Local governments and rural health services
Health security for rural people is often undermined by the lack of physicians, employees and nurses, misdiagnosis and negligence towards patients
Health security is generally viewed as an important index of Human Development. The Constitution of the Peoples Republic of Bangladesh ensured that Health is the basic right of every citizen of the Republic as health is fundamental to Human Development. Health is a basic requirement to improve the quality of life. National economic and social development depends on the status of a countrys health facilities. The healthcare system reflects the socio-economic and technological development of a country and is also a measure of the responsibilities a community or government assumes for its peoples wellbeing. Over the past decade, Bangladesh has renewed its efforts to address large-scale incidents that have threatened human health, such as natural disasters, disease outbreaks, and terrorism. Statistics mentioned underneath denotes the level of progress Bangladesh made in health sector over the decades.
The Constitution of the Peoples Republic of Bangladesh guarantees that health is the basic right of every citizen of the Republic. The Ministry of Health and Family Welfare leads on policy formulation, planning and enforcement. Within this, there are five Directorates: health Services, family planning, nursing services, drug administration and health engineering. In recent years, health policy has focused on sustaining provision of basic services to the entire population, particularly to under-served rural communities. The Union Parishad is the lowest tier of the local government of Bangladesh and plays an important role in rural development. One of its responsibilities involves providing health security to the rural population, which is a challenging task given that only 30% of Bangladeshis live in cities and there is limited infrastructure and a lack of health professionals in rural areas.
A standard upazila (district sub-unit) in Bangladesh is supposed to have a Health Family Welfare Center at Union Parishad level and Community Clinics at village level. The Welfare Centre offers general health services, and basic reproductive, maternal, and child health care services for local people free of charge, and each one has a Medical Assistant trained for three years in disease prevention, health education and basic first aid, and a Family Welfare Visitor who receives 18 months of training in family planning, reproductive health, and preand post-natal care. Community Clinics are government run (having taken the place of local clinics which were established as part of a donor driven mega programme initiated on pilot basis from 1996-2000. They are mostly used by people living within a half-mile radius, but around 50 percent of rural women are not aware of their existence and many rural people prefer to consult with a pallichikitshak, a local village doctor without any formal healthcare training. This is perhaps unsurprising given that clinics are ill managed and understaffed and therefore associated with poor quality care and attention to patients.
Public healthcare is supplemented by efforts led by local entrepreneurs, NGOs and international organisations. A number of local NGOs like BRAC have special reproductive health care programs and facilities for providing antenatal and safe delivery care. There are also numerous private clinics throughout the country and many doctors from the public hospitals deliver services part-time in these clinics to supplement their incomes. The clinics operate on a fully commercial basis and are therefore costly, but those who have the resources prefer them because they are seen as offering better quality than public hospitals.
However, private clinics lack accountability because they cannot be regulated by the government. Despite the facilities and support provided by both the government and private/NGO providers, rural healthcare in Bangladesh is therefore inadequate. For every one million people there are just 241 physicians, 136 registered nurses and 10 hospitals (making the availability of hospital beds 1 for every 4000 people).
The available literature suggests that health security for rural people is often undermined by the lack of physicians, employees and nurses, misdiagnosis, negligence towards patients, irresponsibility, absenteeism and a lack of professional ethics. Furthermore, although the bulk of the population of Bangladesh lives in rural areas, most doctors are based in cities and towns. Doctors are deterred from serving in the villages due to the absence of proper capacity development, accommodation, quality education, transportation facilities, and the lack of career prospects. The Union Parishad also struggles to push for improvements due to the scarcity of resources and dynamic leadership.
A comprehensive National Health Policy was introduced in 2011 and re-emphasised every citizens basic right to adequate health care and the state and the government constitutional obligation to provide the necessary infrastructure.
Its stated objectives were to strengthen primary health and emergency care for all, expand the availability of client-centred, equity-focused and high quality health care services, and encourage people to seek care based on rights for health. However, this has not been effectively enforced over the last five years, and as a result health provisions are unevenly distributed across the country and access to the best care will be prohibitively expensive for the majority of rural Bangladeshis. Union Parishad is one of the most important units of government in overseeing the health security for rural population but it is confronted with chronic problems which it does not have the resources to address on its own.
The functions of standing committees in Union Parishad are crucial, important and significant to improve the service delivery at grassroots level. Basically Union Parishad is a service delivery organization though its efficiency and capacity is still debatable. For the sake of transparent and accountable and viable service delivery organ of the local government, Union Parishad should make its standing committee functional. But the scenario of Union Parishad is not very friendly on the question of effectiveness of standing committees. Most of the Union Parishads made it for official purpose, but practically their implication is not seen anywhere. As per the allocation of business, members of the Standing Committee on Health activate health officers to get the regular status of EPI program, to know the sanitation behavior of the locality and source of safe drinking water.
The members of the standing committees also monitor regularly different Hospitals and Clinics. But in truth, functional standing committee is still end.
Union Parishad is ineffective in ensuring health security of the rural people by reason of lack of commitment and vision of the elected officials particularly the Chairperson of the body prohibit the Union Parishad to provide necessary health services to the community. Inadequate number of physicians, employees and nurses and unwillingness to stay at rural areas and small towns put the health security for rural people in danger. Bangladesh requires a need-based, pro-poor and feasible program to guarantee health security, which will be formulated through a participatory approach with the active participation of the relevant stakeholders. Bottom up policy planning system should be introduced in the public policy formulation. Central monitoring and evaluation system be strengthened so as to make sure that, health facility is available for the rural people.
The lowest tier of local government should be strengthened and given the responsibility to make rural health care service accessible for all. The government of Bangladesh has adopted National Health Policy in 2011. This is a strategic directive and indicator to the mechanism of exploiting available resources to realize the Governments vision for addressing the health issue of the country. Enforcement has essence to promote health security across level. Above all, central government support and enforcement of existing legislation alongside greater cooperation with civil society organisations, the media, academics and the donors is needed to enable local government to ensure a higher standard of basic healthcare in rural areas.Last but not least, social research is worthy to explore the health behavior of rural people and enable the policy makers across level to formulate appropriate policies and programs for promotion of health security.
The writer s an Associate Professor of Government and Politics at Jahangirnagar University in Bangladesh and Visiting Research Fellow (Trinity Term-2018) at the University of Oxford. He can be reached at t.islam@juniv.edu
