The constitution of Bangladesh clearly stipulates securing for its citizens “….the provision of the basic necessities of life, including food, clothing, shelter, education and medical care.” A clear concept of health care delivery systems in Bangladesh are discussed below:
Health care delivery systems
All governments have recognized the importance of improving health care provision in Bangladesh and have pledged to ensure that there is universal access to essential health of adequate quality for all its citizens.
Health care delivery systems in a developing country raise a number of important issues and debates:
- First, access to health care is a fundamental right in itself, as the constitution of Bangladesh recognizes. Therefore, as an end in itself, the government has to ensure that the quality of health care improves over time.
- Secondary, the health of a society’s citizens is critical for the performance of the economy and the capacity of the economy to computer internationally. Therefore, health care is also a means for achieving the broader development goals of the country.
The debates and policy discussions are about determining the priorities for allocating health care, given that in a relatively poor economy the resources available for health care are necessarily going to be limited.
It then becomes important to determine where to spend these resources and how to spend these resources most effectively to achieve the joint goals of universal health coverage as a constitutional right and the goal of improving health to move ahead in terms of economic development.
Who delivers health care?
The health care delivery systems in Bangladesh can be broadly divided into the public sector and private sector, and each has a number of tiers of delivery. This structure has been developing and changing over time, and revelry, the role of the private sector has increased with the rapid growth of private clinics and hospitals.
This has increased the quality of health delivery overall but has also meant that access to access to the private health sector.
In 2002, the total spending on health in Bangladesh was 3.1% of Bangladesh’s total GDP (gross domestic product). But public health spending was only 0.8% of GDP, the remaining 2.3% of GDP being accounted for by private health care provision.
Thus, public sector health spending was only about 25% of total spending on health. In addition, the total spent on health in small because of Bangladesh’s per capita GDP is not very high. In per capita terms, in 2002, Bangladesh spent only US$ 11 per head on health, which means that each individual in Bangladesh on average only had $11 to cover all their health needs.
The low level of health spending and the growing share of the private sector raises important questions about whether the emerging health sector in a country like Bangladesh can address the constitutionality of all its citizens to access health care.
We can also ask whether these developments are appropriate for ensuring a healthy workforce that can contribute to the rapid development of the economy. On the other hand, there is no doubt that the public sector was not well funded, that the quality of health care delivery was often poor.
Therefore, therewith of private hospitals and clinics had at least improved the health care of those who can any for these services.
Parallels to the development of the private sector clinics, there has also been a growth of NGOs (non-governmental organizations) providing health care to the poor. NGOs are classified as part of the private sector, but they are funded by international donors and local charities, and therefore have characteristics of the public sector.
But their coverage is still limited and their future depends on the continued availabilities of funding from these sources, primarily international donors.
Finally, we have to note that the public sector health care system in Bangladesh has had some notable successes particularly in expanding immunization and fighting diarrheal diseases and epidemic control and in family planning.
These areas are not suited for private sector development at all and here Bangladesh can be proud of relatively good public sector performance on which it has to build on in the future.
The public sector Upazila health complex and district hospitals
The public health sector in Bangladesh is based on a number of ties of health care delivery the lowest administrative tier in Bangladesh is the union which consists of around approximately 20 village the only health care available at the union level in Bangladesh consists of a number of health and family welfare centers for the provision of outpatient services.
In 2000, out of 4,484 unions in Bangladesh, 4,062 were covered by centers. Of these 4,062 centers, 2,700 were primarily concerned with the delivery of family planning services, and 1,362 were primarily rural dispensaries.
The focus of the governments’ health care delivery plan has been on the next administrative tier above the union. This is the Upazila, which consists on an average of 20 unions.
The government’s policy has been to implement a nationwide health program based on the provision of primary health care (PHC) services at the Upazila level. Successive governments have committed themselves to establish health complexes in every Upazila.
The aim of the Upazila Complex is to ensure that primary health care services are accessible to the entire rural population. But out of the 507 Upazilas in Bangladesh, by 2000 by only 374 has a completed health complex.
Each of these complexes is intended to provide specialized facilities for medicine, surgery, gynecology, anesthesia, and dentistry. In addition, they are supposed to have an adequate supply of essential drugs and vaccines.
For the vast majority of Bangladesh’s population, an Upazila Health Complex is their first point of contact with formal public sector primary health care. But with a very low level of public spending on health, the quality of services available in the Upazila Health Complexes is not very high.
The next tier of public sector health care is located at the Zila or district level wher4e each of Bangladeshis 64 Zilas can now provide modern hospitals with a bed capacity ranging from 50 to 200 patients. There is a government program to increase the bed capacity in many of these hospitals to 25 beds.
It is estimated that by 2000, there were 34,786 hospital beds in district hospitals, giving a bed-population ratio of approximately 1:3,450. The Zila hospitals are better equipped than the Upazila health complexes, and cases that are more serious are referred to this level.
In contrast to the primary health care system available in rural areas, there is very limited availability of public sector primary health care in the urban areas to service the urban poor. But urban areas also have big public hospitals where serious cases from rural areas are referred in addition to serious cases from urban areas.
The provision of primary health care in care in the urban areas is a gap that needs to be addressed, and the solution lies either in a partnership-based approach with NGO’s and the private sector or in the development of an urban network of public sector primary health care provision.
The big public hospitals in the cities, and particularly in the capital Dhaka, are the apex of the public health system and serve as teaching hospitals where the next generation of doctors is trained. Although the quality of equipment is often very poor, as is the supply of medicines, many of the best doctors in Bangladesh are still to be found in the big public teaching hospitals.
Involvement of NGOs in health service delivery
The role of the private sector in Bangladesh includes both the private health clinics and hospitals but also the NGOs who provide different types of health services mostly to the poor. The NGOs are not part of the state sector, but they are typically not operated on a profit basis and are not likely to charge market prices for the health services they provide.
They are financed by charities, usually international charities, and this sometimes means they can pay their staff more than the public sector, and have access to medicines and other requirements of delivering health services.
The NGO sector has grown in Bangladesh because of the limitation that the government has in raising taxes and making money available to the public sector. The lack of resources in the public sector has meant that access to health services for poor people has not been satisfactory in the past, and this has justified the entry of NGOs into the health sector.
Many international donors also prefer to provide money to NGOs rather than to the government because they believe that NGOs are more likely to deliver services to the poor than the public sector where there have been greater problems of corruption, inefficiency, and absence of good management.
However, the diversion of funds out of the public sector has further worsened the quality of personnel in the public sector as the NGO sector has become more attractive for many health services personnel. The problem is that in the long run, the NGOs cannot cover the whole country not can health care providers depend on the charity of international donors.
Unless Bangladesh can develop its own public sector health system based on taxes it can collect within Bangladesh, the provision of health care across the country will remain patchy and vulnerable to the changing funding decisions of international donors and charities.
It is estimated that there are around 130 NGOs operating in the health sector in Bangladesh. The NGOs in the health sector are involved mostly in delivering primary health care. In 1995, these NGOs collectively reached 25,298 villages and nearly 13.13 million beneficiaries. Given Bangladesh’s total population of around 120 million in 1995, the coverage of the NGOs remains relatively limited despite the attention they get in international circles.
The work of the Bangladesh Rural Advancement Committee (BRAC) highlights the nature of the interventions made by the NGOs. They started their interventions in health care in 1979, in collaboration with the International Centre for Diarrheal Disease Research Bangladesh (ICDDRB), to provide oral rehydration solutions (ORS) to prevent deaths from diarrhea.
The idea was to teach households to treat diarrhea with oral rehydration solutions that could easily be made up at home. These programs were very successful in reducing mortality and became internationally recognized as successful innovations in health care in developing countries.
BRAC subsequently got in government-supported immunization programs as part of their own Child Survival Program (CSP). These immunization programs reached over 30 million individuals by 1990.
An offshoot of CSP has been a primary health care program (PHCP), which is dedicated to health and nutrition education in the field of training of traditional birth attendants, teaching them the importance of sanitation, clean water, and family planning. From the mid-nineties onwards, BRAC has integrated its health program with its overall rural development and education programs.
Within their Women’s Health and Development Programme (WHDP) they have trained girls (aged 11-16) as health cadres to improve health and nutrition. WHDP has also intervened in maternal and antenatal care and set u training facilities for the government’s rural health administrators in health management.
Thus, well- funded and managed NGOs like BRAC and many others have played a positive role in improving the delivery of primary health care to the poor, but the overall health statistics in Bangladesh are still not satisfactory. The NGOs are too small to cover the entire country, and even well-funded ones like BRAC remain dependent on international funding.
Nevertheless, the NGOs have probably contributed to the significant advances that Bangladesh has made in reducing child mortality to below the South Asian average. In 2003, the infant mortality rate in Bangladesh was 48 per 1000 live births, compared to a South Asian average of 68, and a low-income country average of 82.
Role of the private sector in health
It is estimated that the private sector accounts for 75% of the total spending on health in Bangladesh. In recent years, there has been active encouragement by the state to promote private sector investment in health facilities.
The government has provided direct financial support to a number of such institutions including the Heart research Institute, the Institute of Clinical Health, and the Bangladesh Institute for Research in Diabetes, Endocrine, and Metabolic Disorders (BIRDEM).
The number of private hospitals and clinics, primarily in Dhaka and Chittagong, has been steadily increasing, particularly since the 1990s, to meet the demand for health services from people who are able to pay a market price for better health care, given the limited service provided by the public system. The private facilities target a rich client base and are often specialized in particular areas such as cardoon vascular diseases.
The private sector has also established a large number of small clinics and laboratories for testing and analysis. The standards in these clinics vary widely but they are usually run commercial lines with no public quality assurance or control.
The private provision of health services tends to target the middle class and the rich who can afford to pay relatively high prices. They cannot be seen as a solution to basic heath provision to the majority of the citizens.
However, they can cater to specific client groups, devote time and skills to specific diseases; and over time raise the standard and quality of research. There are already links with the public sector in that many doctors and staff in the private sector also work in the public sector.
This can lead to personnel not begin available in the public sector when they are needed, but it can also allow doctors to remain in the public sector where they may not have been prepared to continue working in the public sector without augmenting their salaries in the private clinics.
Disease control and ways of improving the quality of life
An importunate aspect of health care in developing countries in control of easily preventable diseases that would not be widely spread in advance counties. This is because in poor countries the health of the population in adversely affected by other factors such as poor nutrition, poor sanitation, poor hygiene, as well as health care failings such as poor immunization and treatment.
Thus, while improvements in immunization and treatment are critical, in other areas health care has to deal with problems that are not directly due to the health care systems but are due to other factors such as poor quality water and sanitation.
In these cases, the health care system has to respond by tackling problems such as diarrhea and malaria, which will remain recurrent because of these other factors.
The quality of life improvements in developing countries thus depends on the health care system that contributes to both disease control and related factors such as nutrition, water quality, and hygiene.
Control of diarrhoeal diseases (CDD)
Diarrheal diseases are a key factor in mortality (deaths) and morbidity (diseases) or children. Oral rehydration therapy (ORT) has been adopted as the main way of responding to the problem to reduce the number of deaths and the government has adopted a strategy that includes the following elements:
- Epidemiological surveillance to keep track of outbreaks of these diseases;
- Formation of emergency medical teams in times of floods, cyclones, and epidemics;
- Setting up temporary mobile hospitals to deal with epidemics;
- Targeted health education initiatives to teach people about oral rehydration, hygiene, and sanitation.
These programs have been successful because although there has not been a significant decline in morbidity due to diarrhea, mortality has gone down markedly.
The fact that morbidity has not improved in snot surprising given that diarrhea is caused by factors outside the control of the health care system, but the health care system has responded successfully by devising treatments that have significantly reduced the number of deaths.
Malaria control program (MCP)
Malaria is a major problem in countries like Bangladesh where large open water bodies are available for the breeding of mosquitoes. From the 1990s onwards, the number of malaria cases being detected in Bangladesh has rapidly increased, partly due to better detection systems.
The problem has also worsened because mosquitoes have become resistant to many conventional pesticides and the malaria parasite has become resistant to traditional medicines like quinine. The government’s strategy in an address in malaria has included the following activities:
- Intensive and regular insecticide spraying in high-risk areas;
- Continuous monitoring of the resistance to drugs: This information is valuable for international research on malaria drugs.
The long-term solution to malaria cannot, however, be found in these responses. Unless infrastructural improvements reduce the prevalence of stagnant water in which mosquitoes can breed, the health system is again controlling a health problem, not solving it.
Expanded immunization program (EIP)
Many diseases can only be controlled by early immunization. Immunization also has to cover most of the population in order to be successful. The government of Bangladesh, together with many NGOs has put a great deal of effort into immunization programs, which have steadily increased their coverage.
A countrywide program of immunization has been in operation since 1976. By 1990, 65% of children were within the program. By 1994, nearly 70% of 1-year old children had been immunized for polio and DPT (diphtheria, pertussis, and tetanus), and 74% had been immunized for measles. The government’s target is to attain a uniformly high level of immunization (90%), eliminate tetanus, and achieve a 95% reduction in measles mortality and a 90% reduction in measles morbidity.
Poor nutrition is indirectly a major cause of poor health, and a direct factor affecting the poor quality of life. Anemia, vitamin deficiency blindness, and protein every malnutrition in Bangladesh have been caused by poor nutrition amongst vulnerable sections of the population, in particular, low-income groups, young children, and women.
To overcome this massive problem, the government has recognized the importance of nutrition in its National Plan of Action for Nutrition adopted in 1997, which set a target to raise the per capita calorie intake to 2300 kilocalories per person by 2002.
This is the recommended calorie intake for an average person, but this target is difficult to achieve in a poor economy where many people are living below the poverty line.
In conclusion, we can say that health care delivery systems in Bangladesh are not problem-free but it developing day by day.
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