PUBLIC SERVICE DELIVERY SYSTEMS IN BANGLADESH: GOVERNANCE ISSUES IN THE HEALTH SECTOR
Introduction
Bangladesh govt. spends substantial amounts of money on health services; nonetheless, dissatisfaction is frequently expressed over the performance and quality of these services. The main purpose of the present study is to assess the governance issues in the health sector which adversely affect efficient health care delivery including staff absenteeism, leakage in the distribution of medicine and other supplies. An attempt has also been made to provide an overview of the factors which act as barriers to effective utilization of public health facilities.
Objectives of the Study
The specific objectives of the study are to:
1) Identify and prioritize a comprehensive list of governance issues/risk areas within the health sector (i.e. non-availability of drugs and commodities, staff absenteeism, imposition of unofficial fees, etc.).
2). Recommend specific areas where the MPs can contribute in maintaining strict oversight of health service delivery mechanisms and in formulating pragmatic laws, rules and policies regarding improvement of governance thereby ensuring efficient use of public resources.
Methodology
The present study is based on primary data collection and interviews in each of the country’s seven divisions. In each division the sample comprised two district hospitals (DH), four Upazila Health Complexes (UHCs), and four Union Health and Family Welfare Centres (HFWCs)). Thus, 10 health facilities from each division and a total of 70 facilities from seven divisions have been covered for the study purpose. Facilities covered included 14 District Hospitals (DHs), 28 Upazila Health Complexes (UHCs), and 28 Union Health and Family Welfare Centres (HFWCs). A total of 1820 patients were interviewed for the study-of them 1260 (69.2%) were outpatients and the rest 560 (30.8%) were inpatients.
Both quantitative and qualitative data were collected. In addition to patient survey through structured questionnaire, in-depth interviews (KII) were conducted with facility administrators/ service providers. Several Focus Group Discussions (FGDs) were also conducted at the district, upazila and union levels.
Major Findings
The findings show that overall, the poor dominate the utilization of public health facilities. The share of the poorest quintile (bottom 20%) was 26% of total utilization, while the share of the richest 20 % was only 15%. In general, utilization of public health facilities is pro-poor and pro-gender which implies that women and the poor are more likely to use the facilities. Physical accessibility is no longer a barrier in the sense that people do not have to travel a long distance to reach the health facilities and once they arrive at the facilities, they do not have to wait for a long time. But economic accessibility acts as a major barrier. The poorest are the largest users of public health facilities but they also bear a disproportionate share of the burden of ill health and suffering. On the whole, 9 % of the monthly income was spent for the treatment of a single episode of illness. But the poorest households spent 35% of their monthly income for treatment purposes, as against 5% by the richest households. Poor households have to undergo a lot of economic pressure to buy medicine and other health needs.
There are a number of governance issues in the public health service provision, which contributes to poor quality of services. Availability of medicine seems to be the most decisive factor in patients’ perception of hospital services – their main expectation and concern. Prescribed or medicine necessary for treatment is generally not available at the hospital. Nepotism and unofficial payments are widespread. About a third (31.8%) of the inpatients at the DH and one-fifth (19.6%) at the UHC had to make extra payment for getting admission. Of those inpatients that made unofficial payments, about 60% paid once, about a third had paid twice and 8% had to make extra payments at least three times. People from poorer households have at least the same risk of making extra/unofficial payments as those from richer households.
There is widespread staff absenteeism at the public health facilities, around one-third of doctors are absent or unavailable at a given time. The qualitative data also shows that there is a large majority of participants who find that there is an acute shortage of medicines, that doctors are not available, that support staff is showing a hostile attitude, that nurses and ward boys are not available and that they behave unkindly. In general, patients’ rating of quality of public health services is not very encouraging, less than 40% of the patients were satisfied with the services of doctors.
Concluding Remarks
Improving the health of individuals, particularly those belonging to socially and economically disadvantaged groups, is a key objective of the Bangladesh government. The Government attaches due importance on the fact that in order to be effective, the publicly funded health services must be accessible to the poor to meet their health needs. Health care provision involves a complex series of transactions between health service providers and consumers. Good governance and management of these transactions are essential to ensure that the right services are delivered to the right people at the right time and at the lowest possible price. It follows therefore, that poor governance negatively impacts service delivery.
The findings from the quantitative and qualitative data reveal that government efforts to improve health service delivery have not yet produced the desired results. Interaction between service providers and patients is not always direct and the latter are often required to go through intermediaries to get access. Once having access, patients encounter numerous problems getting the required medicine, care and attention by the service providers. In addition, they have to pay unofficial charges for various tests/investigations required to be done while at the hospital. Essentially, it is the poor and vulnerable members of society who are particularly prone to the largest burden of cost and poor service delivery.
Any policies, strategies and plans must give primacy to addressing core governance issues in the health sector. Rebuilding hope among the patients requires that urgent governance issues be addressed to ensure that service providers are available at the facilities, minimum amount of drugs reach the patients and unofficial payments are at the lowest possible levels.
Health care delivery systems have to be more accountable, responsive and able to reach the very poor, and these are the areas where MPs need to play more active role in strengthening monitoring and supervision efforts including strict oversight role. Based on the findings from quantitative and qualitative data, the following recommendations are made to address the problems of governance in the health sector.
Effective involvement and participation of the local community as stakeholders- MPs, Upazila/UP Chairman/Member in planning, management and monitoring of services of health facilities.
Some more specific recommendations about the role of MPs/elected representatives:
• Having regular meetings with staff to promote professional ethics;
• Paying regular unannounced monitoring visits to the facilities to check that doctors are present and procedures are followed in delivering services;
• Absenteeism rules should be clear and a system for controlling presence should be introduced. MPs/ local level representatives should be in a position to take action against unauthorized absence or negligence of duty;
Sponsoring Agency
The Asia Foundation
Team members
1. M. A. Mannan, Senior Research Fellow, BIDS
2. Ms. Badrunnesa Ahmed, Research Associate, BIDS
3. Ms. Siban Shahana, Research Associate, BIDS
4. Dr. Rumana Huque, Associate Professor, Department of Economics, University of Dhaka (external consultant)