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     Volume 8 Issue 53 | January 16, 2009 |

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Cover Story

Getting Back Our Health

The Ailing Area of Public Health

Ershad Kamol

Photos: Zahedul I Khan

'Healthcare for All' has been the catchphrase for many developing countries of the world, including Bangladesh. According to Article 15 and 18 (1) of the Constitution of Bangladesh access to healthcare is ensured for every citizen of the country. In 1978 Bangladesh became a signatory to the Alma-Ata Declaration. But even after over three decades of such lofty declarations Bangladesh is far from being a nation that provides access to healthcare to all its people. True, in the last 37 years of our Independence there have been significant sccesses in basic health indicators: fewer mothers and babies are dying, more children are being immunised, birthrates have gone down to a certain extent, life expectancy has increased and there has been partial success in sanitation. With the majority of the population being poor, underfed and undernourished and an inefficient, inaccessible public health care system, health, or rather the threat to it, has become the biggest obstacle to development. Access to healthcare, especially primary healthcare, seems to be the first and most important step towards achieving the 'Health for All' goal.

Only 40 percent of the population have access to health services provided by the government and private organisations as well as development agencies.

It is not as if we never had any National Health policy. Three consecutive governments promulgated drafts of the National Health Policy in 2000, 2006 and in 2008. But health has never been given the importance in the national budget as it deserves. The government has spent around only US$ 4 per person per year, while the proposed National Health Policy 2000 set the requirement of minimum US$ 12 per person. According to the World Health Organisation (WHO), however, the ideal figure is a minimum of US$ 34 per person per year in this field. This year's proposed budget for the health sector had an allocation of only approximately 6,000 crore taka including salaries and development works. Inefficiency in health governance, corruption, misuse, lack of transparency, incompetence in fund management, partisan policy and favouritism result in funds not being allocated properly.

So far we have not yet seen a parliament-approved National Health Policy, one of the top pledges in the manifesto of the current Awami League led Grand Alliance. Meanwhile health statistics are quite staggering. Only 40 percent of the population have access to health services provided by the government and private organisations as well as development agencies, 25percent of the dying do not get the opportunity to see a doctor before death, 70 percent of pregnant women are deprived of getting pre-natal check-up, 70 percent of women suffer from anaemia, most of the Union health centres do not have doctors, nurses or medicines, Upazila hospitals responsible for providing health services to an average of 2 lakh people get only 2-3 lakh taka per year that means one taka per person.
One of the biggest flaws in government strategy has been the lack of a holistic approach towards the health sector. During its tenure in 1996 to 2001, the Awami League government installed about 13,000 health centres for root level people. But succeeding governments came up with their own ideas and scrapped the earlier programme making a new draft for the health policy. Subsequently, the immediate-past caretaker government promulgated a new draft encouraging the private sector in national health policy. There are many noble objectives stated in the draft of the proposed Health Policy 2008, but it is still not comprehensive enough. In fact, all of the three drafts of the health policies - in 2000, in 2006 and in 2008 - have their limitations.

Following prescriptions of the World Bank, Asian Development Bank (ADB) and other development partners, the government has spent nearly 30,000 crore taka to get the Health and Population Sector Programme (HPSP) and Health, Nutrition and Population Sector Programme (HNPSP) going in the last one decade, yet no major change has been noted in the health sector crisis. The philosophy behind both programmes is to conform to the principles of a free market economy where the 'patient' is now a 'consumer', 'doctor' the 'service provider' and 'treatment' is a consumable 'good'.

Most Thana Health Complexes are dogged by manpower crisis.

“These programmes are nothing but a waste of money," says Professor M Iqbal Arslan of Bangabandhu Sheikh Mujib Medical University (BSMMU). "Only a few persons have been benefited: a few went for training abroad and a few could do business in the name of medicare. In fact, such programmes have no success anywhere in the world, let alone in Bangladesh. For true development of the health sector in the country we have to take programmes considering the socio-economic structure of the country."

Arslan proposes that the first step is to complete the construction of proposed health centres, one centre for 6,000 people, something the last Awami League government initiated in 2000. "The ongoing health centres work at outdoor dispensaries only," he says. "These centres must provide primary health service by registered doctors as well as free medicine. In fact, a total package for primary health service should be provided by the government through these health centres. When only critical patients approach these centres, the doctors can refer them to specialised and tertiary level hospitals, which will also decrease the extra pressure on these specialised hospitals."

The common complaints against doctors working in our public hospitals include that they are not aware of the patient's rights and are apathetic to their jobs, there are allegations of negligence, absence in the workplaces, misbehaving with patients, utter disregard for accountability, a tendency to ask for 'commission' and general corruption. The laws related to public health laws lack the necessary reforms to make them more appropriate for present needs which, are not implemented properly.

Professor M Iqbal Arslan
Professor Rashid-e-Mahbub

Doctors also have to be oriented about patient rights and this is a vital component missing from medical education and training. According to Professor Arslan the curriculum of the medical graduates must be upgraded. He says, “Doctors, nurses and other health workers do not care for the patient's rights as our medical curricula does not give adequate information or motivation on human rights and health rights. They are not trained in managerial work, though often they have to take such responsibilities at their workplace. At the same time the medical graduates must be motivated about their job and social responsibilities. Continuous mass campaigns can also be made on these issues among the patients, citizens and health professioanls; and every health centre must have a complaint box to receive the complaints and opinions of the people on the health services.”

Infrastructurally also, the existing health centres are flawed: buildings are dilapidated and ill-maintained, face insufficient water-electricity supply and are notorious for low standard indoor-hygiene-toilet, food, pathology and x-ray facilities. These centres work as only outdoor dispensaries where the doctors from Upazila Health Centres visit the patients only a few days of the week. Most hospitals at the Upazila level do not have ambulances, and if they do, they are usually out of order, or if they are in workable condition patients cannot avail them. Around 60 percent of the posts for doctors remain vacant or the doctors are absent in the workplaces. Everyday, on an average, about 200 patients stand for outdoor services in every hospital, but beds remain empty since the people are not confident about the treatment of these hospitals. On the other hand, the tertiary and specialised hospitals, including the medical college hospitals are overflowing with patients. For people from low and middle-income groups, the government hospitals are the only place to get healthcare. While millions of people in this country do not see a doctor when needed, thousands of unemployed young doctors are living in frustration and switch to other professions. This is because we have not been able to properly utilise this skilled workforce depriving people of the basic right to healthcare.

Patients get free medicine at an Upazilla Health Complex in Jingira.
This should be the case all over the country.

Professor Rashid-e-Mahbub, president of National Committee for Health Rights Movement (NCHRM) and former president of Bangladesh Medical Association (BMA), has suggestions about how to solve the ongoing problems. In June 2007, NCHRM presented Dhaka Declaration. Professor Mahbub believes that proper job management of doctors - at present there are about 40,000- can significantly improve the sector. But the healthcare sector is in crying need of more nurses; the number of nurses is only about 9000. “Each year over 4000 fresh physicians are registered from 17 public and 36 private medical colleges in the country. So the number of doctors is not a problem, only the management. The government should also realise why the doctors are reluctant to stay at the workstations in remote areas.”

He says that the health centres must be run under local governments. ”The doctors, nurses and services should be under jurisdiction of Union Parishad so that people can complain if they are not satisfied with the primary healthcare service. The newly appointed doctors must be provided with salaries and other facilities at root level health centres. There may be a separate recruitment body for these centres, which will also monitor and evaluate their professional responsibilities,” he says.

For the urban areas these types of centres must be under jurisdiction of Municipal and City Corporation, says Mahbub. For over 1.5 crore people in Dhaka there should be many city corporation-run hospitals as well as community health centres providing primary health packages. Even physicians of alternative medicines such as Homeopathy,

Everyday, on an average, about 200 patients stand for outdoor services in every hospital, but beds remain empty since the people are not confident about the treatment of these hospitals.

Ayurvedic and Unani can be incorporated into this programme. The paramedics may assist these doctors. This will provide jobs for unemployed medical graduates, decrease extra pressure on specialised hospitals and improve the health sectors in general, says Mahbub.

According to Professor Mahbub immediate steps should also be taken to break the deadlock in the Bangladesh Medical and Dental Council (BMDC) to ensure the organisation more funding, democracy, promotion to make it more representative and free from bureaucratic management. “BMDC, which is responsible for ensuring medical ethics, is stymied due to the prevailing system which nominates members, majority of whom do not actually represent the profession. Lack of funds, democratic systems and predominant bureaucratic control, internal conflict and judicial verdicts relating to these conflicts have made the council ineffective. At the same time Bangladesh Medical Association (BMA) instead of serving the interest of political parties should function properly as per its mandate," observes former BMA president professor Mahbub.

“Purchase of medicine in the health sector is riddled with corruption. Instead of purchasing drugs through the Central Medical Store, the government should distribute funds to the hospital management for the crevice of public health. Corruption in health ministry and Health and Family Planning Department must also be controlled through strong monitoring,” he adds.

With the public health sector failing to meet the demand for primary healthcare, many NGOs have tried to make up for the void.

Appreciating the NGO activities, Professor Mahbub says, “They are doing well especially in maternity and family planning sectors. But, they should have separate bodies for primary health sectors instead of operating satellite clinics at the urban areas using government infrastructure. NGOs may operate primary health services in the places where communication is really difficult such as Chittagong Hill Tracts, haor and char areas.”

Upazila Health Complexes also have dental care units.
A waiting room in a health centre near Dhaka.

NGOs can also play an effective role in awareness programmes in schools, brothels and garment factories on how to prevent and treat infectious diseases such as HIV/AIDS, malaria, dengue, bird flu, water-borne diseases and so on.

The good news is that Bangladesh has actually made major strides in the areas childcare. The mortality index of children particularly under five mortality, infant and neo-natal mortality has come down dramatically. At present the under five, infant and neo-natal mortality rates are 65, 52 and 36 per 1000 live births respectively. In early 1980s when the mortality rate for under five children was 173 per 1000. Maternal mortality rate is 3.2 per thousand. The success has been achieved because of successful implementation of Integrated Management of Childhood Illness (IMCI), successful implementation of Expended Programme of Immunisation (EPI) to prevent infectious diseases good preventive management of diarrhoeal diseases with ORS and others, de-worming, vitamin A supplementation and improvement in exclusive breast feeding and appropriate complementary feeding. A good number of trained health workers are now working at the Upazila Health Complexes.

Child specialist Professor M Abid Hossain Mollah says, “Under government initiatives we have successfully created skilled manpower in this sector. In fact, it's a very good example of private-public partnership incorporating the donor agencies. Almost all of the Upazila Health Complexes these days have skilled man power for vaccination and to educate people on nutrition both for mother and child.”

“When all of the Upazila Health Centres will provide such facilities by the skilled manpower the scenario will improve more. If the programmes continue at the current momentum the mortality rate for under five, infant and neo-natal children expected to be 52, 36 and 21 per thousand by the year 2015. I believe we will be able to achieve the millennium development goal by that year,” hopes Professor Mollah.

The country's private health system is still at the infant stage in terms of the number and quality of services. Many clinics are unauthorised and do not maintain even the minimum standards. Still, none of the private clinics could qualify as a full-fledged hospital. Some expensive hospitals with well-arranged and advanced equipment are far away from the reach of even the middle classes, let alone the general people. Incidences of complicated diseases are on the rise, but we lack quality treatment to curb the rate.

Dr. Shakeel Akhtar, one of the members who worked on the Dhaka Declaration and also teaches at a private medical college, says, “It can't be said that the quality of the private medical colleges and even most of the public medical colleges is up to the mark in the country. The standards of both private and public medical colleges need to be improved.

“A few of the highly expensive private medical hospitals provide quality treatment by the specialised local and foreign physicians. But it can't be said that they are more qualified than the experts working in the public hospitals. In fact, proper monitoring should be carried out all the year round to ensure quality treatment from these private hospitals.”

Pharmaceutical experts, moreover, demand monitoring and quality control at the diagnostic centres. Most of these centres are highly expensive but do not have any consultant or trained technicians. Which is why, test result from one diagnostic centre to another one varies.

Professor M Abid Hossain Mollah
Dr. Shakeel Akhtar
Professor ABM Faroque

Acrucial hurdle to be crossed is making available medicine at affordable costs. In 1992 the government signed the Trade Related Aspects of Intellectual Property Rights (TRIPS), an international agreement administered by the World Trade Organisation (WTO). This together with the faulty National Drug Policy 2005 has paved the way for local and international profiteers to patent medicines, the growth of a flourishing and export-oriented pharmaceutical industry of the country has been restricted. This will make medicines and health services expensive by the year 2015 predicts Professor ABM Farooque, a teacher of Department of Pharmaceuticals technology of Dhaka University. “The government without analysing or bargaining signed the (TRIPS). Without ensuring national interest such an agreement will increase the price of drugs beyond the reach of even the financially solvent people and will damage our grooming pharmaceuticals industry.”

“Till 2015 we are allowed to produce only essential medicines for public health in generic names without using the patent names. What will happen after 2015? Are we prepared? In fact, the current government should consider the issue giving top priority,” he adds.

While state-run health centres near cities are better run, it is a different scene in the rural areas.

Professor Faooque suggests bargaining with the international agencies to extend the tenure of producing medicines using generic names. At the same time he explains, the government should invite investment for producing raw materials for making medicines in the country. In this way, the price of raw materials for drugs will be reduced. The government should never encourage any more multinational companies to produce drugs in the country for the welfare of our pharmaceuticals industry, which is exporting drugs abroad. Immediately a new drug policy should be announced in favour of the public and our pharmaceutical industry. Moreover, the government should declare a new list of the essential drugs and set up a mechanism to keep the list updated and items be available in all health care centers. Care should also be taken by the government to keep the prices of the medicines in control and fix them according to their production costs. Necessary steps should also be taken to train the medicine sellers on the minimum sense of marketing and to control, strictly, the sales of expired and fake medicines.

Professor Farooque also suggests ensuring accountability of the doctors, producers and seller of the medicines of alternative health services like Homeopathy, Ayurvedic, Unani, Herbal medicine and Acupuncture, to ensure scientific standardisation and updating of these kinds of medicine as well as strictly banning the services of quacks.

But it is not just healthcare that needs to be rejuvenated and made accessible for the people. The environment that we live in must also be conducive to good health.

Around 60 percent of posts for doctors remain vacant or the doctors are absent from their stations.

Environmental pollution, lack of pure drinking water and poisonous and polluted food need to be controlled for the interest of public health. The level of 'arsenic', a harmful chemical component, is increasing in the surface water, resulting in two lakh cancer affected people in the country. Moreover, every year, a large proportion of our population is affected by a high rate of water and air-borne infectious and non-infectious diseases caused by environmental pollution. Safe and non-contaminated foods and drinks, good nutrition, fresh air, proper disposal and management of general and hospital waste, effective drainage system, preventing industrial pollution are all part of public health.

“We do not have sufficient mechanism to control industrial waste management, hospital waste management, sanitation management and environmental pollution to create a healthy atmosphere for public health," says Professor Farooque. "Controlling this pollution and by ensuring nutritious food, the public health sector will significantly improve. To monitor food and drug standards of the country an independent body like Food and Drug Administration can be formulated including the experts.”

Awami League in its manifesto has pledged to ensure health rights for all through proper implementation of the national health policy. The newly appointed Health Minister recently visiting Dhaka Medical College Hospital focused on a few programmes that the government is going to implement for the development of the sector despite fund constraints. It is expected that the government will form a holistic health policy after proper research and by taking into account the opinions of experts rather than blindly following donor prescriptions. Ongoing irregularities in the health sector have to be improved. In addition the government has to initiate programmes to increase the number of trained nurses who can work at home and abroad. In fact, there is scope to export trained nurses in many developed countries. Any health policy must aim to develop a skilled and friendly medical workforce. At the same time the government should modify the National Drug Policy and make a new list for essential drugs make available good quality and safe medicines at affordable prices to people of all levels.


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