Corona pandemic, which has hit us with its high incidence rate and hug fatalities along with hunger caused due to adopting lockdown as its preventive and control measure, is not desirable in any way. Living with this reality, as World Health Organization said, may be prolonged. Thus, in addition to manage the COVID-19 crisis in a pragmatic way, we should focus on reforms our health sector to resolve its long-standing and deep-rooted problems for making the health system functional.COVID-19 crisis has markedly shown the gravity of problems in the health sector. It has also helped us to understand the importance of the health sector. We have also learned that dependency on the private sector for health care is nothing but foolishness. And depending heavily on other countries for treatment is the same as relying on foreign army for ensuring the sovereignty of a country. Travelling abroad has become a tradition for many of us even for common ailments. Therefore, our policymakers perhaps did not realise the need of a functional health system for the country. Actually it was out of their imagination that such a dreadful contagious pandemic like COVID-19 would attack and no country would welcome us to travel there for receiving treatment.
All the stakeholders including the upper echelons of our government might have by this time realised the need for comprehensive reforms in the health sector. Thus, it is the time to move forwards for reforms.
The reforms should be based on a Master Plan, for addressing the root causes of problems, not on a piecemeal basis. The management of the health sector, as an evolving and complex sector, requires experienced and trained human resources. As per the rule of Bangladesh Civil Service (BCS) all the officers must be transferred to another ministry / department at the end of a given period. This basically works as a hindrance to acquiring skills and experience in a particular area. Therefore, huge deficiency in experience and skills is often observed among the top officials working at secretariat level. Although this is common in all ministries, Ministry of Health and Family Welfare (MOHFW) cannot afford it.
Tremendous shortage of experienced and trained managers is also seen in the lower tiers including DGHS. The healthcare managers with field level experience including the Upazila Health and Family Planning Officer (UHFPO) and the Civil Surgeon (CS) have lack of opportunity in one hand, and provide little effort on the other to develop themselves efficiently since they have little chance to be posted in upper echelons of the management. Medical officers recruited under BCS are usually determined to build their career in clinical line. Not having much scope of getting promotion in the upper tiers of the management further discourages them to hold such a post. Even those who hold these posts become demoralised and get frustrated. Additionally, severe lack of adequate managerial trainings (e.g., human resource management, accounting and financial management) including the foundation one also impedes them to become an efficient manager. Therefore, they are heavily dependents on lower level staff (e.g. accountant, clerk) working in the non-transferable posts of their office for any managerial decisions related on finance and expenditure.
Filling up the higher posts in DGHS by the Professors of Medical Colleges is a major deterrent of not getting promotion of the field level managers in upper level. Due to not having prior administrative experience they also largely rely on the lower level staff of their departments for decision making on finance and expenditure.
The health sector, hence, mostly relies on unskilled, inexperienced, and unprofessional personnel for making crucial decision including finance and expenditure. This calls for increasing the management capacity of health sector including asking for adequate budget and exhausting the allocated budget through ensuring its quality expenditure.This calls for developing a completely separate structure for the management of the health sector. The field level managers including UHFPO, Superintendents, and CS should be trained through providing all kinds of administrative trainings including human resource, finance, and budget management. Acquiring a master degree in Health Economics or Public Health must be fixed as a prerequisite for their promotion in the higher posts. Recruiting Health Economics/Economics or Public Health graduates is also essential for financial management efficiently by creating appropriate posts in each tier of the health administration including Upazila. Alternatively a separate cadre for health manager can be created in BCS where merely Medical graduates, Health Economics graduates, and Health Care Management/Administration graduates can apply. Attention should also be given on the Department of Health Engineering for increasing their professional efficiency.
These experienced and skilled managers should be gradually placed in the higher posts over 5 to 10 years period. Professor of the Medical Colleges can be appointed in the important positions of the newly created Medical Education Department. Special emphasis should also be given to increasing the quality of medical education by upgrading the curriculum through including problem-based learning methods. The knowledge of basic Health Economics and Public Health should be included in the syllabus of MBBS programme. The Medical Technologist education should be solely handed over to the State Medical Faculty to mitigate the chaos in medical technologist education as well as recruitment.
In addition, the primary healthcare infrastructure needs to be strengthened with an emphasis on preventive healthcare including infectious disease control. For this, organograms of all health centres from community clinics to Upazila Health Complexes have to be updated. Strong primary healthcare infrastructure giving emphasis on preventive healthcare has to be developed for every 25,000 to 30,000 urban people. Besides, required human resources have to be employed after updating the organograms in all the secondary and specialised hospitals. Necessary steps should be taken to introduce an effective referral mechanism by strengthening the health system through executing these reforms.
The reforms are also essential in provider's payment mechanism. Output-based incentives need to be added with the current input based payment structure. Such incentive structure is already in operation in some departments including Bangladesh Police. However, if Public Financial Management rule does not allow such incentives for medical professionals to the wider extent, the Medical Cadre should be brought out of the BCS like the judicial cadre. The private sector needs to compel for making itself-standing through employing full time medial staff based on a standard approved organogram. The private sector also needs to come under standard accreditation policy.
The current size of formal sector and magnitude of tax-GDP ratio do not support for introducing social health insurance for the entire population in near future. Therefore, for the time being, emphasis should be given on public finance. Additional allocation can be ensured by imposing 1-2% additional VAT on non-essential commodities or imposing some levy on mobile phone call rate.
All the aforementioned reform issues need to be outlined based on a Master Plan. A National Health Commission like China should be formed for faming as well as executing these reforms and for adjusting with evolving situation. However, we need to enact an Act for establishing the National Health Commission. Thus, we urge to form a national taskforce immediately for drafting the Act.
The writer is a Professor, Institute of Health Economics, University of Dhaka.
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