A health commission incorporating public health managers and local government institutions could manage tax funds to procure and regulate healthcare quality and coverage, writes Abu Muhammad Zakir Hussain
REFORMS are expected to address problems in quality and quantity coverage or target attainment or both. Problems may be due to poor planning, budgeting, management and leadership skills, including weak supervision for quality and poor monitoring for quantity. Good management should consider human resource development and management; the management of medicine, logistics, technology and information; physical structures; and services. One fundamental aim is to 鈥榣eave no one behind鈥�, addressing equity, the fulfilment of health needs of all, which needs appropriate and adequate financing.
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Financing for universal coverage
PUBLIC tax-based Beveridge model, which allows people to buy private insurance, funds health care in many western countries. Besides public hospitals, governments recruit private hospitals as well, when necessary. Primary health care is given through individual general practitioners or groups of such people, contracted by local public bodies. Social health insurance is an approach where premiums are paid by the management and the staff. For the jobless, premiums are covered by public taxes. National health insurance is universal health coverage, funded by pooled insurance premiums but managed by contracted organisations.
Out-of-pocket payment is the most regressive and inefficient method of healthcare procurement as it is not based on informed decision and has no negotiating power. The purchase of care by a single purchaser chosen from multiple providers offers price negotiating powers to the purchaser, besides imposing favourable purchasing conditions that benefit service receivers. A single management entity accrues a smaller administrative cost.
The Bangladesh government also organises healthcare services through public taxes. But the tax base is inadequate for universal health coverage, especially in urban areas. To address this problem partly, local government institutions must allocate at least 15 per cent of their budget for health care. Additional taxes, eg, sin tax must be channelled to health care. Two per cent tax should be levied on health services on certain foods, drinks and private vehicles, which have adverse health implications. Fund might also come from co-payment from patients through registration fees for all, at all levels, as per the economic status of service seekers, which would also prevent the moral hazard. A portion of the corporate social responsibility from entrepreneurs should also be realised for health services. The finance ministry should fund local government institutions directly to enable them to undertake their health responsibilities.
A health commission with national, divisional, district and upazila offices, incorporating public health sector managers and local government institutions may be entrusted to manage the tax fund to procure and regulate healthcare quality and coverage by the public sector and the private sector. The combined entity should also participate in planning, budgeting, monitoring, review and public hearing at all levels.
Healthcare financing should be needs-based and the internal rate of return should dictate the priority of budgeting. Budget heads should be (1) human resources, its management and development, (2) planning and budgeting, (3) financing and accounting, (4) public communication, (5) knowledge and information management, (6) service and programme management, including clinical care, (7) incentive, (8) medicine, (9) vehicles, machines, supplies and equipment, (10) technology and innovation, ((11) sustainable and user-friendly physical structure, (12) renovation, maintenance and repairs, (13) stakeholder engagement and (14) operational costs, including transport costs for supervisory travel.
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Addressing in-service inefficiency
ON THE fringe. three categories of service providers have been entrusted with providing primary healthcare services. But their services are not complementary. The community health care providers are wrongly supposed to provide alone all sorts of stationery services at community clinics which overburdens them. The field staff may be given the same responsibilities while dividing their target population equally. This will enable the catering of more necessary services at the entry, the community clinics. A task group should develop an efficient terms-of-reference for them.
Operational budget for these fringe staff is nominal and fixed for all weathers, distances and conditions which compels the poorly paid staff to spend additional money on travel especially in hard-to-reach areas. Community health care providers pay electric bills for community clinics from their salary. Although 65 local influential form community groups and community support groups to support community health care providers and bear the coast of repairs and maintenance of community clinics, they are hard to find around. They are also alleged to demand medicine from community clinics, which comes free. It is warranted that the community support groups should be abolished. It is also warranted that the operational costs for community clinics should be sent to the upazila health and family planning officers on a yearly basis.
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Planning flaws at unions and solutions
THE union health sub-centres, 1,260 in number, are the most inefficiently managed health care units in the sector. All of them should have adequate office space for an assistant health inspector and other required officials, who will provide outpatient-based preventive, promotive and limited curative care, primary diagnostic services and normal delivery services. They will be given through medical officers 鈥� two although WHO recommendations 15 鈥� a medical assistant, a midwife, a medical technologist, a pharmacist, a guard and a support staff. All of them, except the last two, should have separate office/clinic and residential arrangements as per entitlement. The last two officials will be selected from among local people.
Assistant health inspectors and medical officers should also function as supervisors for community clinics. Besides, medical officers should also provide consultation services for waiting patients enlisted with the community clinics. Adequate travel and food allowances should be allocated for them to cover travel to distant clinics. A 20 per cent top-up needs to be added to the salaries of medical officers and 10 per cent for other non-local staff to attract them to stay in unions. No private practice or collaboration with the private sector by them should be allowed. If the conditions are not abided by public-sector service providers, local general practitioners or these people and providers of other categories as a team with due skill mix may be contracted in or out.
Contracting the general practitioners will have to be needs-based, efficient, based on the number of people to be served and the illnesses to be treated by complexity. The qualifications and readiness of general practitioners and their chambers should be assessed for contracting. What additional support, including training and logistics, will be required by the general practitioners to be contracted will have to be assessed before contracting. Information is also required if chambers of general practitioners will need to be renovated or supported with logistics. A law will be required for these sorts of contracting. The process of buying services from the private sector, including general practitioner services, should be left with the divisional level, which will be participated in by the upazila and district level management and public bodies concerned.
A public-private partnership scheme may be thought of, conversely, where general practitioners or groups of general practitioners will finance the construction or renovation of union health sub-centre complexes on government land (concession), operate and transfer the sub-centres after the contract period is over, to the government. The government may then again invite all local general practitioners to submit bids which will then require a lower bid amount.
At this point, we advise the government to reign in the infrastructural duplication between family planning and health departments. Both the departments have medical officers and medical assistants providing maternal and child health services in unions. To prevent duplication, family planning personnel should cater the same services from those 3,300 unions where there are no health department facilities.
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Equitability of clinical, public health services
UPAZILA public health units will be responsible for planning, budgeting and implementation of locally planned activities and nationally bestowed programmes, undertake personnel management and the management of logistics, physical facilities, information, training, monitoring, review and supervision and submit performance and expenditure reports for all the three primary healthcare tiers. Public engagement will be ensured at each level in planning, budgeting, review, public hearing and community awareness.
The upazila clinical and diagnostic care may be tagged to district hospitals, where upazila health and family planning officers will have no role. Upazila health and family planning officers will act as field, community clinic and union-level top planners, implementers, reviewers, supervisers and monitors. It would include disease prevention and control activities through disease surveillance and vaccination. They would also assess and address patient complaints, pharmacovigilance, polypharmacy, induced care, patient and provider safety, and adverse effects of vaccines, service coverage, health communication, staff attendance in all kinds of health facilities, all health-related procurement, all health management information and the regulation of both the public and the private sector health facilities in upazilas and unions.
They should be supported by a medical officer for disease control and prevention, a nutritionist, a health-related communications officer, a management information officer, a logistics officer and an accountant. A mirror image functioning is also warranted at district and divisional levels for primary healthcare services. Local level planning, both activities and budget, may be developed within a given ceiling at unions, upazilas, districts and divisions.
The family planning department has maternal and child welfare centres in districts and upazilas and in a few unions. These are duplications. Maternal and child welfare centres are not at the centre of patients鈥� interest as district hospitals and upazila health complexes with expert service providers are available nearby. Maternal and child welfare centres should come under a unified system of care under the health department.
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Resource management
Human resources: Allocation for adequate and appropriate human resources with right kind of service provider mix for a given epidemiological profile at a given location should be a priority. The World Health Organisation suggests 4.45 service providers as a minimum per 1,000 population to attain Sustainable Development Goal 3. The organisation also suggests a skill-mix ratio of 1:3:5 physician: nurses: paramedics. The WHO proposition would lead to a staggering estimate. We suggest that our efforts are driven towards recruitment along this line, starting with 10 per cent of the estimates now.
We recommended the provision of technical personnel for urban areas from the ministry of health and family welfare and administrative and support staff from the local government, rural development and cooperatives ministry. This should be the practice for urban primary health care. Additional fund for urban primary health care should come to local government institutions from the finance ministry directly. Planning, budgeting and implementation review of urban primary health care should be the combined responsibility of local government institutions, health and family welfare ministry and the local government, rural development and cooperatives ministry.
Line/programme directors and their assistants will have to be deployed based on their proved experience, educational qualification and leadership quality and should be selected through interviews by a board to be constituted of five superior officers and guest selectors who have required qualifications in the relevant field and are well known for their honesty.
Logistics: Human resources and logistics should be complementary to each other and based on local needs. Appropriate skills must be ensured to handle the allocated logistics before procurement. Assessment of local needs should be a requisite for any deployment and procurement. An equitable availability of resources could address all the health needs of the population on every location. Logistic support for urban areas should come from the health and family welfare ministry through its divisional, district and upazila primary healthcare offices.
Additional health facility: If need be, private hospitals, clinics and diagnostic centres might also be contracted when warranted. The situations for such contracting will be clear in writing, eg, in emergency or overloaded situation. The contracting conditions, i., payment conditions should be clear. The conditions should be reflected in their licensing conditions.
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Improving quality and coverage
Medicine: Medicine is the most important commodity that service seekers appreciate. The existent list should be reviewed and updated every five years. There should never be any incidence of stockout of enlisted medicines. It is necessary that use of the medicine given at community, union and upazila levels is monitored and the quality of prescription is supervised by clinical experts. Fund for medicine in urban areas should come from local government institutions and the finance ministry should top this to ensure the remaining fund from government revenue.
Technology: A table of necessary equipment, furniture, vehicle, supplies and the other relevant tools should be available at three tiers of primary health care and at the district and the divisional offices relevant for urban primary health care. This list should be reviewed and updated every five years. The latest available technology, eg, software-based automated data recording and transmission, telemedicine, e-medicine etc should be ensured inasmuch as possible that would ensure efficiency.
Physical facilities: Physical facilities should be distributed equitably with efficient designs. Adequate and appropriate offices, residence and clinic spaces should be available to relevant officials as per eligibility of the positions that either exist now or will be created in future. Four-room community clinic archetype facilities should be developed throughout the country. But the number of such facilities should be based on population dispersal and density. While in urban areas, one such facility may suffice for 50,000 people, in hard-to-reach areas, one may be necessary for 2,000 to 3,000 people. Health facilities owned by other sectors, usually in urban areas, should be checked for their use and, if necessary, a corner of such facilities may be used as a community clinic or equivalent to a union health facility.
A continuous availability of electricity and safe water should also be ensured by the government at all tiers. It is also necessary to ensure that the health facilities and their basic amenities should ensure sustainability and disaster adaptability. Every health facility/office should be comfortable for officials and for waiting service seekers, or patient attendants, suitable for different ages and sex. At least two cleaners should be recruited at union health facility, and one at each community clinic, selected through contracting, to be held at divisional level in the presence of the relevant civil surgeon, urban health and family planning officers and one local public representative. In urban areas, additional physical facilities should be built by the local government institutions. Any shortfall in this regard should be met up by the finance ministry.
Community engagement: Since the engagement of the community has been suggested, adequate fund 鈥� budget for snacks and tea for meetings, for example 鈥� should be needed to bring them into the system. Every health facility should have a public management body composed of upazila and union chair as per relevance and local healthcare providers. These should replace the older ones.
Orientation, training and continuous education: The personnel promoted to a position should always be given training to suit the newly assumed position. The orientation and training should be preceded with a need assessment exercise and the training or orientation curriculum be organized according to its findings. As part of capacity build-up, seminars should be organised at union and upazila levels to be participated by the community and union level workers every month. Community workers would bring complex cases to the discussion table, for solution or referral by attending medical officers.
Patient-centred services: Every healthcare worker at upazilas, union and community levels should know of the various quality indicators and parameters. Induction and refresher trainings should be organised for them, that should emphasis on service quality and competency.
Supervision: Supervision has to be done through some structured protocol and job-related tools. Clinical audits would be warranted for medical prescription.
Monitoring and supervision: Monitoring might be conducted online. It has to be continuous or episodic, according to the applicable tier. A standing monitoring framework should be developed and used. Dedicated monitors may be recruited from among retired officials, the private sector or private individuals with required experiences. Selection would be through an interview board composed of officers. Their contracting should be based on an agreed terms-of-reference.
Various groups of monitors should be deployed for different purposes, ie, for the monitoring of the fulfilment of contracting conditions in various fronts, eg, covenant on free services to 10 per cent of the poor service recipients in private hospitals; the submission of service-related information by private service providers and hospitals and other functions mentioned. The monitoring teams or groups would be supervised and monitored by the urban health and family planning officers, civil surgeons and divisional directors. Adequate allowances but only for supervisory and monitoring and, in rare cases, travels should be ensured for supervisers of upazila and union levels.
Other management functions: Management decision should be evidence-based. This is a culture that needs to be developed fast. Managers should learn how to manage programmes, personnel, finance, logistics, information technology and software and contracts. Healthcare management should be gender- and poverty-sensitive and emphasise improving community awareness on family planning, adolescent care, disease prevention and nutrition improvement and other services mentioned. A government order should be in order in this regard. Management and review meetings should be supported with adequate logistics and fund.
Regulation of clinical and diagnostic services: Health and performance related information should cover both the public and the private sector. Urban health and family planning officers, civil surgeons and divisional directors should be entrusted to monitor, not supervise, licensing conditions only for the private sector and other performances and services, mentioned. Leaving these responsibilities to the hospital management will ensue a conflict of interests.
Innovation, change and learning: No de novo action or recommendation that brings in any change in the system should be adopted ever, without unbiased piloting and job analysis. The condition of efficiency and reduction in price and cost in services delivery should be ensured. The catchment area of each facility of all tiers should be mapped which would also help to line up the referral system. Every family and its members should be registered with the help of a unique number. Community-based birth, death and marriage registration by age and sex should be a priority to assess the impact of the healthcare interventions and goal attainment.
Referral and transport: Strong emergency and critical care services should be ensured at referred sites. High-level health facilities should also be able to provide care for complicated non-communicable diseases as per competence. Health services should be available round the clock in referred facilities. A penalty fee should be applied to those who seek care at higher levels without referral. Ambulances may be of different types based on the topography of a location, eg, boats, three-wheelers, pedalled four-wheelers, etc and should be free for every registered family. Except motor ambulances, other types may be given to local entrepreneurs to run and maintain, conditional to their use as an ambulance, when necessary, on a priority basis. Public bodies, linked to the health facilities, may be entrusted to monitor their use.
Incentive: The health sector should develop a culture of incentivising good performance annually. The incentive may be monetary or non-monetary. Monetary incentives may be given as a top-up of the salary. It may also be recognition given at public meetings at district and national levels. Contrarily, non-performance should make a staff liable to punitive action, eg, the degrading of salary by one or two steps. Transfers should never be considered a punishment.
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Abu Muhammad Zakir Hussain is a former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO and former staff consultant, Asian Development Bank, Bangladesh.