attitude of the public is one of secrets and lies; shame and denial with very little progress from the nineteenth century notions of mental ill-health being either a character flaw or an expression of possession by evil spirits and demons. Throughout history, physical health problems have been viewed as biologically based and thus it requires more valid expressions of distress and medical attention. Mental health concerns have been relegated to the domain of character and personality and thus less deserving of professional attention. It should be noted that with the accumulation of evidence of the biological basis of most mental health problems, this artificial distinction between physical and mental ill-health has started to recede, slowly but surely.

   Mental Ill-health covers a very broad range of problems which can be approximately categorized into the following major classes: psychotic disorders (the prototypical illness being schizophrenia); mood disorders (unipolar depression and bi-polar disorder—previously known as manic-depression); anxiety disorders (e.g. phobias, panic disorder, obsessive compulsive disorder) ; substance abuse and dependence (includes cigarettes, alcohol, marijuana, heroin cocaine, amphetamines, ecstacy, GABA, LSD, etc); personality disorders (e.g. borderline personality); cognitive dysfunction (e.g. dementia); eating disorders (anorexia, bulimia); sleeping disorders (e.g. insomnia), sexual dysfunctions, somatoform and factitious disorders (conversion reactions, hypochondriasis, feigned illnesses) and dissociative disorders (amnesia, multiple personality disorder).

   While community level data for developing countries is very sparse, estimates of community prevalence in the US show the following figures (table 1). The accumulating evidence suggests that aside from substance abuse and dependence which is quite context related these community prevalences do not vary significantly from country to country. Just to get some idea of the scale of mental health problems in Bangladesh, it is worth noting that as per these prevalence data, and using a population figure of 140 million for Bangladesh, approximately 5 million people in Bangladesh are suffering from generalized anxiety, another 5 million from major depression, 2.4 million from obsessive compulsive disorder, 1.26 million from panic disorder, 1.4 million from schizophrenia, and 840,000 from Bipolar disorder or Manic depression. Estimates for substance abuse and dependence are hard to come by and vary by substance. For example, approx 50 per cent of Bangladeshi adult males smoke tobacco. This translates into roughly 16-18 million adult male smokers who are unable or unwilling to give up the habit despite well documented adverse health consequences. A variety of studies have suggested that the number of individuals using illicit drugs in Bangladesh (marijuana, codeine based cough syrup (Phensidyl), sedatives, heroin, buprenorphine in order of frequency) ranges from 100,000 to 1.7 million.

   How big a burden of disease do mental health problems constitute? Recent estimates (Weiss et al., Chapter 7 in International Public Health, eds. Merson, Black and Mills, 2000) using disability adjusted life years (DALY) lost show that mental health problems account for 12 per cent of the total burden of disease in the low and middle income countries. It is interesting to note that although compared to mental health problems, cardio-vascular disease has a much higher profile in public imagination the actual burden for mental health problems is higher (12 per cent) than that for cardiovascular disease (10 per cent). Of the total burden of mental health problems, unipolar depression accounts for 33.3 per cent; intentional self-injury (suicide attempts) accounts for 12.5 per cent; Bipolar disorder or Manic-Depression accounts for 9.2 per cent; psychotic disorders (7.5 per cent); obsessive-compulsive disorders (6.7 per cent); alcohol and drug dependence 6.7 per cent; panic disorders (3.3 per cent); Alzheimers and other dementias (3.3 per cent); Epilepsy (3.3 per cent); Posttraumatic Stress Disorder (0.8 per cent); other neuro-psychiatric disorders (13.3 per cent)

   The above figures are most likely a substantial underestimate of the true burden of mental health concerns. In addition to the specifically labelled diagnoses above, relationship centered conflicts (marital, parental, employer-employee; other relationship) often lead to significant mental distress (mild to moderate depression and anxiety) which are not categorized in the above diagnostic scheme.

   Despite the huge burden of mental health problems, professional help is almost impossible to come by in developing countries. As of 2002, there were approximately a total of 32,702 registered physicians in Bangladesh for a population of 132 million (or 1 physician for roughly 4043 individuals). This compares to roughly 1 physician for 409 individuals in the US and 1 physician for 2500 individuals in India. Recent anecdotal estimates suggest that there are a total of about 140 members of the Bangladesh Psychiatric Society (only about 50 have specialty qualifications in psychiatry training and less than 20 have internationally recognized qualifications). Even if we use the very generous figure of 140 psychiatrists in Bangladesh, this translates into 1 psychiatrist for every 1 million people. This is in comparison to 1 psychiatrist for roughly 7567 people in the US (37,000 psychiatrists for a population of approximately 280 million). Psychiatrists in Bangladesh constitute only about 0.4 per cent of practicing physicians. The comparable figure in the US is 5.4 per cent.

   Needless to say that a vast number of psychiatrists practice in Dhaka and in addition to psychiatrists who are licensed to prescribe medicine as well as provide counseling / therapy, there are a handful of clinical psychologists in Bangladesh (probably no more than 50 in total) who are trained to provide therapy/counseling, but not medicines.

   As a practicing psychiatrist educated and trained in the U.S. and coming back to practice in Bangladesh after almost thirty years, I am struck by how similar the mental health issues are in Dhaka to those I helped treat in Boston, while at Harvard Medical School.

   From the perspective of my own there is a very limited out-patient private practice in Bangladesh over the last two years and with an exclusively middle class clientele, the distribution of clients is approximately as follows: marital conflict (25 per cent); other relationship conflicts (20 per cent); bipolar disorder (22 per cent); psychotic disorders (5 per cent); substance abuse and dependence (3.85 per cent); panic disorder (3.85 per cent); obsessive compulsive disorder (2.56 per cent); generalized anxiety disorder (3.85 per cent); unipolar depression (2.5 per cent).

   After about two years of private practice in Dhaka, I have a few general observations with regards to both clients and mental health professionals in Bangladesh. I want at the outset to re-iterate that these are based on anecdotal observations and an analysis of my own practice and thus may not be completely generalizable.

   First of all, with regard to clients, not surprisingly there is great reluctance on the part of individuals to acknowledge that they have a mental health issue and that they may benefit from professional help. When they do seek help however, most clients cling to the belief that a short course of medication and or therapy is all that is needed to cure their problems. Realistically, however, the vast majority of mental health problems, similar to physical health problems are chronic and require long term (and often life long) pharmacological and or therapy interventions. As in the case of diabetes, hypertension, or heart disease, most mental health problems cannot be cured but can be controlled, provided clients take the appropriate medications needed every day, modify their lifestyle accordingly and follow-up with their mental health professional on a regular basis.

   I want to elaborate somewhat on the issue of marital conflict for a number of reasons. Although it is a major reason for clients to seek professional mental health services, it is distinct from other mental ill health categories in that it is not a specific diagnostic entity, it does not have any biological /physiological basis and requires almost exclusive therapy and counseling to address its fundamental roots. In the case of relationship conflicts in Bangladesh, there is a tendency to try to solve it within the family and only come to a therapist if everything else has failed. The problem with this approach is that private concerns of the couple become general knowledge within the extended family and this is often a cause of embarrassment and shame to one or both of the partners. Family interventions invariably involve some apportionment of blame and tend to be viewed as favoring one partner over the other.

   It is worth summarizing what the appropriate role of a therapist is as there seems to be very little understanding of this among the general population. A therapist is someone who is first and foremost neutral and non-partisan with regard to the two partners. Confidentiality is the sine qua non of the therapist client interaction. For the therapy to work the client must be free to talk about their innermost desires, fantasies, secrets without fear of public exposure. A therapist does not give advice—this is a major misconception of the role of the therapist. A therapist explores with the client, usually individually (but at times together as a couple) what the implications are of various behaviors and actions which may be contemplated by the client/s. He/she also explores with the client what the impact of various actions may be on children and other interested parties. At no point does the therapist suggest that the relationship should be maintained or not maintained. That decision is always one that the client has to make having thought through the implications of such actions. The role of a therapist is that of a facilitator and not a coach. This is often a source of great frustration to clients who seek specific advice –‘should I stay or should I leave’

   With regard to mental health professionals in Bangladesh, my sense is that with notable exceptions, many patient interactions with psychiatrists tend to be relatively brief and similar to other interactions with physicians in Bangladesh, i.e. very much centered on medication options, with little patient education and even less time devoted to counseling/therapy. Very often the patient is not told what diagnosis has been made and the basis for that diagnosis. There is a tendency to indulge in poly pharmacy with an often confusing array of medications prescribed—there seems to be a belief that if one medication is good several will be even better. Very rarely does the patient understand which medicine is for which symptom and how long they have to continue taking it. This lack of attention to patient education often leads to doctor shopping and arbitrary medication usage practices with adverse consequences for the progress of the client.

   Mental Health is too big and complex a landscape to fully describe and analyse in such a brief report. I have tried to touch upon a few salient features focussing on my private experience as a psychiatrist. I would like to conclude by making a plea to de-stigmatize mental health issues and remove them from the current veil of ignorance, suspicion, and denial. It would not be an exaggeration to state that all of us have friends or family members who suffer from mental health problems. This de-stigmatisation is not just an abstract concern but one that touches each and every one of us.