PUBLICLY financed health services cover clinical, preventive and promotive services in many countries, including Bangladesh. But as people globally are more interested in instant relief from maladies, the clinical management of illnesses gets priority. The national health services in countries such as the United Kingdom, Australia, Spain, Portugal, Sweden, Norway and Canada are tax-based public financing system although some of these countries charge co-payment from patients. Primary healthcare services are bought from the private sector which includes general practitioners.
Hospital care is, however, managed by government health departments although under duress, hospital care is also bought from the private sector as well. In the United States, clinical care is still managed by private health maintenance organisations. Beneficiaries insure themselves privately. But preventive and promotive services are, even in the United States, managed publicly. By and large, except in this sub-continent, public health and clinical care management fall under separate and independent domains,, even in Thailand and Indonesia.
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Separation of public and clinical health care
ALMOST a fourth of the people in poor countries do not possess enough money to even pay for emergency health care. So, the expectation that they would pay for health problems that they did not suffer from yet will be, too, far-fetched to think of. The educational background, skills and experience that are warranted to cater clinical and public health care are different. These have been amply seen during the Covid outbreak. The market value for clinical care and public health care are different and to bring the clinicians to manage public health care is to fan inefficiency.
Management-wise, there is a clear and deep chasm between these two facets of care. One is patient-oriented while the other is pluralistic and oriented on disease prevention and control and health promotion. Budget-wise, a clear distinction exists between these two areas of management 鈥� heads and subheads of budget, for example. Clinical care would be very different from that public health care. Clinical care that includes diagnostics and the regulation of private care are extremely vast and complex; and so is public health care but with distinct types of interventions. Goals and targets are different and they have different unlinked indicators to pursue.
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Multifariousness of public health care
ONE needs the following experiences, skills and education to practise public health 鈥� managing different tiers of public health with varied activities and components, especially human resources; disease and nutritional surveillance including community-based sampling, sample collection, transportation and testing in local laboratories; awareness building; knowledge of the social determinants of health; techniques of disease control and prevention; knowing the community and the techniques of community engagement; developing plan and budget, financing and financial management; rules and laws of procurement of goods, services and works; managing stores, transport and the distribution of goods; the techniques of monitoring, management information, research and learning; the protocol of supervision for quality of care; leadership and; and听 governance; the management of hotel components of a hospital, besides other services.
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Suggested infrastructure for public health
The following structure for public health should be built. Relevant organisations, institutions and offices have been presented in the form of an organogram. The diagram is a fully-fledged structure, from top to bottom. Only the disease control, prevention, nutrition and health promotion related positions have been depicted. The indoor of the upazila health complex and the laboratory would be linked to the directorate of clinical/hospital and diagnostic services.
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Other required actions
Directorates: the director and additional director generals of public/primary health care services may be deployed from the existing senior most positions of the current Directorate General of Health Services while the latter position may be re-designated as the director general of hospital and diagnostic services. The piece of land earmarked for the construction of the office for the community clinic health support trust may locate the office of the directorate general of public/primary health care.
Re-organisation: The community clinic health support trust, the bureau of health education and other disease related programmes and line directors, eg tuberculosis control and HIV/AIDS control, and lifestyle, and health education and promotion are brought as programmes, to be managed by programme managers, under the directors/chief of primary health care; communicable disease control; and the bureau of health education. The directors of budget and finance; administration; management information system; and human resources positions may remain with the directorate general of clinical/hospital and diagnostic services and the same positions would be created for the directorate general of public/primary gealth care or vice versa.
An alternative may be to assign those of the budget and finance and management information only to the directorate general of public/primary health care. It is warranted that officials get these positions by dint of seniority and experiences and that they are also designated as line directors, which was the idea at the initiation of the sector-wide approach in 1997 and 1998. The directorate general of public/primary health care will also have relationship to the health engineering department, the transport equipment maintenance organisation and the national electro medical equipment maintenance workshop.
Urban health: As of now, no primary health care structure exists in urban areas. The local government division has been implementing an urban primary health care project since 1999 on an ad hoc basis. the local government, rural development and cooperatives ministry has no mandate for health care while local government institutions are legally responsible for the same but without any capacity or financial support. Required infrastructure needs to be developed to cater urban health care. Health facilities, at least in part, in urban areas, owned by different sectors, may be used to provide primary health care. Based on mapping, additional health positions may be created, each for 10,000 population, as transport is better in urban than in rural areas.
Creation of additional positions: For making the structure effective, the creation of a few additional positions will be necessary. These are director, urban health care and, in districts and upazila, medical officer of disease control; health education officer; and nutrition officer. These positions are in keeping with the Health Policy 2000 and 2011. The creation of a position of public health nurse at the upazila level will also be useful. The review of the positions, functions, recruitment rules, benefit package including the severance conditions and carrier ladder will have to be streamlined for some positions.
Universal health coverage: Quality, coverage and equity targeted processes and techniques will have to be updated in the light of the aim to ensure universal coverage of service seekers. Financing mechanism needs to be adequate and appropriate, keeping universal health coverage in mind. Other health system components also require to be strengthened through appropriation and ensured adequacy. Tax-based financing of health care seems promising. Relevant laws and contract management skills among the public health officials will be required.
Demarcation of public and clinical health: The relationship between hospital and diagnostic care and public health care should be thrashed out at upazila and district levels subtly and intelligently, with clear-cut positioning and interfacing. This should not be a Herculean task. Adequate service providers at all levels including in urban areas and for field positions, and physical structures must be created or renovated in the light of population ratio, eg more service providers at the union level. Positions that cannot be filled should have a-contract in or contract-out mechanism locally; field workers and general practitioners may be piloted.
Administrative measures: The creation or re-designation of the positions would require approval of the public administration, the law and the finance ministry. The law of 2018 that established the community clinic health support trust and the 2009-2010 Local Government (Municipality) Act will have to be reviewed. All this should not take more than three months at most in the present situation. Initially, the director genera of public/primary health care has to be assisted by a panel of relevant experts.
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Abu Muhammad Zakir Hussain is a former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO and former staff consultant, Asian Development Bank, Bangladesh.
