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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
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