The Constitution of the People’s Republic of Bangladesh has ensured that “Health is the basic right of every citizen of the Republic”.
Health is a basic requirement to improve the quality of life. The majority of the people being poor depend on government health structures for remedies from illness in rural Bangladesh.
Bangladesh has achieved much progress in the public health domain, but the rich and the politically blessed can extract major services from the public health system.
The issue of inequality in health is gradually spreading. The local government body in rural Bangladesh which is supposed to oversee basic health service has been colossally futile to ensure fair access of marginal people to basic health facilities.
Health Security is generally viewed as an important index of Human Development. The Constitution of the People’s Republic of Bangladesh ensured that “Health is the basic right of every citizen of the Republic” as health is fundamental to Human Development.
Health is a basic requirement to improve the quality of life. National economic and social development depends on the status of a country’s health facilities.
Although the private clinics are operated privately, many doctors of the public hospitals deliver services part-time in these clinics. In these clinics costs are high and they work on a fully commercial basis.
Over the past decade, Bangladesh has renewed its efforts to address large-scale incidents that have threatened human health, such as natural disasters, disease outbreaks, and terrorism.
The statistics mentioned underneath denotes the level of progress Bangladesh made in the health sector over the decades.
Major progress has been made in improving the Nation’s ability to address the public health and medical consequences of potential threats as evident from the state of the World Children’s 2015 report produced by UNICEF.
For example, states and localities have developed and exercised emergency response and recovery plans; laboratory capacity has increased; disaster communication systems have improved, and plans have been put in place to deliver medical countermeasures to communities if needed.
Numerous local responses to health incidents have improved as a result of these efforts. Nonetheless, many challenges remain.
Health security has been viewed as an essential part of human security, but policymakers and health professionals, however, do not share a common definition of health security.
The health system in Bangladesh is dominated by the public sector while the private sector i.e. local entrepreneurs, different NGOs and international organizations complement the GoB efforts.
On the top, the Ministry of Health and Family Welfare (MoHFW) is the leading organization for policy formulation, planning and enforcement from the top to down level.
Under the MoHFW, four Directorates Namely Directorate General of Health Services, Directorate General of Family Planning, Directorate of Nursing Services and Directorate General of Drug Administration are mandated to provide health services to the citizens of Bangladesh across the level.
With a realistic vision in mind, the government has been directing its endeavor with a policy of health safety and security to make sure that the provision of basic services to the entire population, particularly to the under-served population in rural areas is sustained.
Union Parishad is the lowest tier of the local government of Bangladesh that serves the interests of the local people.
The majority of the population of Bangladesh living in the rural area are confronted with various health security threats that jeopardize their basic need, to a great extent.
Union Parishad as the lowest tier of the local government is associated with several tasks related to health security for rural people.
Unfortunately, the ancient unit of the central government is confronted with complications on its way to ensure health security in rural Bangladesh.
Bangladesh as a developing country deserves credit for having an extensive health infrastructure throughout the country.
The country has six Administrative Divisions and 64 Districts while the Districts are divided into Upazilas (492) and Upazilas into Unions (4,554). Each Union consists of approximately 25,000 people and the Unions are usually sub-divided into nine villages.
While specialized hospitals are available at the divisional level, in some areas postgraduate hospitals exist and all Districts have various types of hospitals.
At the Upazila level, there are Upazila health complexes which are treated as the first referral centers for primary health care.
These have been established to take the health service delivery system including the primary health care system to the doorsteps of the rural poor.
Primary health care service is monitored through four-tier systems i.e. Upazila level, Union level, Ward level, and community level in order to make sure that, quality of health service is provided to the people.
The standard set up for health services in an Upazila consists of a health complex, Union Health & Family Welfare Center (UHFWC) at the Union level (4,554) and Community Clinics at village levels, although the Community Clinics established under the Health and Population Sector Program (HPSP), a donor-driven mega program initiated on a pilot basis from 1996-2000, are not functioning now.
Services at the Upazila level are divided into three units: the clinical services unit, support services unit and field services unit, all under the administration of Upazila Health and Family Planning Officer.
Each Union Health & Family Welfare Centre (UHFWC) has an available staff comprising: a Medical Assistant trained for three years in disease prevention, health education, and basic first aid, and a Family Welfare Visitor who receives 18 months of training in family planning, reproductive health, and postnatal and prenatal care.
These health centers offer general health services, and basic reproductive, maternal, and child health care services for local people free of cost. NGOs are also contributing to health services in the rural area.
At the village level, there are community clinics; satellite clinics as most peripheral level health services facilities aimed at ensuring minimum care of rural people.
Many NGOs have special reproductive health care programs and facilities for providing antenatal and safe delivery care.
There are also private physicians and numerous private clinics throughout the country even at District and Upazila.
Although the private clinics are operated privately, many doctors of the public hospitals deliver services part-time in these clinics. In these clinics costs are high and they work on a fully commercial basis.
Solvent people prefer private clinics for quality service, which they think is better than in public hospitals. The private clinics are beyond accountability and control of the government in terms of service rates and health risks.
Other than these, in recent years a number of international private hospitals have been established in Bangladesh, mostly in Dhaka, some through collaboration between multinational companies and local entrepreneurs.
These hospitals have meant that richer patients can receive treatment without going abroad, but treatment costs in these hospitals are so high that common people cannot afford them.
Many rural people prefer to consult with a palli chikitshak, a local village doctor without any formal training in health services.
Around 50 percent of rural women are not aware of the existence of Community Clinics in their areas (Community Perception.
In most cases, these clinics are used by the people living within a half-mile radius of the centers, and these government-run clinics are blamed for lack of quality care and attention to the patients.
The clinics are ill-managed and poorly staffed with manpower that lacks career prospects and motivation. On the other hand, although the bulk of the population of Bangladesh lives in rural areas, most doctors are based in cities and towns serving a meager number of populations.
The poor economic condition of the people living in rural areas and the scarcity of civil amenities in rural areas remain as challenges towards the promotion of the health security of rural people.
The purpose of local government is to ensure service delivery, but in the health sector, it is apparent that the management of health facilities is decentralized to the local level but there is the delegation of policy, finance, or administration which remains with the central government (Local Government Division.
Complete devolution of power to the local level may not have been practical in Bangladesh because of the risk of elite capture and weak capability of the Union Parishad in policy formulation, design and delivery of health services.
At the union and village level, health care services are delivered through both the Union sub-center (USC) and Union Health and family welfare center (UHFWC).
Pro-people primary healthcare service is not properly implemented within the well-knit rural health care infrastructure.
This is the smallest and most outer healthcare service unit having a sub-center that ensures out-patient services for injuries, wounds and ailments and with no diagnostic, surgical, or bed facilities.
These health centers offer first standing health care facilities through fifteen health and family planning personnel.
A USC is managed by one medical officer, one medical assistant, one pharmacist and other support staff while FWC is managed by one medical assistant, one family welfare visitor, one pharmacist and other support staff.
The field supervisory personnel of the health and family planning sector at the union level have mandatory provisions to attend the monthly meetings of the union council and discuss problems and issues relating to the delivery of health and family planning services.
At the village level, there are community clinics; satellite clinics as most peripheral level health services facilities aimed at ensuring minimum care of rural people.
The functions of standing committees in Union Parishad are crucial, important and significant to improve service delivery at the grassroots level.
Basically, Union Parishad is a service delivery organization, though its efficiency and capacity, is still debatable. For the sake of transparent and accountable and viable service delivery organs of the local government, Union Parishad should make its standing committee functional.
But the scenario of Union Parishad is not very friendly on the question of the effectiveness of standing committees.
Most of the Union Parishad made it for official purposes, but practically their implication is not seen anywhere.
As per the allocation of business, members of the Standing Committee on Health activate health officers to get the regular status of the EPI program, to know the sanitation behavior of the locality and source of safe drinking water.
The members of the standing committees also monitor regularly different Hospitals and Clinics. But in truth, the functional standing committee still ends.
The government has recruited 4000 MBBS physicians, these doctors already posted to the available health centers.
Unfortunately, the healthcare facilities in the rural and upazila area remain very much underutilized due to the absence and negligence of doctors and their private practice (service in the exchange of fee) at the place of their work during and after office hours, lack of referrals due to lack of proper communications or absence of an ambulance, inadequate supply of medicines or no supply at all and workout instruments and investigation facilities.
The rural poor have been more marginalized than the urban poor in getting access to health facilities. The impact of health security on human capital and socio-economic development is widely acknowledged.
As for some positive sectors we have made some advancement also on the clinical side. We have witnessed the installation of most modern and sophisticated diagnostic equipment, surgical gadgets and other advanced technologies at Upazila Health Complex.
We have a good number, though not enough for a population of 16.5 crores, of experienced and skilled manpower, advanced health service devices, and technologies, what we lack is an equal distribution of resources and unquestioned sincerity of the service providers.
Pro-people primary healthcare service is not properly implemented within the well-knit rural health care infrastructure.
Added to these infrastructures about 6000 community clinics were established during 1998-2001 under the HPSP program which has been rejuvenated during the HNPSP Program.
Each community clinic is meant to serve 6000 people’s clusters at the grass-root delivering primary healthcare and reproductive healthcare.
Manned by a health assistant, each community clinic started serving the people. However, subsequent govt. in 2002 stopped the functioning of the community clinics.
After the general election in 2008, the new government re-introduced community clinics under HNPSP and already established more than 13,000 community clinics and put them into service.
However, all these well-knit rural health service facilities remain highly underused due to lack of commitment and lack of proper utilization of the facilities, maintenance and proper management.
A large number of Bangladesh’s people, particularly in rural areas, remained with no or little access to health care facilities.
The lack of participation in health service is a problem that has many dimensions and complexities.
Education has a significant effect on participation in health services and administrative factors could play a significant role in increasing the people’s participation in Bangladesh’s health sector.
But the present health policy is not people-oriented. Like many developing countries, Bangladesh is also exposed to a plethora of economic reforms that result in widespread inequalities in society in terms of resource accumulation.
Bangladesh has achieved much progress in the public health domain, and the wealthy and political elites can extract major services from the public health system, while access to private healthcare is confined to the rich.
The issue of inequality in health is gradually spreading. Discrimination is categorized in terms of accessibility, affordability, gender, and geographical location.
The bottom-up policy planning system should be introduced in public policy formulation. Central monitoring and evaluation system be strengthened to make sure that, health facility is available for the rural people.
Bangladesh, being a poor country with scarce resources, cannot afford to provide sophisticated medical care to the entire population. Emphasis is therefore given to primary health care covering the unnerved and undeserved population with the minimum cost in the shortest time.
The rural poor have been more marginalized than the urban poor in getting access to health facilities. The impact of health security on human capital and socio-economic development is widely acknowledged.
Good health reduces the loss of working time work and increases school attendance for children. Health constitutes an important element in both the Human Development Index (HDI) and the Human Poverty Index (HPI).
Being healthy is a valuable achievement in itself, and can be of direct importance to a person’s effective freedom.
The burden of income erosion as the major outcome of poor health further affects the poor disproportionately.
Thus, broadly, better health reduces poverty and reduces poverty improves health. It is evident that nearly 90% of Bangladeshi children receive vitamin A supplements and over 80% are vaccinated, contributing to an impressive reduction in infant and child mortality by more than two-thirds since 1990.
Therefore, the importance of health can be interpreted in three broad dimensions: (1) intrinsic dimension, (2) instrumental dimension, and (3) empowerment dimension.
From an intrinsic point of view, improved health is a direct measure of human well-being and is an achievement in itself.
In the instrumental sense, better health is important because it has an economic rationale. Better health reduces medical costs, both of the government and the households.
In the case of children, better health leads to better attendance in school and higher levels of knowledge attainment.
Better education and knowledge lead to better-paid jobs and larger benefits for the future generation. For women and the poor, better health means empowerment because it also empowers them to participate in economic and public life.
Inequality in health in effect exacerbates inequalities and fragmentation of society between the rich and the poor.
Union Parishad is ineffective in ensuring the health security of the rural people because of the lack of commitment and vision of the elected officials particularly the Chairperson of the body prohibits the Union Parishad to provide necessary health services to the community.
Lack of Integrity and dishonesty of the elected representatives of Union Parishad is responsible for inadequate delivery of health service, Union Parishad is the failure to negotiate with the service delivery agencies of the government and unable to put a proper strategic plan in place to bring relevant stakeholders on a common platform to ensure health security.
Lack of resources/ skills and expertise of the UP leadership is considered as the prime factor for the failure of health service delivery; absence of integrity, initiatives, commitment, vision and close engagement of the UP leadership with government extension agencies are the key factors that undermine the spirit of health security in rural Bangladesh; the inadequate number of physicians, employees, and nurses; wrong treatment; negligence towards patients; non-attentiveness; absence from duty, lack of professional ethics, and unwillingness to stay at rural areas and small towns put the health security for rural people in danger; inadequate supply of medicine and ambulance; and moreover, inaccessibility of the poor people to the utilization of both public and private sector resources also remain as a barrier to attain health security in rural Bangladesh.
Besides these, lack of Integrity and dishonesty of the elected representatives of Union Parishad is responsible for inadequate delivery of health service, to some extent.
Education, awareness, and motivational strategies are important factors for ensuring people’s participation in health services and the success of different health programs.
Bangladesh requires a need-based, pro-poor and feasible program to guarantee health security, which will be formulated through a participatory approach with the active participation of the relevant stakeholders.
The bottom-up policy planning system should be introduced in public policy formulation. Central monitoring and evaluation system be strengthened to make sure that, health facility is available for the rural people.
The lowest tier of local government should be strengthened and given the responsibility to make rural health care service accessible for all.
Decentralization of service delivery is to be made probable through the establishment of satellite clinics and EPI for outreach and grass root level people.
Union Parishad to be empowered with delegated authority to take part in the local level planning of public health arrangement and better implementation of programs.
Strong partnership with development organizations has an essence. Community-Based Organizations (CBOs) may also, under the direct supervision of and joint collaboration with the Union Parishad, experimentally manage some rural health centers.
The NGOs working in the remotest areas of the country may also supplement the government institutions by extending health networks in those areas.
The extensive network of the NGOs can also provide aid to the local government to increase the consciousness regarding health, sanitation and family planning among the poor and rural people.
The government could direct its efforts in collaboration with Local Government/Union Parishad to impart proper training to the village doctors in rural areas on a regular basis so that they can ensure primary healthcare to the rural people.
Keep a provision for the arrangement of regular training for the doctors as well as the nurses and health technicians working in the public sector down to rural areas?
Community leaders, religious leaders and mass media can play an active role in increasing consciousness regarding healthcare services and the rights of people.
Social research is worthy to explore the health behavior of rural people and enable the policymakers across the level to formulate appropriate policies and programs for the promotion of health security.
Ensure people’s participation in health service is very noteworthy for the sake of formulating a balanced and apt health policy of Bangladesh.
Health services based on primary health services are to be made more viable in Bangladesh to improve the health status of the people, especially in rural areas where more than 70 percent of the people are living and are an underserved and underprivileged group.
Community-based health service providers in the rural health complex and other organizations are to be encouraged to invest more in the health security of the rural community.
Effective coordination between the standing committee and government officials would enable line agencies to harmonize their development activities in the light of aspirations of the community for health security.
Campaigns of government health programs, such as family planning, safe motherhood, expanded program of immunization, should be increased under the umbrella of Union Parishad in partnership with Community-Based Organizations, School students, Mass Media, and community people.
Education, awareness, and motivational strategies are important factors for ensuring people’s participation in health services and the success of different health programs.
The abilities and the deeds of health personnel working should be supportive of the rural people with the intention of improvement of the participation of the community in rural health service.
The Government should revise the current pay structure and improve the working conditions of rural doctors since public salary is not enough which resulted in the involvement of physicians in the private sector.
Corrupt practices and the unwillingness of some government doctors to stay at their posted place restrict the accessibility of the rural people to the health services, to great extent.
These doctors should be identified and punished in order to improve the efficiency of health services. Regular monitoring and supervision should be undertaken in the government health sector for ensuring access of rural people to the available health facilities.
Television programs, radio programs, open discussion and newspaper advertisements could complement this attempt.
Institutional capacity building of Union Parishad is essential to meet the demand of people in the area of health and other social services.
Provision should be made to provide UP with adequate logistic support like computers, internet accessibility and other office equipment.
Effective coordination between UP representatives and government officials both at Upazila level as well as at the field level has essence as to make sure about the better health services for rural people.
Field-based extension worker i.e. livestock, fisheries, agriculture, education, health and family planning is to work with and for the Ups would facilitate the promotion of health security.
An open budget is an innovative initiative to ensure transparency as well as to also recognize the aspirations and needs of the community.
Thus, the practice of open Budget is to be made operational enabling UP to address the health security related constraints.
‘Citizen Charter’ to be disseminated among the people to learn about the social services of UP and hence, NGOs and civil society bodies should undertake awareness programs.
According to the rule, every UP must form 13 Standing Committees (SC) concerning different areas of its operational and developmental activities.
But in most cases, such SCs are formed as “ceremonial” than as a compulsion. Activation of SCs could significantly enhance the service delivery of UP in health security.
The SC could direct its efforts towards quality control, supervision and monitoring of the health services.
Effective coordination between the standing committee and government officials would enable line agencies to harmonize their development activities in the light of aspirations of the community for health security.
By discovering the windows of openings, UP could mobilize resource mobilization to deliver good services in the area of health.
To seek and generate funds from non-conventional sources UP could make the best use of GOB policy priority on PPP (Public-Private Partnership. Union Tag officers must be made active to undertake proper monitoring of health service delivered.
‘Citizen Charter’ to be disseminated among the people to learn about the social services of UP and hence, NGOs and civil society bodies should undertake awareness programs.
NGOs and CBOs must be encouraged for their participation in undertaking ‘social audit’ of the performance of the UP in the area of health sector adhering to the policy decision of the government.
Institutionalization of the relationship between the Union Parishad and government agencies, NGOs, CSOs and the private sector is to be formalized by adopting a policy to cover the community with a facility of health security.
The government of Bangladesh has adopted National Health Policy in 2011.
This is a strategic directive and indicator of the mechanism of exploiting available resources to realize the Government’s vision for addressing the health issue of the country. Enforcement has the essence to promote health security across the level.
(Dr. Mohammad Tarikul Islam is an Associate Professor of the Department of Government and Politics at Jahangirnagar University in Bangladesh. He is the Visiting Scholar of Oxford and Cambridge. Before joining the university, Dr. Islam was serving the United Nations for seven years)
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