THE health sector reforms commission was formed to propose ways and means to develop a people-oriented, easily available universal healthcare system. ‘People-oriented care’ must fulfill people’s health needs with quality. This will be possible only when people can obtain their required healthcare unconditionally with dignity.
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Infrastructural reforms
THE chief secretary, proposed by the public administration reforms commission, would be the head of the proposed Bangladesh Health Service and will replace the incumbent secretary of health services. S/he would be a physician with health sector management experience. S/he would be accountable to the health minister. Three deputy chiefs with experience of formulation of policy and strategy will assist the chief for (a) clinical and diagnostic care, (b) public health service (including urban health and family planning), and (c) medical and allied education. The director general of health services would be bifurcated into director general of clinical and diagnostic services and the director general of public health. The director general of medical and allied education will also be responsible for allied disciplines.
Primary healthcare technical staff, including the technical cadre officials of director general of family planning, could be merged with the director general of public health at equivalent posts, as they desired. The 330 non-technical general cadre staff from the upazila to the national level may be transferred, as they desired, to some other cadre services, or the posts of these 330 officers may be ended after they retire. The performance of the family planning department is sliding since 2011 while it is duplicating the infrastructure for maternal and child healthcare with that of the health department, without any use. Local government health departments, which are too weak to deliver the mandated responsibilities even in the Dhaka city, should be merged with the director general of public health. Two additional directors general’s posts should be created under the director general of public health for these two merged departments.
Hospitals run by the Family Planning Department and the Nursing Department may be merged with the director general of clinical and diagnostic services, with an additional director general for nursing and midwifery services. Among these, only the director general of public health infrastructure would be a new one. The relevant line directors and programme and institutional directors may form the director general of public health. Officials of all these offices know their job. Conducive working conditions would further enhance their efficiency. The unused land of the community clinic health support trust may be used for the construction of the office of the director general of public health.
As an independent entity, the health services authority may offer suitable salaries and perks to deserving service providers, within a given grade or one grade above but at a deserving step of the grade. Dedication and performance, especially in hard-to-reach areas, should be considered virtues for higher grade/step, promotion and training.
An independent health service authority would do away with unnecessary structural duplication and inordinately large number of posts, incoordinated, delayed and inappropriate decision making and inefficiency of management, which will, thus, substantially reduce budget requirement and less time in making accurate decisions. A management forum should be formed with the seven officials mentioned above and some other relevant managing directors and directors general, eg Essential Drugs Company Ltd, the drug administration and the Central Medical Stores and Depots.
The commission also propounds a health commission, for inter-sector collaboration, policy and strategy formulation, monitoring and performance evaluation, salary fixation and governance, including public accountability. This may be formed by the interim government. Members may be chosen from the relevant backgrounds — epidemiology, public health management, hospital management, social welfare, accountancy, food, disaster management, local government, law, public administration, education, information technology, procurement and logistics management and mass communication. This should be headed by a respectable health sector professional. The commission may be formed with five to seven members, each with three staff- a researcher, a secretary and a computer operator.
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Priority action
THE most important first step and of immediacy is the passage of an ordinance with several chapters that will set in motion the implementation of the health sector reforms commission recommendations. The chapters might be (1) Bangladesh health services, (2) Bangladesh health commission, (3) free primary health care, (4) free hospital care for 20 per cent of the marginal population and (5) social health insurance. While the first two may come into functioning immediately, the implementation of the latter three may need to be spread over several years.
This ordinance has to give a direction on where the existing ministry officials will go,which may be transference to vacant posts or creation of supernumerary posts in other ministries. The chapter on Bangladesh health cervices should abolish the current community clinic health support trust, enacted in 2018. The trust has fractured a seamless health department, delinking community clinics from supervisory and monitoring chain of upazila and upper-level health department offices, by creating a trust with confusing arrays of accountability. All the chapters should also clarify the decentralised human resource and financial management authorities and functioning, starting from the upazila level. Details on these have been given in the commission report. Primary health care will have to be defined in the ordinance as (a) the control of infectious and non-communicable diseases, (b) the treatment of common for simple diseases and referral, (c) nutrition, (d) family planning and (e) maternal, neonatal, children, adolescent and elderly care and (f) health, nutrition and family planning-oriented communication.
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Financing
THE budget will be developed at different management levels, starting from upazila, based on a upazila and urban area-wise decadal survey that will cover disease and nutrition profile; people’s health and contraceptive practices; their health nutrition and contraception-related knowledge; and the distance between people’s home and health facility.
For free primary health care at union and community level in rural areas and at ward level in urban areas, the following should be assured: (1) essential medicines, which need to be updated to 250 from 117, (2) the construction of conducive housing and service structures at these basic primary healthcare levels including refurbishment of community clinics as per the design of the Japan International Cooperation Agency, (3) the recruitment/deployment of adequate number of skills-mixed service providers and, finally, (4) some low-technology equipment, machines and supplies.Ìý Once these are assured, the cost and quality of hospital care, to be available through referral, will come down.
The finance ministry will send fund for these four requirements from public tax, 60 per cent of corporate social responsibility, sin tax, development partner’s fund, surcharge from mobile phones and toll gates, and philanthropic donations. Hospitals on their own will collect local donations, crowd fund and co-payment (for preventing moral hazards). Unions/wards may be selected in phases for readying. The entire country should be covered in five years. In urban areas, a small part of the six public sector owned hospitals and clinics and private hospitals may be used for catering primary healthcare and new constructions, if required, should follow this initial step.
For the 13 per cent of formal sector workers, the commission recommends an ‘office for social health insurance and other fund and contract management’, the membership of which should be drawn from persons experienced in bidding, bid evaluation and contracting, informatics, finance and accounting, public health and clinical care, etc. The office may itself collect premiums from the staff/workers and their employer and select service provider(s) and pay for stipulated hospitalized services but preferably recruit a third party, a health maintenance/management organisation for managing hospital services under the supervision and monitoring of the ‘office for social health insurance and other fund and contract management.’ The health management organisation will manage free hospital service for the 20 per cent of the marginal population as well — 10 per cent in private hospitals and 10 per cent in public hospitals.
Forty per cent of the fund, beside the tax-derived fund, would be earmarked for the 67 per cent of hospital service recipients for subsidy in public hospitals. Hospitals will, in addition, collect variable fees for the given services from service recipients, at staggered rates, as per their affordability, independently for purchasing the requisites and services, if required. Levying of fee should ensure post-payment equity, which may be helped by bracketing recipient’s income with others, horizontally and vertically through a Delphi technique among relevant experts including economists, audit, accounting and finance, and public health experts. Fees will be collected by the accounting and finance section of the hospital, as is done in private hospitals. This will reduce administrative cost.
Service cost may be estimated locally by the service providers. It should exclude recurrent fixed costs,l mostly salaries, but should estimate depreciated capital costs — building, vehicle, machines and equipment and the recurrent variable costs. The annualised capital and the recurrent costs should be recovered from the 67 per cent service recipients as per affordability. The money realised will be distributed as incentive to all sorts of service providers (20 per cent), based on their performance, including the community-based workers within the administrative boundaries; the rest may be deposited in the government treasury, if the government has provided all necessary resources. If not, the hospital authorities/board will procure the necessary resources as per Procurement Act 2006 and Rule 2008, from the money realised. If saved, the rest of the fee recovered will be deposited in the treasury. The law and the rules, however, need updating to accommodate a decentralised procurement. Decentralisation under strict multilayered monitoring is necessary as centralised procurement has not proved to be a panacea. These manoeuvres will encourage public sector providers to attract service recipients through market competitiveness.
A critical and emergency fund should be created for patients who cannot pay at the time of service. While social health insurance and free service for marginalised population will be taken care of, the rest who have to pay for service will be paid from this Fund upfront, to be recovered when the patients/relatives are in a position to pay. This fund will be at the disposal of managed by the directorate general of clinical and diagnostic services.
The strengthening of the referral system will reduce subsequently the variable costs of diagnostic care, medicine and hospitalisation. The cost of these, machines, equipment and technology, have to be lowered so that the consequent prices can be lowered. The commission report underscores the methods of reduction of these costs. The controlling of induced/unnecessary care will be yet another avenue, which will be monitored online through the unique identity to be given to the patient.
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Expectation from ordinance
ONCE passed, the ordinance will set the stage and provide support for the relevant players to play out their respective roles, which are already known to them. The issues of governance, provider commitment, educated recipient, infrastructural and facility readiness which plague the quality and coverage of health care now will be addressed once the ball is set to roll through the ordinance as a result of which the offices will start functioning efficiently. The only issues will be supplying adequate fund, allocative efficiency and prioritised, transparent and appropriate expenditure based on a visionary plan and strategy, which will be taken care of through these offices suggested by the commission, the selection/development of officers with leadership quality and efficient management, reward for good performance and exemplary punitive action for lackadaisical or nonchalant performance, that fail to satisfy the service recipients.
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Other priority actions
SEPARATE ordinances would be time-honoured and extremely important for (1) epidemic control and post-disaster healthcare management, which will give widespread authority to the director general of public health, as is given in the neighbouring countries for coordination the relevant sectors on an emergency footing, (2) hospital and diagnostic services accreditation which will establish an independent authority to manage improvement of care quality in all types of hospitals and diagnostic centres, (3) the health protection act for service receivers as well as service providers, (4the) the act for decentralised management of hospitals and medical universities and private practice by the public sector clinical personnel and the separation of consultancy and teaching and research for dedicated work in the respective areas and (4) the updating of the Drug Administration Act, the Bangladesh Medical and Dental Council Act, Bangladesh Medical Research Act, the Nursing and Midwifery Council Act and three alternate medical care acts.
Some other actions, based on seriousness and circumstances, may be taken up by the health or the prime minister through government order and official notification.
Finally, it must be understood and appreciated that physical and mental strength is the first priority and fundamental stepping stone for national/economic development. Even for education, we need strong mental capacity — better merit helps in better learning. We cannot think and analyse facts with vision if our brain is underdeveloped. We cannot produce if we are physically weak. However, it is true that allocation may not be translated into efficient fund management alone. At this point, we need to remind ourselves of the remark of Albert Einstein, which says: ‘You cannot solve a problem with the mind that created it,’ ie we need fresh and wise minds that have experienced the sector but are not part of the quagmire that the sector is in now.
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Abu Muhammad Zakir Hussain, now chairman of the Community Clinic Health Support Trust, was a member of the health sector reforms commission. He was director of Primary Health Care and Disease Control of the Directorate General of Health Services, staff consultant of the Asian Development Bank and regional adviser of environmental health and climate change of SEARO, WHO.
