THE Local Government (Municipalities/City Corporation) Act, 2009, within the remits of some conditions, such as accordance with government standards and confines, bestowed the responsibilities of ensuring a considerable range of healthcare services on the 329 municipalities (pouroshovhas) and 12 city corporations that the country has. This includes authorization to register mandatorily in private hospitals and paramedic institutes. This is in addition to the licensing of these facilities by the Directorate General of Health Services.
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Health-related responsibilities of local government institutions
SOME health-related activities that local government institutions are expected to undertake, as per the Act 2009, are: (1) enforcing the owner or occupier of any building or land to keep their premises in a clean, sanitary and wholesome state; (2) removing waste that includes holding occupiers of all private buildings and lands within a local governance institute, LGI, responsible for the removal of waste from such buildings and lands; (3) provision and maintenance, in sufficient number, and in proper situation, public latrines and urinals and sewerage for the separate use of each sex; (4) registration of all births, deaths and marriages; and (5) adoption of measures to prevent and restrain infectious diseases.
The LGIs have responsibility, if required by the government, to (1) establish and maintain hospitals for the reception and treatment of people suffering from infectious diseases; (2) promote public health, including health education; (3) establish and maintain such number of hospitals and dispensaries as may be necessary for medical relief of the inhabitants, that will include provision of medicines, instruments, apparatuses, appliances, equipment and furniture for these facilities; (4) (a) establish and maintain of first aid centres; (b) establish and maintain mobile medical aid units; (c) promote and encourage society for provision of medical aid; (d) promote medical education; (e) pay grants to institutions for medical relief; and (f) organise medical inspection of school children.
Local governance institutes are also responsible for supplying wholesome water for public and private purposes; approving, controlling, regulating, and inspecting all private sources of water supply; and providing an adequate system of public drains with due regard to the health and convenience of the public. The municipality shall levy fees on the private owners of such facilities and shall control, regulate, inspect and may require the provision, alteration, covering, clearing and closing of private drains. LGIs are also responsible for preparing a drainage scheme and constructing drains at public and private expense, after approval from an appropriate authority. They are required to set apart suitable places for use by the public for bathing, washing clothes, or drying clothes; to specify the times and the sex of persons for their usage; and to prohibit, by public notice, the use by the public of any such place; accord licenses to private bathing facilities for public use; to provide dhobi (washerman) ghats; regulate the use of dhobi ghats; and levy fees for their use, including the provision of licensing for washermen and the regulation of their calling.
Local governance institutes may, with the previous sanction of the relevant authorities, declare any source of water, spring, river, tank, pond, or public stream, or any part thereof, which is not private property, to be a public watercourse and may provide such amenities, make such arrangements for lifesaving, execute such works, subject to the provisions of any law for the time being in force relating to irrigation, drainage and navigation; regulate the use thereof; keep public water sources free from pollution; and take punitive action against someone who would pollute this source of water. They provide licenses for boats and other vessels plying for hire in a public watercourse and may, with the previous sanction of the government, declare any public watercourse a public fishery and thereupon accord the right to fish in such water.
The LGIs will have authority to ensure the safety of foods and beverages in public places and will prohibit the manufacture, sale, or preparation, or the exposure for sale, of any specified article of food or drink in any place or premises not licensed by the municipality; prohibit the import into the municipality for sale, or the sale, or the hawking for sale, of any specified article of food or drink by persons not licensed; prohibit the hawking of specified articles of food and drink in such parts of the municipality as may be specified; regulate the time and manner of transport within the municipality of any specified article of food or drink; regulate the grant and withdrawal of license and the levying of fees; and seizure and disposal of any animal, poultry or fish intended for food which is diseased, or any article of food or drink which is noxious. The LGIs have the authority to provide license to keep milky cattle for the sale of milk, or sell milk, or export or import milk for sale, or manufacture butter, ghee, or any other milk or dairy product, nor shall any premises be used for any such purpose; frame and enforce, with the previous sanction of the prescribed authority, a milk supply scheme, which may, among other matters, provide for the establishment of milkmen鈥檚 colonies, the prohibition of the keeping of milky cattle in the LGI or any part thereof, and the adoption of such other measures as may be necessary for ensuring an adequate supply of pure milk to the public.
Besides, an LGI has also been bestowed with the responsibility of licensing private markets, slaughter houses, establishing veterinary hospitals and dispensaries, animal vaccination, detention, destruction or disposal of dangerous animals, disposal of carcasses, etc.
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Local government institutions and urban health care
ONLY a few municipalities and some city corporations have a reckonable health department. Some nominal health departments exist that are often headed by engineers or other categories of staff. Not even a city corporation has adequate structure and human resources to fully cater to the required healthcare, bestowed on them via the 2009 Act. LGIs do not have the financial prowess or technical strength to undertake the healthcare responsibilities of their population, as they cannot garner funds to commission the required healthcare infrastructure.
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Stumbling blocks to enabling LGIs
THE ministry of local government rural development and cooperatives is the parent ministry of the LGIs, although the LGIs are autonomous. The word 鈥榟ealth鈥�, however, does not exist in the rules of business of the ministry itself, so it cannot allocate funds for healthcare. LGIs receive untied grants from the ministry, which some LGIs apportion for healthcare along with their own funds. Some union parishads, not all, do in fact allocate about 14 to 15 per cent of their budget for health services. The ministry of health and family welfare, on the other hand, is the responsible ministry for healthcare in the country, according to the allocation of business. But while it has appreciable primary healthcare infrastructure in rural areas and useful secondary and tertiary healthcare infrastructure in urban areas, the same cannot be said about the primary healthcare infrastructure of the ministry in urban areas. The urban population, in particular in slums, is therefore left out of the primary healthcare gamut. The ministry cannot transfer any cash support to the LGIs to enable them to fulfil their healthcare obligations. The Treasury Rule prohibits this. LGIs are not in a position, on the other hand, to master adequate funds. The LGIs also fail to raise taxes, even when warranted by law.
Experientially, health is not a priority for LGIs. According to the Treasury Rule, only the ministry of finance can allocate funds directly to the LGIs, like any other ministry, subject to the fulfilment of the conditions of other relevant ministries. It is good to know that the ministry of finance has recently initiated a scheme to fund some LGIs on a pilot basis.
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A recent past experience to take note of
A LOCAL Government Division circular (that I drafted as a consultant for the EU Support to Health and Nutrition to the Poor in Urban Bangladesh Project), issued belatedly on March 22, 2021, has the following healthcare service-related provisions, none of which have been implemented yet:
LGIs, in collaboration with the ministry of local government rural development and cooperatives and the ministry of health and family welfare, will decide the need for human resources for health and develop a model human resources infrastructure. The different categories of human resources included in the infrastructure will be deployed and paid for by the Health Division and Health Education and Family Welfare Division of the ministry of health.
LGIs would create non-technical support posts, recruit and pay for these posts; create and update healthcare infrastructure; provide logistical support; and create a conducive working environment.
LGIs will implement national programmes in collaboration with the health ministry and will monitor, coordinate and supervise the health activities of non-government and private sector managed healthcare services.
LGD, in consultation with the health ministry, will develop urban health-related policy, strategy, plan, and programme.
Nationally, funds for urban health will be under the control of the health ministry. The distribution of this fund will be done in consultation with the finance ministry, while the health ministry will provide equipment, machines, medicine, training and tools for national programmes to LGIs.
LGD will give untied grants to LGIs for health and nutrition services. LGIs will also allocate a portion of their income for the same and will bear the expenditure for repair and maintenance.
The ministry of health will include LGIs鈥� health and nutrition-related plan, review, monitoring and evaluation in its plan. In its national and local level planning and reviews, the ministry of health will include LGI officials. LGIs will populate the District Health Information System with the relevant information.
The health ministry and the LGD will implement recommendations of the Urban Health Coordination Committee and the Urban Health Working Group, which was formed earlier in 2016 that still remain non-functional.
In case of any dispute, instructions or advice will be taken from the Cabinet Division.
Earlier, in 1999, I drafted a memorandum of understanding as the director, Primary Health Care and Disease Control, Directorate General of Health Services, and the Local Government Division of the local government ministry issued it as a government circular (Poura-1/F-3/98/926 dated September 15, 1999). The content of this circular was not very different from the 2021 circular mentioned above. One exceptional provision in this circular was to hand over the health and family planning facilities that are not used for training to LGIs (to the then-four city corporations). It needs no emphasis to state that the responsibility of healthcare in urban areas, even according to the 1976 Pourashabha Act and the later Acts under which the city corporations were established (first in 1983 for Dhaka City Corporation), was bestowed on the LGIs. It was nonetheless underscored that urban health service providers will be deployed by the ministry of health and family welfare, as stated in the 2021 circular. The circular also mentioned the expressed role of the ministry of finance in financing urban healthcare.
None of the 2021 or 1999 circulars, however, was even placed for discussion. Thus, the Act of 2009 remains in limbo, as are the two circulars, and no effort has ever been taken as of now to honour and implement the Act.
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Way forward
READERS may now fathom the conflict between the 2009 Act, revised in 2010, and the rules of business (for the health service part). The Act did not mention that the responsibilities of catering health services lie with the ministry of health and family welfare. It also did not fully clarify the mutual healthcare responsibilities and remits of the two entities. The healthcare provided by some other public sector-owned health facilities also needs to be put under scanner, viz, what laws or rules of business govern the establishment of these facilities by other sectors.
A reconciliation, in light of the above narratives, is warranted between the health ministry, the local government ministry and local government institutes before the next five-year-long sector-wide plan of the health ministry flows into operation. The so-called sector-wide plan of the health ministry foresees upgradation of the existing 35 government outdoor dispensaries in the country, with the creation of 22 posts instead of the present five, including specialists and upgraded diagnostic services in each. It is also imperative to see that the number of health facilities in the other different sectors ensures the efficiency of resource utilisation.
It needs to be assessed as to whether the healthcare facilities of the other public and private sectors are being used efficiently and effectively and whether some of these facilities may, fully or partly, be used for urban healthcare. This will preclude the unnecessary and inefficient build-up of urban health facilities. It will be advisable, in fact, to develop a standard ratio of different types of service seekers and the number of required types of care outlets accordingly first, map out the existing permanent healthcare-related facilities of all the public and private sectors by type and the range of healthcare provided in these facilities, and establish new ones only thereafter. The ratio mentioned will have to consider the transportation, the travel facilities and the time taken to reach the envisioned unit of health facilities.
For ensuring the implementation of the 2009 Act and the ministry of local government circular mentioned above, modifications to the Allocation of Business of the local government ministry or the Treasury Rule relevant to the health ministry or both of these two will be required. The finance ministry may, based on its piloting, initiate direct funding of LGIs as an alternative for enabling LGIs to undertake their healthcare responsibilities as per the Act. However, enhancing and strengthening the technical and managerial skills (planning, monitoring, supervision, review and evaluation) of the LGI health department officials will be necessary. Collection of tax by the LGIs will not be adequate for two reasons: B and especially C category LGIs lack strong leadership to realise tax locally (they are apprehensive of losing elections if they are too adamant to collect tax), and the other reason is the poverty of the inhabitants of most of the B and especially C category LGIs. Collaboration between the health ministry and LGIs at least in the initial phase will be necessary for strengthening the LGIs.
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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.