Health System in Bangladesh

 

 

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. In short, it is the infrastructure through which the desired services to the intended population are delivered. Home care of a sick baby, health care in private sectors, behavior change programmes, vector-control campaigns, health insurance and financing are all integral part of the system. It includes inter-sectoral actions through comprehensive approach to ensure family, community and country health. Health service delivery, workforce, information, products, financing and stewardship are the six building blocks for strengthening of the health system in a country. Current status and future challenges of the system in Bangladesh can be conceptualized within the gamut of the six building blocks.

 

Health Service Delivery

Since independence, Bangladesh has made significant progress in health outcomes. The country has made important gains in providing primary health care and most of the health indicators show steady gains and the health status of the population has improved. Health services are provided both through public and private sectors. The public sector is largely used for out-patient, in-patient and preventive care, while the private sector is used largely for outpatient and in-patient curative care. The Ministry of Health and Family Welfare (MoHFW) is responsible for planning and management of curative preventive as well as promotive health services to the population of the country. But in urban areas, delivery of health services including Primary PHC services is mandated to the Ministry of Local Government, Rural Development and Cooperatives (MoLGRD&C).

 

For improving effectiveness of the public sector interventions and for providing services responsive to the needs and demands of the population, the Government of Bangladesh, since 1998, has been pursuing a sector-wide approach (SWAp). The initial Health and Population Sector Programme (HPSP) of he period 1998 – 2003 was replaced later by Health, Nutrition and Population Sector Programme (HNPSP) in 2003- 2010. The MOHFW designed the Program Implementation Plan (PIP) for HNPSP which covers 38 Operational Plans (OP) to be implemented by 38 Line Directors.

 

The present government has taken steps to revitalize PHC services by making the community clinics operational. These community clinics, one for every 6000 rural populations, were constructed in 2000-2001; but were not used for service delivery during the previous governments. These service points have some unique characteristics. They are managed by a Community Clinic Management Group which includes local public leaders and representatives. The policy in this regard is to place the responsibility for the health of the people in the hands of the people themselves. A quick assessment of the community clinics, supported by WHO in 2009, showed that with the expansion of the health-care facilities to the peripheral level the distribution of health-care inputs and their utilization became more equitable and the utilization rate of these facilities was almost universal.

 

Functional community clinics with adequate staff, supplies and logistics along with strengthened union and upazila level services is required to be rapidly institutionalized to  improve the delivery of preventive and curative services at the PHC level, particularly for vulnerable women, children and marginalized population.

 

In the public sector, Upazila health complexes, and district hospitals, are providing curative care at primary and secondary levels respectively. Tertiary- level curative care is mostly provided at national and divisional levels through large hospitals affiliated with medical teaching institutions. While curative, preventive, promotive and rehabilitative services are rendered by public sector facilities and institutions, the private sector facilities, now gradually taking a big share of services at all levels, are mostly providing for-profit curative services.

 

In spite of availability of all those services at different levels, utilization of the services by the population is comparatively low. Improvement of the access of the population to quality services and increase responsiveness of the service delivery system to the needs and demands of the population is a difficult challenge to be addressed by the government.

 

Health Workforce

Bangladesh has managed to develop nation wide network of medical colleges, nursing and paramedical institutes. There are 59 Medical colleges (41 of them are private), 13 nursing colleges (7 of them are private), 69 nursing institute (22 of them are private), 17 medical assistant training schools (10 of them are private), and 16 institute of health technology (13 of them are private). In spite of this growth to health workforce production, the country is still having health workforce shortage and geographical imbalances. The World Health Report 2006 identified Bangladesh among 57 countries with a serious shortage of doctors, paramedics, nurses and midwives.

 

The nurse–doctor and medical technologist–doctor ratios are among the poorest in the world. While the majority of people live in rural areas, the majority of health professionals work in urban areas. Vacancy rates in government health services in remote upazilas are much higher than those near major cities. Different assessments have highlighted major quality gaps in the teaching–learning process and facilities in health workforce educational institutes.

 

The rapid growth of the private sector in medical education necessitates a more stringent regulatory function to be performed by the government. There is also a growing recognition of the need for regulatory bodies for health professionals that can work more closely with the related government agencies to ensure the quality of health workforce education and practices as well as accountability of educational institutions and health professionals to the public.

 

Health Information

Present government has taken significant initiatives for improvement of the MIS at all levels for enabling the system to deliver timely reliable information to the planners, managers and professionals of the health sector for evidence-based decision making.

Regular and timely publication of health bulletin, modernization of the data collection and storage system, publication of health information system (MIS), assessment report using Health Metric Network HMN) assessment tools are few examples of recent initiatives of the government to improve Health Information System (HIS) in the country.

 

But much is needed to be done to make the system to provide reliable and timely quality information for planning and management of health programmes. Currently three MIS, viz. health, family planning and nutrition are functioning separately with very little coordination between them. Large programmes such as, malaria and tuberculosis have its own vertical information system. All city corporations and municipalities, being under the Ministry of Local Government, are also maintaining separate system for collection of health related information in their areas.  Effective coordination between different units and agencies engaged in generation of information needs further attention to make the system comprehensive, effectively managed and more reliable. Moreover, capacity of the MIS staff working at different levels to collect, store,analyze and disseminate information is also a major area to be addressed. Recently published HIS assessment report clearly indicates the weaknesses in data management and resources for health MIS.

 

Medical Products, vaccines and technologies

Enhancing access of the common people to essential quality medicines has been one of the priorities of the government. With support from the government a big pharmaceutical industry is there to to manufacture drugs for the local consumption as well for exporting in other countries of the world.Currently, the local production meets about 97% of the overall local demand for drugs and 100% of that for the essential drugs. The internal market (private sector) for pharmaceutical products is worth annually approximately US$ 740 million. In addition, Bangladesh exported to 76 countries in 2009 amounted to approximately USD 49 million, demonstrating value in cost and quality of the products manufactured in Bangladesh.

 

Considering the global and local development in the sector over the last two decades, the Ministry of Health & Family Welfare updated the National Drug Policy (NDP) in 2005. Repeated assessments have been conducted to improve the capacity of the Directorate-General of Drug Administration (DGDA), to effectively function as National Regulatory Authority (NRA).Moreover, there is limited effort to promote rational use of allopathic and effective use of traditional medicines. There is no responsible official body for organizing a national programme to promote rational use of drugs.

  

Currently there is no vaccine production in the private sector in Bangladesh; however, with GOB encouragement and with its own initiative, the private sector has already made substantial investment in developing vaccine production infrastructure. The missing component that will ensure the production of WHO pre-qualified vaccines and to ensure the production of quality drugs in the country is to have the functional National Regulatory Authority (NRA) with support of National Control Laboratory (NCL) as per WHO recommended standards. Implemention of Institutional Development Plan for NRA and NCL are needed to be immediately taken up as per recommendation of WHO.

 

Health Financing

In Bangladesh, about 3% of GDP is spent on health, out of which the government contribution is about 1.1%. In term of dollar, the total health expenditure in the country is about US$ 12 per capita per anum, of which the public health expenditure is only around US$ 4 only.

 

In Bangladesh, historically, supply-side financing of health care services has been the backbone strategy for improving the access of poor households to essential health care services. A bulk of health care financing here is coming from out-of-pocket  that indicates people are willing to pay for better care. More than two-thirds of the total expenditure on health is privately financed, through out-of-pocket payments. Of the remaining one-third (public financing), about 60% is financed by the Government out of tax revenues, development outlays,  and the remaining  40% through international development assistance. An implication for this out-of-pocket payment for the population in the lower quintile is that they are forced to pay for health care when their ability to pay is at the lowest limit.

 

Community financing mechanisms and risk-pooling systems are nearly non-existent except in small pockets of NGO innovation. A few NGOs have started a health insurance component within their package of micro-credit programmes.

 

Bangladesh has now acquired experiences in implementing activities under demand-side financing mechanism through piloting maternal health voucher scheme in 33 upazilas of the country. After only two years of operation of the pilot, a case-control evaluation concluded that the scheme had an unprecedented impact on access equity and utilization of maternal health services. The cost-effective evidences generated by the evaluation can form the basis for scale-up of the current initiative and extension of the mechanism in other areas during the next health sector programme.

 

Health Stewardship 

Presently, number of steps has been taken by the government to improve its leadership and regulatory role to  improve equity and quality of services, especially to reach the poor and the disadvantaged. Initiatives for development of new health policy, revitalization of primary health care by making all community clinics functional with required human resource, supplies and logistics, recruitment and appropriate deployment of human resource for health and gradual extension of e-health services to the rural areas are some of the examples for health development in the country.

 

In spite of recent improvement, further steps are needed to be taken immediately for making the services responsive to the needs and demands of the population.  Governance of the system is still considered to be weak for providing equitable services. Strengthening the regulatory mechanism, especially over the for-profit private sector, is a demand to be full-filled as soon as possible.  Considering the availability of functional local government system, further decentralization of authority and responsibility with proper accountability at all levels is required to be institutionalized.

 

For more information please visit the following webpage:

*      Ministry of Health and Family Welfare

*      Directorate General of Health Services