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 recomm