LECTURE 4: HEALTH SYSTEM AND BANGLADESH
Course: Introduction to Health Bakibillah
Lecturer, Dept. of Public Health, Daffodil International University
UNDERSTANDING CONCEPTS OF HEALTH SYSTEMS
• According to WHO, a health system includes “All the activities whose primary purpose is to promote, restore or maintain health.”
• Traditionally health systems were described in terms of capacities, indicators and activities (e.g. number of hospital beds, physicians, nurses, govt.
programs)
• Literature present HS as a set of functional components
• Hurst described HS as a series of fund flows and payment methods between population groups and institutions
• Roemer argued that HS should describe 5 characteristics - Productive resources
- Organization of programs
- Economic support mechanisms - Management methods
- Service delivery
WHAT IS A GOOD HEALTH SYSTEM?
• A good health system delivers services to all people, when and where they need them
- equitable, effective, efficient, timely, safe and patient centred
• The exact configuration of services varies from country to country, but in all cases requires:
- A forceful financing mechanism
- A well-trained and adequately paid workforce
- Reliable information on which to base decisions and policies - Well-maintained facilities and logistics to deliver quality
medicines and technologies
PROBLEMS WITH HEALTH SYSTEMS
• Problems with health systems are not only confined to poor countries but also rich countries
- Large populations without access to care because of inequitable arrangements for social protection
- Struggling with escalating costs because of inefficient use of resources
- Health outcomes are unacceptably low
- The persistence of deep inequities in health status is a problem from which no country in the world is exempt
- At the center of this human crisis is a failure of health systems - Failing or inadequate health systems are one of the main
obstacles to scaling-up interventions to make achievement of internationally agreed goals such as the MDGs a realistic
prospect
CHALLENGES OF HS
• Globally, Health is a US $ 3 trillion industry.
• Globally, Every year 100 million people become impoverished due to access to health care services.
• Large Health inequities persist across the globe.
• Extreme shortage of HWF in 57 Countries and 36 of them belong to African continent.
• About 50% of medical equipment in developing countries is not used either because the health workers don’t know how to use it or lack of maintenance.
SUMMARY CRITERIA OF A HEALTH SYSTEM
• Primary goal is to improve population health
• Responsiveness, equity, quality
• Transparency and accountability
• Public-private partnership; innovation needed
• It’s not static but always changing
• Research is needed to improve health system
• Community participation is essential
FUNCTIONS OF HEALTH SYSTEM ACCORDING TO WHR 2000
• Stewardship (often referred to as governance or oversight)
• Organization and management of service delivery
• Human and physical resources
• Financing
GOVERNANCE OR STEWARDSHIP
It reflects the fact that people entrust both their lives and their resources to the health system
• The government in particular is called upon to play the role of a steward because it spends revenues that people pay through taxes and social insurance
• As government makes many of the regulations that govern the operation of health services in other private and voluntary transactions
WHO HEALTH SYSTEM FRAMEWORK
SIX BUILDING BLOCKS OF HEALTH SYSTEMS
1. Service delivery 2. Health workforce 3. Information
4. Medicines, vaccines, technologies 5. Health financing
6. Governance and stewardship
SERVICE DELIVERY
• Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources
HEALTH WORKFORCE
• A well-performing health workforce is one which works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstance, i.e. there are sufficient numbers and mix of staff, fairly distributed; they are competent, responsive and productive
INFORMATION SYSTEM
• A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status
MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES
• A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost- effective use
FINANCING
• A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them
LEADERSHIP AND GOVERNANCE
• Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system-design, and accountability
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Indicators for Monitoring HS Building Blocks
1. Service
delivery 2. Human
resource 3. Health financing 4.
Information 5.
Essential Medicine
6. Leadership and Governance
1.1. No of facilities
per 10,000 pop 2.1. No of doctors
per 10,000 pop 3.1. Total health expenditure (THE) per head per year
4.1.
Performance index
5.1.
Availability of 14
selected essential medicines
6.1 Transparenc y
1.2. No. of
inpatient beds per 10,000 pop
2.2. No of
Nurse/midwives per 10,000 pop.
3.2. THE as
proportion total GDP 4.2.
Timeliness of HMIS data
5.2.
Existence and
updating of national medicines policy
6.2
Accountability
1.3. No. of
outpatient dept.
visits per 10,000 pop
2.3. Urban rural distribution
3.3. General government
expenditure on health as a proportion of general government expenditure
(GGHE/GGE)
4.3.
Completeness of HMIS data
6.3
Responsiveness
1.4. Service
readiness score 2.4. Annual number of production per 10,000 pop
3.4. The ratio of household out-of- pocket payments for health to total
expenditure on health 1.5. Impacts and
outcomes : MMR, IMR, U5MR, TFR
2.5. Retention
2.6. Absenteeism 2.7. Training
HEALTH SYSTEM OF
BANGLADESH
INTRODUCTION
• Bangladesh is a non-federal country governed by parliamentary democracy
• The National Parliament is called Bangladesh Jatiya Sangsad
• There are about 58 ministries and divisions
• A ministry is headed by a minister, with a secretary to head the bureaucrats
• Some ministries are divided into functional divisions, with each division having a secretary to head the bureaucrats of the respective divisions
• The Ministry of Health and Family Welfare is one of the largest ministries of the Government of Bangladesh
INTRODUCTION (CONTD.)
• Bangladesh is divided into 8 administrative divisions
• Each division is divided into several districts (total 64)
• Each districts is further subdivided into several upazilas (total 491)
• Each upazila into several unions (total 4554)
• Each union into nine wards (total 40,977)
• Wards are divided into several villages (total 87, 310)
• However, ward is the lowest administrative unit of the local government, having at least one representative elected for 5 years by popular vote
• The city corporations and municipalities are designated as urban areas, with 12 city corporations (4 metropolitan cities) and 324 municipalities across the country
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Service Delivery
Level of care DGHS DGFP Service providers
Community Community clinics (CCs), EPI
outreach session
Satellite Clinics Health Assistants, Family Welfare Assistants,
Community Health Organizers
Union Rural
Dispensaries FWCs,
(MCWCs?) SACMO, FWV, MO (?) in FWCs and MOs, MAs, Pharmacists in RDs Sub-district UHC (31 or 50
beds) MCWC (?) Doctors, Nurses, Midwives, Paramedics, FWVs, SACMOs (MAs)
District District Hospitals MCWCs Specialists, Doctors, Nurses, Midwives, Paramedics,
FWVs, SACMOs (MAs) Regional /
National Medical College Hospitals /
Specialized Hospitals
Azimpur MSHTI, Mohammadpur fertility Centre
Specialists, Doctors, Nurses, Midwives, Paramedics,
FWVs, SACMOs (MAs)
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Human resource: Doctors and Nurses in Bangladesh
1997 2007 2012
0 10000 20000 30000 40000 50000 60000 70000 26608
45273
58977
536 2945
4986
15408
21715
30418
13211
19354
27000
Doctors Dentist Nurse Midwives
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Health Information
As of service delivery, MIS-Health organized by both health and family planning departments
Recently computerized up to sub-district level
Covers only public sector facilities (only 26 NGO and private facilities are covered)
Produces periodic reports such as Voice of MIS (quarterly), Yearly Health book
Still not used adequately for planning purposes
Use of MIS data at collection level is very minimum
There is scope to improve quality of data in terms of accuracy, timeliness and completeness
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Financing: Trends in health expenditure in Bangladesh, 1997–2011
National Reports WHO estimate
1997 2000 2003 2005 2007 2008 2009 2010 2011 Total Health Expenditure in PPP$ per capita 20 24 30 37 46 52 58 61 67 Total Health Expenditure in US$ per capita 9.2 10.1 11.5 13.7 16.2 19.4 22.4 24.8 26.5 Total Health Expenditure as % of GDP 2.7% 2.8% 3.0% 3.2% 3.4% 3.5% 3.7% 3.7% 3.7%
Public expenditure on health as % of THE 36% 31% 28% 26% 26% 36% 37% 37% 37%
Public expenditure on health as % of GDP 1% 1% 1% 1% 1% 1% 1% 1% 1%
OOP as % of total health expenditure 57% 59% 61% 64% 64% 62% 61% 61% 61%
NGO expenditure as % of THE 1% 2% 2% 2% 1% - - - -
External assistance to NGOs as % of THE 5% 7% 9% 8% 8% - - - -
Other private expenditure as % of THE 1% 1% 1% 1% 1% - - - -
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Medical products, vaccines, technologies
• CMSD – is responsible for selection, procurement, and supply of medicines
• EDCL is a government company that produces and supplies essential medicines
• Big purchases are by CMSD (Central Medical Stores Depot)
• Districts can procure locally
• Vaccines are dealt by EPI Headquarter; IPH
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Governance and Stewardship
• Least understood aspect of health systems
• The system for accountability is poorly established
• Low level of regulatory control
• Undue interference
• Health and Family Planning is poorly co-ordinated
• Overlap between public and private sectors
• Private sector is beyond any regulatory control
• PHC in urban area is under LGRD Ministry
B A N G L A D E S H H E A L T H S Y S T E M G O V E R N A N C E
• The Ministry of Health and Family Welfare (MoHFW) is the lead agency responsible for formulating national-level policy, planning, and decision-making in the provision of healthcare and education
• The national-level policies, plans, and decisions are translated into actions by various implementing authorities and healthcare delivery systems across the country
• The Ministry and its relevant regulatory bodies also have indirect control over the healthcare system of the NGOs and the private sector
BANGLADESH HEALTH SYSTEM GOVERNANCE (CONTD.)
• Implementing authorities under the ministry of Health and Family Welfare
- DGHS (Directorate General of Health Services) - DGFP (Directorate General of Family Planning)
- DGDA (Directorate General of Drug Administration) - DGNM (Directorate General of Nursing and Midwifery) - HEU (Health Economics Unit)
- HED (Health Engineering Department)
- NIPORT (National Institute of Population Research and Training)
- Transport and Equipment Maintenance Organization (TEMO)
BANGLADESH HEALTH SYSTEM GOVERNANCE (CONTD.)
• Regulatory bodies under the ministry of Health and Family Welfare
- Bangladesh Medical and Dental Council (BMDC) for MBBS, BDS, MA and Post-Graduate Physicians
- Bangladesh Nursing and Midwifery Council (BNMC) for Nurse,
Midwife and Allied HWF (FWV, CSBA)– both graduate and diploma - Bangladesh Pharmacy Council (PCB) for Pharmacist – graduate and
diploma
- State Medical Faculty (SMF) for Medical technologists - Bangladesh Homeopathic Board (BHB) for Homeopathy
practitioners- both graduate and diploma
- Bangladesh Board of Unani and Ayurvedic Systems of Medicine (BUASM) for Unani and Ayurved practitioners- both graduate and diploma
B A N G L A D E S H H E A L T H S Y S T E M G O V E R N A N C E (M A N A G E R I A L H I E R A R C H Y - F A C I L I T Y W I S E)
Level of facility Personnel
Ward Health: Health Inspector (HI) > Assistant Health Inspector (AHI) >
Community Healthcare Provide (CHCP)
Family planning: Family Planning Inspector (FPI) > Family Welfare Assistant (FWA)
Union Health: Medical Officer (MO) > Sub-assistant Community Medical Officer (SACMO)
Family planning:
Medical Officer (MO) FW > Sub-assistant Community Medical Officer (SACMO) > Family Welfare Visitors
Upazila Health: Upazila Health and Family Planning Officer (UHFPO) >
Resident Medical Officer (RMO), Medical Officer (MO)
Family planning: Upazila Family Planning Officer (UFPO) > Medical Officer MCH-FP > Assistant UFPO > Senior Family Welfare Visitor
B A N G L A D E S H H E A L T H S Y S T E M G O V E R N A N C E (M A N A G E R I A L H I E R A R C H Y - F A C I L I T Y W I S E)
Level of facility Personnel
District Health: Civil Surgeon, Superintendent (District Hospital) >
RMO > MO
Family planning: Deputy Director (DD) > Assistant Director (FP), Assistant Director (CC) > MO (CC) > FWV
Division Divisional Director > Deputy Director > Assistant Director
Director (Medical College & Hospital) > Deputy Director (Medical college and Hospital)
Principal (Medical College) > Vice Principal National Director of Institute > DD > AD
BANGLADESH HEALTH SYSTEM GOVERNANCE (CONTD.)
• Essential service delivery and urban primary healthcare
The urban primary healthcare in Bangladesh is principally the responsibility of the ministry of Local Government,
Rural Development and Cooperatives (MoLGRDC), carried out through the city corporations and
municipalities
These local bodies run a number of small to medium sized hospitals and outdoor facilities
Besides, large-scale primary healthcare activities under Urban Primary Healthcare Project (UPHCP) and Smiling sin Franchise Program are run by NGOs in collaboration with the city corporations and with the financial assistance from donors
CONCLUSION
• Strong service delivery structure present
• Private sector is booming but no routine data is available
• Number and distribution of HRH is problematic (More doctors than nurses)
• Out-of-pocket expenditure is too much (2/3rd of THE)
• Drug policy is good and price of essential medicine is low
• Governance and stewardship needs urgent attention
