Listen to the reform agenda, please!
Bangladesh is under "strict lockdown" for the past many weeks but what is happening under its guise is anybody's guess. Barring educational institutions, all else is open. It is a textbook case of implementation failure of a public policy. Public health experts have been calling for a "zoned" lockdown. Although this had fallen on deaf ears earlier, fortunately, some of the border towns are enforcing this now.
In Bangladesh, the Covid-19 vaccination campaign is all but stalled. This is an unfortunate situation which could have been avoided had the government listened to the experts. Voices suggesting hedging the bet by diversifying vaccine sources were loud enough. An important reason why the countries in the North are seeing light at the end of their long tunnel is the quick rollout of vaccines. India is also following the same route. About 15 percent of their target population is already vaccinated, compared to our three percent. The government's plan to vaccinate 25 lakh every month needs rethinking, as this would take five years to vaccinate the entire target population. We must aim to complete this job in a year's time. It is daunting, but doable. The country is endowed with an effective child vaccination programme which owes its success to the historic partnership between government and civil society organisations in the 1980s. This needs to happen again for timely implementation and ensuring nobody is left behind. The government's commitment is high but in order to acquire the requisite vaccines for the nation, they have to be "diplomacy-smart".
The budget and subsequent discussions have brought to focus once again the issue of investments in health. The abysmal allocation (less than one percent of GDP) is a national embarrassment. The absorptive capacity of the Ministry of Health and Family Welfare (MoHFW) has always been a matter of concern. They cannot spend the money they have, so why bother asking for more? Bangladesh has done well in many of its health indicators in recent times. This is credited not only to the interventions by the government, but also by NGOs. Through collective effort, we have experienced notable improvements in social determinants of health including women's empowerment, education, poverty alleviation and food security. Reaching the next level, such as fulfilling the Sustainable Development Goals, would require increased attention on many of the so-called "higher hanging fruits". Experiences from other countries going through such transitions call for a quantum change in the way health services are envisioned and delivered. In other words, this requires a total reform. Small changes here and there won't help.
Over the past year or so, the demand for a complete reform has been gaining momentum. There is a remarkable unison among the experts on the fragility of the Bangladesh health system and how it could be improved in a sustainable way. Concrete recommendations put forth on how to approach such reforms pragmatically included the following.
As a first step, the government should form, through an Act of Parliament, a high-level Permanent Health Commission to decide on the roadmap to achieving the vision for health. The government has committed, repeatedly in various global fora, to implement Universal Health Coverage (UHC). UHC, as we know, is achieved when everyone can access quality health services they need without suffering financial hardship. The Commission should be headed by an individual of repute, who should have an excellent and holistic understanding of public health and the factors that affect and are affected by it. It is critical that s/he should have enough clout and status to implement reforms across various sectors (a cabinet minister status). Commissioners should be drawn from people with expertise in related areas including public health, medicine, economics, finance, business, gender, politics and civil society.
The second step is to make the health sector more accountable. An important measure towards this is to set up an independent National Health Security Office (NHSO). This body would be tasked to act as the financier of the health sector. This office would be the holder of the entire health budget and would disburse to different sub-sectors (such as hospitals, primary healthcare, related institutions) based on population needs and demands. The Office would monitor the expenditures through strict regimes of internal audits and monitoring. An autonomous Office, headed by an individual with the rank of a senior secretary, would do away with the current faulty system where both the purchaser and provider roles are vested in the same place (MoHFW).
In all of this, management and governance are the keys. Much has been written about the poor management of our health systems, both public and private. We have examples galore on the poor delivery of health services by the public system. Absenteeism is the name of the game and at any given time, not even two-thirds of the relevant staff are found in facilities which require their presence 24/7. I don't think we have analysed it enough, let alone address the root cause of why such management and governance failures happen. The same goes with the private sector healthcare where the absence of regulatory enforcements has turned it into an uncontrollable monster.
Fourth, we must re-emphasise primary health care and community participation. Primary healthcare (PHC) has been a subject of systematic neglect. Only 25 percent of the budget is spent on PHC, which serves 70 percent of the population. The Community Clinics (and union and upazila level centres) have brought the infrastructure close to people, but not the care. There is a perennial shortage of healthcare workers, equipment and essential drugs, which make these less popular destinations for the ill. If the PHC system was strong, we wouldn't have seen so much Covid-related pressure on our city hospitals. Similarly, there is no alternative to community participation in healthcare and its management. Experts have repeatedly emphasised on the value of a "whole of society approach" in combatting the Covid-19 crisis, but to no avail.
Finally, we need to revamp planning, research and data systems. Any reform requires appropriate, relevant and timely availability of data. A number of institutions in the public sector are vested with this role. Unfortunately, most of these are laden with problems due to lack of leadership, bureaucratic dilly-dallying, lack of capacity and inadequate financing. The government should review their role and activate them.
Initiating the above reforms will require commitment of the highest office. As has been shown in many countries, leaders who have initiated reforms such as UHC have become national heroes. Such reforms would be befitting as we celebrate Mujib Borsho and the nation's golden jubilee.
Mushtaque Chowdhury is Convener, Bangladesh Health Watch and Professor of Population & Family Health, Columbia University.