New direction in health care

Mahbuba Zannat

Photo: Amirul Rajiv

The advancement in country's health sector since the last 40 years though not insignificant, leaves much to be done in the public and private health sectors including preventive care, ethical medical practice and making healthcare accessible for all.

It is said that 51 percent of the people in the country are still out of the health service coverage. Low quality and expensive treatment and absence of the health care centers hinder their access to health care services.

The people living in char and hilly areas are still suffering much though the country has a superb health structure from the union to the tertiary level. For lack of proper government planning, monitoring system and accountability, very few health care providers actually go to the villages and remote areas to ensure health rights of these people.

However, the sector at least can be applauded for success in Expanded Programme on Immunization and the declining trend in infectious diseases. The population growth rate, maternal mortality and infant mortality rate has been reduced much compared to 40 years ago.

To improve the health care system at the grassroots level, the government also started setting up community clinics equipped with primary health service mechanisms ten years ago. 13,500 community clinics have been providing primary health care including antenatal and postnatal care for every 6,000 people in a community.

The fertility level shows a declining trend. It has halved in the last twenty years, showing the total fertility rate as 2.7, which was 4.3 in 1989-91 and 6.3 during 1971-75.

Use of modern contraceptive over the past three decades have increased tenfold, from 5 to 48 percent, according to the last Bangladesh Demographic and Health Survey (BDHS).

Unmet family planning need now is 23 percent, which was only 11 percent 6 years back meaning people are becoming more aware of family planning that has direct impact on women's health.

According to the USAID, twenty years ago many experts claimed that the nation's conservative culture and low standard of living would be insurmountable obstacles to family planning and child survival programmes in Bangladesh. However, over the past three decades, health indicators have improved dramatically.

Bangladesh ranks 129 amongst 169 countries from the health side, says the UNDP Human Development Report of 2010.

Eighty two percent of the children aged between 12 and 23 months are fully immunised. Supplementary feeding of children, who are also breastfed, has greatly increased during this period. Vitamin A supplementation among children 9-59 months reached 88 percent resulting in significant decline of night blindness.

But still, 85 percent of births have been taking place at homes and many with the untrained birth attendants, which is dangerous. Reducing neonatal mortality has become an emerging challenge for Bangladesh.

Corruption, negligence, and politicisation of the sector, often threaten its advancement.

Bangladesh Medical Association (BMA), the body entrusted to preserve the interest of the doctors, has become a political organisation while the Bangladesh Medical and Dental Council (BMDC) and Pharmacy Council, the registration authorities of the doctors and pharmacists, have been lying inactive for years together.

Though there is no vivid improvement in the nutrition sector especially when 45 percent of the under 5 children are suffering from malnutrition, a process to mainstream nutrition is going on. A draft document has already been prepared merging the stand alone National Nutrition Programme (NNP).

But upgrading the status of the nurses, central examination system to upgrade the private medical education, drug procurement centrally to curb corruption of the civil surgeons, and new packaging of the government supplied drugs to ensure availability of the drugs to the patients, achieved acclamation from the people. Formulation of the National Health Policy is now just a matter of time.

“Still, if we want to move forward we must strengthen and activate the regulatory mechanisms in public health service,” said former health adviser to the caretaker government, Dr AMM Shawkat Ali. He suggested reforming BMDC with representation from private medical colleges. “Activating patients' charter to let the patients know about their rights and responsibilities in the health care centers and to address their complaints by the respective health institutions is also important. Health cadre service must be free from political influence while the hospitals outside the capital should be developed to provide quality service. It is the government, who has to establish mechanisms to make the doctors willing to stay in rural areas and to ensure rural people's health services” according to him.

E health
One of the advancement in keeping pace with the digital age, the 'E health service' ushers hopes to bring more changes in health service delivery system.

Though it is yet to run in full swing, a link between the upazilla and district hospitals and the ministry has been established.

“It makes getting information from the upazilla level and sending government's decisions to those places prompt. At the same time, documentation and immediate consultation with the doctors for the rural people has been made easier,” said Prof Dr Abul Kalam Azad, director, Management Information System of the DGHS.

Different NGOs have been involved in providing health care service in the country including safe delivery, HIV/AIDS prevention and primary health care. Providing health service through public private partnership has been proved an effective way to extend health services to all.

“Our achievement in the last 30 to 40 years is immense. But it needs political commitment to hold that success and move forward because we are yet to prepare an ideal health service system,” said Prof Rashid E Mahbub, former president of Bangladesh Medical Association. It needs to use manpower through proper planning, he said, adding that there should be close cooperation between the health and family planning sector. At the same time, increased health financing, accountability and continuous monitoring is important to move forward, according to experts.

Sanitation
Sanitation is closely related to people's health as diarrhoea, typhoid and skin diseases are directly related to water and sanitation.

Overall, 8 percent of households in Bangladesh do not have toilet facility. This problem is more acute in rural areas where 10 percent of households have no toilet facilities, compared with 2 percent in urban areas.

Still urban sanitation system is also frustrating. Perhaps half of the urban population of Bangladesh lives in slums and squatter settlements, and at least 30% live under the poverty line. In 2003, 40 percent of urban population practiced open defecation or use unhygienic latrines, according to the ADB Evaluation Report 2009 of Urban Sector and Water Supply and Sanitation in Bangladesh.

The access of the urban population to safe drinking water in Bangladesh has improved, but over 6 million still have no such access.

“It is possible to ensure 100 percent sanitary latrine coverage by 2013 as the budget allocation has been increased significantly in the last tow years. But providing safe drinking water to all may not be possible by next year as the AL government's election manifesto highlighted,” said Country representative of WaterAid Bangladesh, Dr Khairul Islam.

He suggested need assessment for specific planning and government's financial support to the poor for sanitary latrine. A separate budget should be allocated for maintenance of those latrines, he said. According to him, the total issue should be taken care of by the local government and obviously accountability of the LGRD needs to be ensured.

The writer is Staff Reporter, The Daily Star.