Health systems in most developing countries cannot provide the necessary health care because of serious deficiencies in financing, efficiency, equity and quality. To improve the functioning of health sector, various reforms have been undertaken from time to time. These efforts include decentralisation of service delivery system, resource mobilisation for health sectors, rationalising the role of the private sector and involvement of non-governmental organisations, community participation, and making better use of available resources.
In the last three decades, health sector decentralisation policies have been implemented on a broad scale throughout the developing world. However, decentralisation has not been implemented in terms of empowering lower levels of government to effectively design, finance as well as administer health services and involving local public and private actors. Even if the authority and power are devolved to regional and sub-regional levels, these local units have often limited managerial capacity and technical expertise. Thus, the intended reforms are not successfully implemented when responsibility is transferred to a large number of local authorities (e.g. districts) without strengthening and supporting these units. Evidence also suggests that there is no single uniform model of decentralisation applicable for all the developing countries.
Inadequate investment in health care by the public sector has instigated the adoption of alternative financing mechanisms in the health sector. For example, cost-recovery schemes e.g. user fees/charges, social insurance schemes, private insurance, community financing and health cards or voucher systems have been introduced in many countries. In most cases, the application of user fees is easier and faster than the reallocation of resources, and the revenues locally collected and retained contribute a significant portion to the current expenditure at local level. In a limited scale, health insurance schemes (public, private or community) have been implemented. However, under-utilisation of private insurance in low-middle income countries leaves the burden for the public sector to provide financial security to marginalised population to protect them from any catastrophic illness expenditure. In some settings, the community-based health insurance schemes targeting rural populations have been successful but not scaled up nationally.
With regard to NGO involvement in the health sector to expand the access, coverage, quality and sustainability of health services to underserved populations, evidence shows that several NGOs have designed cost effective service delivery programme, which could be good models for national level replication. Government institutions can deliver quality services in collaboration with NGOs since NGOs could play an effective role in mobilising local people and initiating innovative techniques to serve poor and marginalised populations. But, sustainable improvement of people’s health will be possible only when community members are aware of their health needs, share their knowledge in decision-making, identify health problems and use available resources to meet the local needs.
Most developing countries often lack efficiency, availability and balance of human resources for managing a successful health care system. Different initiatives on recruitment, capacity building and incentives to improve the efficiency of the health workforce have been undertaken, but did not result in significant improvement in service delivery. With regard to human resource development, capacity building of required skills, reallocating and sometimes reducing personnel to have the right skill mix at the right place, introducing decentralisation of management, reviewing the entire system of wages and incentives, and a strong and transparent co-ordination mechanism to address human resources development issues such as development/training, deployment, motivation and retention may have great impact on health worker’s performance as well as will improve the quality of health service delivery system of a country.
Experiences demonstrate that the people who can pay for health services take the benefit more from public sector subsidies to health care, as tertiary hospitals often receive the major portion of the health budget. Most of the reforms in health sector intended to improve proportionate allocation of resources across the country have not resulted in increasing utilisation of health care services by the marginalised population.
The health sector of Bangladesh has evolved over the last three decades through various reform initiatives, which could broadly be divided into two eras: the period prior to 1990 and the post 1990 period. In 1986, the government decentralised development and health activities by introducing upazila (sub-district) system. A significant reform was attempted in 1998 with the introduction of the Health and Population Sector Programme (HPSP), both the population and health programmes were merged into one sector. As HPSP could not achieve the expected results, the government launched HNPSP in 2003. It was decided that both the Directorates – Health and Family Planning – would be under their respective administrative and organisational structure and provide services to the people as they were functioning prior to HPSP.
Reform initiatives in the health sector of Bangladesh indicate that the period from 1975-90 witnessed significant progress in institutional development, both in respect of education and training as well as for service delivery. Female field workers had improved doorstep services, which was introduced in mid-seventies, together with follow up and referrals. Besides, in order to meet the growing needs of the female population of reproductive age, large number of female paramedics were trained. Both basic and refresher training for all categories of field workers, paramedics and supervisors have been strengthened. It is observed that the availability and balance of trained human resources contribute to effective health service delivery system in Bangladesh as indicated by significant reduction in both fertility and mortality and increase in life expectancy. The urban concentration of the physicians and nurses is a major problem in Bangladesh and reallocating and sometimes reducing personnel to have the right skill mix at the right place is urgently needed for reaching the targets of vision 2021.
In Bangladesh, decentralisation has occurred in terms of deconcentration of powers. The Secretary of the MOHFW has transferred some of his authority and responsibility from the national level to Line Directors. These Line Directors, though subordinate to their respective Director Generals of Health and Family Planning, are playing almost an autonomous role both in administrative and financial matter. According to the decentralisation review under HPSP, little actual decentralisation of the functions has occurred. The activities and power have been decentralised to the level of senior programme managers who are posted at the national level, not to the lower tiers of administration such as district, sub-district and union level. Another limitation is that the structure and processes for the functions in the health sector are linked to broader civil service structure and processes, and they are, therefore, not amenable to change in a single sector. As a whole, decentralisation has not been materialised in Bangladesh due to structural constraints and intransigence of the bureaucrats to share power and authority with the lower tier of administration.
The government is providing health services free-of-cost at the primary and secondary level health facilities and also family planning services at all government health facilities. Official user fees are charged for tertiary health care services. To a small extent, government started to charge user fee at sub-district health facilities, which are located in rural areas. The government did not initiate this fee to address the issue of resource gap but to ensure sustainable improvement of quality of services. However, there is an encouraging lesson from the experiences of some leading NGOs in Bangladesh, which suggests that cost sharing is possible with poor people.
In Bangladesh, the government health system allows the populations to have free access to primary health care, family planning and reproductive health services in rural areas. Family planning services are also provided free at the government tertiary hospitals in urban areas. Maternal and child health services have been given highest priority in the health policies and programmes. Activities undertaken to improve health outcomes of women and children include strengthening primary health care, community-based maternal and child health and family planning programme, immunization services, and developing adequate female field workers to provide services at clients’ residences.
Collaboration between the government and the NGOs has been in place for a long time in Bangladesh. NGOs are allowed to work both in urban and rural areas to play a complementary role in government service delivery system. NGO designed service delivery and cost recovery system could be good examples for replication.
It is clear that various reforms had mixed successes and failures. Successful implementation of reform initiatives requires proper planning. It is important to be pragmatic and examine the context and determine the reform measures which constitute the best means for developing a strong health system in terms of equity, efficiency, and sustainability. Practically, there is no single uniform approach to health sector reform applicable for all the developing countries.
Every developing country needs to adopt the reform measures that are appropriate for its unique economic, institutional, and cultural conditions. In this case, the experiences of other countries will help Bangladesh to formulate the national reform and appropriate reforms will result in improving health outcomes.
The writer is Country Director, Population