Feat and defeat in health

Md. Khairul Islam

Photo: Hemanta Nath/driknews

Bangladesh will celebrate its 40th year of independence shortly. For a history of a nation four decades is not a substantial time, yet the gains of four decades in different socio economic aspects will be assessed. In health, we may compare our status and achievements globally and regionally, especially with our neighbours, and reflect on the lessons learned. In this regard, this is a humble submission on the eve of such a great occasion and marking the 20th anniversary of The Daily Star.

As a nation - we have achieved a lot in health in the last four decades. We often speak about our progress and achievements in child health specifically in terms of immunization and use of ORT and corresponding reduction in diarrhoeal diseases. Our life expectancy at birth has increased substantially while fertility rate has declined with corresponding rise in use of family planning methods. Knowledge in HIV and AIDS has increased substantially amongst the young people. Medicine industry grew in Bangladesh spectacularly after the national drug policy 1982; now Bangladesh exports medicine. Private medical service and education has grown over the years which reduced medical trip abroad significantly. This is not an exhaustive list.

There is room to learn from our past experiences. The liberation war of 1971 had greatly influenced the health system. The simple make shift hospitals and people's participation challenged the traditional concept of medical service provision and human resources in health.

The concept of primary health care emerged in Bangladesh during and immediately after the liberation war; well ahead of the Alma Ata declaration by WHO in 1978. Several innovations followed in terms of saving lives since then. To name a few Bangladesh is directly associated with the invention of ORS, community based distribution system of family planning methods, satellite clinics to reach the unreachable, Directly Observed Treatment Short Course (DOTS) for TB, Community Led Total Sanitation (CLTS), keeping neonates warm and many other best practices in health. It is to be noted that most of these innovations, which were later scaled up globally, are low cost and dependent on front line community health workers.

In the recent past, garment industry in Bangladesh flourished capitalizing on the available cheap labour, especially by young women. However the sector which pioneered the utilization of women work force is Health; unlike the garment industries, it utilized the skills of the women retaining them in their own communities. Though not much has been achieved in promoting maternal health yet most of the investments in health, benefitted the poor especially women and children. About one-third of the population used to defecate in the open just about seven years ago. Now this has come down to less than 7%. The use of latrine has taken up even by the lowest income quintile group; remarkably higher than the Indian situation. Inequity still exists with gross under investment in the hard to reach areas like Chittagong Hill Tracts, haor areas, coastal islands and revering chars etc. Given the current poverty situation of the country, it is time we treat coastal belt with more urgency and importance, the way we did for the Monga affected areas in the past, especially in context of the impact of climate change.

Bangladesh should be further commended for its excellent coping capacity and management of epidemic during post disaster, emergencies and pandemics. Spectacular amongst them is the flood management in 1998. Two thirds of the country was inundated and Dhaka city was in its worst form; water remained stagnant for almost 2 months with merging of wastes from the sewerage and water lines. Yet, the episodes of water borne disease and related mortality were insignificant. The same phenomenon was repeated after cyclone Sidr and Aila; Containment of epidemics during Swine Flu and Bird flu was also remarkable. Despite limitations in resources, government institutes like the Institute of Epidemic and Disease Control and Research (IEDCR) did commendable work.

Photo: Jashim Salam/Driknews

The health service delivery system is quite extensive with necessary infrastructure at various levels. The addition of Community Clinics by the government will further help to extend the services to the communities. Huge number of workforce of different disciplines is engaged in these establishments. A typical WHO framework for health system would have 6 elements i.e. finance, workforce, commodities, governance, technology and information. We have only a few of these elements in place. Anyone can say that despite an ideal health infrastructural chain, our health system is not working well. There is no accountability; broader governance and local management are extremely weak. The system is centralized and highly politicized. Health and family welfare services are channelled through bifurcated systems leading to inefficiencies, poor economies of scales and increased confusion.

In the education sector the education policy was finalized first and then the sector program was designed. However in Health, sector wide health programs are designed for five years without finalizing the national health policy and strategy. The formulation of the health policy is progressing akin to “climbing a slippery bamboo”. Leadership in the health sector and quality of staffs in critical positions is visibly inadequate. Senior officials and policy makers in health need to learn from their counterparts in the Education sector

One of the most pragmatic and recent initiatives in health sector is the revitalization of community clinic. This grass root facility has the potential to be a community institution like the mosque, temple, school etc, and rise beyond the partisan politics. However the policy and procedures related to community clinic need to support the growth of such an indigenous institutions. The community clinic service provider will not report to the community group or to the Union Parishad or even to the Upazila Parishad rather report to a staff under Upazila Health and Family Welfare Officer and upwards to the central levels. This undermines the total concept of a 'community's clinic' in its real sense.

In establishing the community clinics communities donated the most precious investment i.e. the land. The members of the community clinic management groups, many of whom manage construction of mosques, schools or are involved in managing a disaster, could not be trusted by the Ministry of Health to manage simple repair and maintenance of the clinics. The Health Ministry feels more comfortable to float tender for regular repair and maintenance and pay 4-5 times more than the actual. The mindset of the officials who are designing operations of the community clinics needs to change and believe in local governance and the democratic process.

Our people have proved in 1971 and many more times that in the interest of the nation they can go beyond partisan politics and manage their institutions very well. All we need to do is to believe in our people's capacity and demonstrate it by entrusting responsibilities at local levels -the community clinics can be the starting point.

The writer is Public Health Professional and Country Representative, WaterAid Bangladesh