A REFORM agenda must precede the question — why reform? This question is, however, redundant when it relates to a dynamic sector such as health. As new knowledge on different aspects of healthcare science is generated constantly and society and beneficiaries also update their knowledge continuously, people’s needs and demands for health care by type and volume change. Inventions also require the updating of skills and knowledge of service providers. Since the physical, social, political, climatic, economic, organisational and the corporate world are in a flux, the health sector functions also ought to be in a state of fluidity.
The sector, therefore, needs to adjust itself continuously with its external environment that is in a state of friction, pull and push, opportunity and threat, and strength and weakness of multifarious nature, some of which also emanate from within the sector and from its own units and elements. A good plan is half of the success of an endeavour. A good plan hinges on the capacity of the frontal lobe of people’s brain that assimilates and analyses the required information, juxtaposed to experience. As of now, we do not possess enough information and understanding of the health sector to lead a meaningful reform.
Aim of reform: Improvements in care quality and coverage equitably — need-based complete care for all — are the fundamental aims of health sector reform. It is expected that in doing so, state-of-the-art tools and techniques will be used. Creating a physically and mentally productive nation is an economic goal of health care. The other crucial goal should be the prevention of pauperisation that may result from the buying of health care. The assemblage of the relevant resources in right proportion at right time and on warranted locations creates an enabling environment for providing expected services. Ensuring the availability of right ratios of different categories of skilled service providers at different units of a health care facility in the light of popular need is an aim, too.
We also aspire for the existence of all the necessary health system elements, as discussed below, on all locations. They will vary according to place, person — number and type of service seekers — and time. Decision-makers have to keep themselves abreast of the needs and variations and the related problems when they go for a reform. Examining how is the availability and resource distribution in the system, especially human resources and finance in the light of place, time and person is imperative.
Systems thinking: Dynamic relations between the system’s units need resource balancing and adjustment in the light of findings from periodic examinations of the system, its component parts and compositions. The understanding of a system’s units singularly and holistically and their functioning conditions- interactions and relationships between them; prerogatives and prohibitions; policies and principles; strategies and plans; rules, regulations and conventions; and the working conditions, ie the governance practices and approaches, need to be understood besides examining the technical and the management capacity of those involved in providing the care. Succinctly speaking, for reform, we need systems thinking.
In ordinary parley, people talk about day-to-day and apparent problems and their quick-fixes. But these are not reforms. This is coping. The system’s approach examines the components of the system, analyses why and how they make the whole. It is about looking at the whole to understand its parts and looking at the parts to understand the whole. It is to find out the bottlenecks in the system by examining the whole of the system and each of its parts. We need to appreciate that any problem in a part of a system causes weakness in other parts. So, piecemeal findings and fixings of problems that is apparent will not solve the problems. Deep inner structures, patterns, profiles and predicaments need to be understood. We need to look into when and why they interact and when and why they do not. Organisational strength, weaknesses, opportunities and threats, barriers and enablers have to be explored before offering solutions.
Governance: Governance determines the structural and other indicators of appropriateness, adequacy, transparency and the processes of financing, procurement and the use of works, services and goods, and human resources. One particular issue is malpractice in providing service, eg advice of unnecessary tests, polypharmacy, induced care such as unnecessary Caesarean operation. We need to decide which punitive action should be taken for these and other wilful negligence and criminal offences committed by service recipients and service providers. We need to reason what if there is deliberate or inadvertent inefficiency or ineffectiveness in catering services? Setting and imposing rules, fixing remits of interactions and practices, in particular among and between human resources, are an important governance function. Checking the adequacy and appropriateness of governance functions also need some contemplation — should the licensing conditions be reviewed? How to monitor and supervise compliance of the laid conditions?
Health services: Healthcare quality and coverage are poor from people’s perspective. One reason of the poor service quality is said to be the apathy of service providers towards service recipients, particularly to the poor and illiterate. These seep in through the cracks of poor accountability although it is not a linear issue. Standard operating procedures are not available for all types of services. They are hardly followed even when they are present while some need updating. Poor diagnostic skills are said to be a reason for medical migration. Poor governance, leadership, management — programme implementation, monitoring and supervision — and lack of vision are blamed,Ìý in part, for the weaknesses. Hospital accreditation and the accreditation of medical, nursing and paramedical institutions have been suggested for improving clinical care. What quality indicators should be prioritised has not been set yet although a huge list of indicators is available, which includes patient-centred care. Health communication is a strong component of health services. It needs strengthening by updating the recruitment rules of the Bureau of Health Education and use its resources more efficiently, besides adding up state-of-the-art resources.
Another important facet, where service-oriented reform is a religious requirement, is urban primary health care. How will it be ensured for the urban population will have to be worked out. Past experiences are patchy and hazy. Responsibility and ability do not commensurate in local government institutions.
The bifurcation of maternal, neonatal and child health care in a piecemeal manner, from top to bottom, care and management-wise, causes duplication and, hence, inefficiency. The duplication of care is not illogical in some instances, but not for maternal and child health care. We should come out of the politically motivated decisions.
Health care financing: There are five common sources of healthcare financing — tax, social health insurance, national health insurance, private health insurance and out-of-pocket expenditure. A decision is expected on which one Bangladesh should adopt. Public health facilities now have a mix of tax-based and out-of-pocket financing. Privately provided health care is an out-of-pocket expenditure, which is the most regressive and inefficient financing approach. Financing should be prioritised, efficient and result-oriented. To this end, we may think of rules and standards for budget allocation, one of which might be allocative efficiency.
Adequacy and appropriateness that ensure the efficiency of financing are imperative. But, these need bridging of information gaps, for example, on the unit costs incurred on different healthcare services. Besides allocative efficiency, procurement efficiency also hinges on the way we buy and pay for services. For example, should we buy service with public tax or through some other modes of purchasing? Which among them is the most progressive, efficient and feasible? Furthermore, how should we pay for the care we buy? Should it be in the form of salary, a package or bundles of care that includes referral services as well? Or should it be performance indicator-based or in any other forms? As salary does not incentivise, should there be any incentive for good performance, to top up salary? How, in that case, will we control moral hazard?
Addressing the needs of the poor and ensuring and assessing not only service equity but its individualised costing and pricing and their impact on socioeconomic equity needs to be understood. We need to think about the monetisation of equity, eg how much economic equity is attained or preserved after payment for medical care. How will we assess this? Should the health sector go for estimating Gini-coefficient? Which equity measure should be adopted to charge beneficiaries for services — horizontal, vertical or both?
Health information system: We need to decide what minimum indicators-based data should be used to assess progress in attaining the planned goals and when and how. We need to decide the sources of the information and how much and what type of information should come from sources — research, survey and routine reports. How should the source of information be contracted and paid for, if needed? What experiences have we gleaned from our past piloting? What should be the basis of replicating and scaling up positive experiences?
Adequate, valid and appropriate information is not available timely for developing and adopting policy, strategy or plan of action. Plans are historic. We need to work out how to ensure that information is collected easily, timely and accurately. We need to review and update the present software and their use pattern and ensure their universal usage.
The disease surveillance system is poor. This has been amply proved during the Covid-19 outbreak. No policy, strategy or plan exists to strengthen surveillance in the country. Infrastructural innovation is needed to this end.
Leadership in healthcare: Efficient and effective management and leadership would be required to build up dedicated and hard-working teams and drive them to the envisioned goals and would help the care providers to shun their boxed beliefs. What should the health sector leaders do to establish effective intra- and inter-office and intra- and inter-organisational relations and hierarchy? Where should the remit of a staff begin and end within and outside the organisation? Are the present bindings known to them? Should managers be given responsibility for regulating the quality and cost of care, both for the public and the private sector health care, within their domains? How would and should the leaders and managers address public resentment?
Human resources for health: Promotion, posting, deployment, accountability, skills enhancement for planning, budgeting, budget control, efficient buying and expenditure, project/programme implementation, personnel management and health informatics are crucial management functions that need smart managers. One crucial question in this regard is: should clinicians be encadred or only public health officials should be encadred? Should education be delinked from clinical/hospital care, ie should professorial posts in educational institutions and consultants in hospitals be separated or there may be a mix? Answers to these questions have deep ramifications for buying and paying health services. Job analysis and the review of job description are necessary at all tiers for an update. Do we need any reformulation of the recruitment and retirement rules of medical, public health, nursing and paramedic posts? Do we need to examine the training tools and job aids? Is the training given cost-effective?
We need to develop standard ratios of service recipients and service providers by category and think of the measures for immediately and prospectively fill in vacant posts? Should the private sector healthcare providers, eg general practitioners, nurses and paramedics, be inducted as a short-term or long-term arrangement in the public sector? If so, how? Should clinical care be bought for the care-seekers by the government at market price? Should the public sector care-providers be allowed to practise in the evening? How will the problems of commitment among public-sector service providers be addressed then? What is the benefit of service provision between 8:00am and 2:00pm in public hospitals? Why not 9:00am-to-5:00om working hours with two days’ weekends?
Health facility design and distribution: Health facility design and its need and population-based spatial distribution are important for the equitability of care. It is important from both the demand and the supply side considerations. A hospital has a hospital and a hotel component, besides storage, electricity, sanitation, waiting space, recreation facility, patient and staff related transport, residence, etc. Are these disaster-proof? If not, should a retrofitting be done? The complexity of the tiered architectural designs, that is both service-provider and service-recipient conducive, is warranted. Another evolving scenario on the horizon is whether we should propose gray-field or green-field public-private partnerships? What will be the different services, works or goods procurement contract conditions in this regard or for other relevant purposes?
Logistics management: Because of political pulls and pushes, mis-procurement has been rampant in the health sector. The purchase of goods, work or their repairs is not infrequently unnecessary. Goods often lay in the store as these cannot be fitted in the available physical facility or the skills do not exist among the staff for the goods. The procurement, transport and use of goods, eg medicines or vaccines, fly in the face of their shelf life. Procurement processes are complex, time-consuming and cannot be claimed to be transparent. The monitoring and accountability of goods is questionable. The scope for store management exists to be more efficient. What needs to be done to solve these problems? The health and family welfare ministry established a transport and equipment maintenance organisation and a national electro-medical equipment maintenance workshop. What should be done to invigorate them? What may be the other alternatives?
Healthcare-related education: Past efforts to improve the quality of medical, public health, nursing and paramedic education did not deliver the expected results. The reasons need to be examined. A wise and broad view needs to be assumed for designing healthcare education system so that an adequate number of personnel and skills-mix for all types of healthcare needs are available. We also need to think if we should create a career path for research-oriented workers. The quality of education akin to services in the private sector goes unmonitored.
Service recipient and service provider safety: Safety for patients should be treated as important as that of service providers. If we want the service recipients to be treated as emperors, the service providers should be treated as kings. The question is: are service providers safe and happy with their remunerations and other working conditions? If not, why? Sufficient measures need to be taken to retain service providers even in remote areas. We need to assess why people take law in their hands in hospitals and design an appropriate and subtle measure to mitigate this problem.
Public health infrastructure: An independent infrastructure is warranted for public health that will also include urban health. Relevant positions need to be created or redesignated from among the existing ones and filled at all the applicable tiers. The relevant organisations have to be enlisted and brought within the infrastructure.
We need to appreciate that public health and clinical care are completely different ball games. A public health expert cannot conduct a surgery and likewise, a surgeon does not know what cascading steps and actions would be warranted for controlling a disease. Clinical care needs diagnostics-based individual care and, when necessary, referral care. People in their thousands need individual and hospital care of different types and magnitude to be catered by varied categories of staff. These are complex enough to deserve a separate infrastructure for clinical, hospital and diagnostic care. A public health infrastructure is also needed for disease prevention and control; health promotion and nutrition; mitigation, resilience and adaptation to climate variation and its devastation; besides managing administration of even hospital care, which includes financing, procurement, etc. The practice of public health needs collaboration and coordination with other relevant sectors and partners, organisations, offices, consensus on the roles of different horizontal sectors. These alone are formidable tasks.
Healthcare laws, rules, policies, plans and programmes: We need new laws and need to update some laws to suit contexts, programmes, care priorities and strengthen capacity of the institutions and organisations bestowed with the responsibility of health care. We need to study the existing laws, policies, sector-wide programmes, ordinances, rules, regulations, conditions, conventions and practices to upgrade, abolish, improve or strengthen them. Some of these are stumbling blocks — the treasury rule does not allow the ministry to dish out cash to the local government institutions and the allocation of business does not allow local government, rural development and cooperatives ministry to finance local government institutions. So, how would the local government institutions discharge their healthcare responsibilities?
Coordination and collaboration: The positions of of directors and later of line directors for tuberculosis and HIV/AIDS control exist. Should this be continued? Should ophthalmological services still require a line director? Why was there no line directors for mental health? For a more impactful function of disease surveillance, there is no line director. The Institute of Epidemiology, Disease Control and Research , designated to conduct surveillance for issuing early warning of an impending epidemic, does not have any outfit and adequacy of finance to go beyond Mohakhali. The Institute of Public Health and tuberculosis clinics and hospitals have become redundant as they were bereaved of their activities. Paramedic institutes and medical assistant training schools lost their father figures. The National Institute of Preventive and Social Medicine could not be upgraded since its inception. People forgot why the Institute of Public Health Nutrition was created. There are health facilities that have become abandoned properties.
An effective coordination does not exist among relevant sectors and within the sector, for example, for nutritional services despite the creation of a nutrition council, chaired by the prime minister. What to do?
Where and for what can the director general of drug administration and the director general of health services may collaborate with each other? How the drug administration may be strengthened so that it may play a crucial function of pharmacovigilance throughout the country and regulate the drug market? Should something be done to ensure that the director general of health engineering department works more closely with the health services directorate general? For what and how?
We also need to find out how the community should be engaged effectively and in what. Our experience in this regard is choppy and sketchy.
Final words: For any, reform we need to find out the root causes and the core problems of our failures, one of which is the lack of dynamism in addressing the contextual needs. Usually, we refrain from going deep into the causes behind causes. So, solutions are often only stop-gap measures rather than well-planned actions and strategies to address the problems. Well-thought-out policies and plans with good workable strategies will be the stepping stone for reforming the sector. Setting a good policy, plan and strategy would require theoretical exposure, practical understanding, working experience and wisdom and vision. The stronger these traits are among reformers, the more successful would the reform be.
We need to come to some consensus as to how far we will go in reforms: physical facility, community awareness and engagement, services, teaching, research and information, logistics, medicine and technology, financing, human resources, governance; leadership and management for an equitable quality and coverage of health care.
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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.