“You need political commitment, in the first place, for decentralisation of healthcare”

Last Sunday, former health minister Dr AFM Ruhul Haque revealed the findings of a study on the Bangladesh health care system. Haque, in collaboration with the non-government organisation Eminence Associates for Social Development, conducted the study last year. 

The study, titled "Bangladesh health sector: present challenges and future guidelines", identified various problems of medicare facilities. 

Rashid-e-Mahbub, public health expert and chairman of the Bangladesh Health Rights Movement, reflected on the study's findings and discussed the overall conditions troubling our healthcare system in an interview with The Business Standard. 

The study found that one of the biggest problems for Bangladesh is the centralisation of the healthcare system. In the rural and suburban areas, doctors, medicine and facilities are hardly available as opposed to the urban areas. What is your take on the study? How do you think this centralisation problem can be solved?

Yes, our healthcare system is highly centralised. And there are many problems associated with centralisation. But whatever you need to do, you need a political commitment in the first place. Political commitment  means whether the government is willing or not. 

First, the authority has to come up with essential policy decisions and consensus on whether they really want decentralisation. If they do, then the focus should be on how the process would take place and in what form. Only then a meaningful outcome will be visible.

If the government is not willing or lacks political will, we are helpless. Then the responsibility goes to political parties and professionals and civil society groups. They, in the interest of the people, demand change from the government.

I think since the independence of Bangladesh, we have been talking about this. Even during the Ershad regime, there was a health policy related to decentralisation. 

Under the current government, there were two health policies, and decentralisation is mentioned in both. So, the topic of decentralisation is not something new, however, it was never implemented.

One of the reasons for not starting the process is that our healthcare depends much on international donations. Donor dependency is a big issue. If the international community/donors do not insist on decentralising the healthcare system, the implementation will not be possible. 

There is also a conflict of interests. The world is run by capitalist thought. A neoliberal economy suggests less government spending on education, healthcare etc. and that people should spend their own money [what we see happening in the United States]. 

The notion is that government welfare should be limited. So the government prescribes to the idea that treatment can be availed by spending money.

There are some similarities with our primary education. While it is free to study, the state of primary education is abysmal. And quality is not ensured. As a result, inequalities are rising. 

In the same way, public medical facilities are inadequate. The "out of pocket" cost is much higher in comparison with other South Asian countries. And continues to get higher and higher. 

I do not understand the rationale of coming into a public platform and talking about these things. AFM Ruhul Haque is a member of parliament; he could have raised his voice in the parliament. A former minister, a chairman of a parliamentary committee, coming to a public platform – it doesn't mean much.

We do organise such studies and public releases, press briefings to draw government attention. But he is a part of the government. As a member of the parliament, he can lobby with the health ministry and the prime minister. Did he tell the PM that they were thinking about these points?

The study also found irregularities in the purchase of medical equipment and negligence in the maintenance of hospital equipment. Valuable resources are wasted, and we have also seen many allegations of mismanagement. Why do you think this is the case? 

These stem from a lack of commitment. Many more things are needed along with decentralisation. 

The authorities successfully pushed the public against the doctors. People are angry at doctors, and the two sides are in a face to face situation.

The blame is put on the doctors. That they do not want to go to villages or suburban areas. But the fact is there is little scope to work in the villages. They never tell us this fact. 

Rather than solving the problem at hand, the focus is on the blame game. Moreover, the private sector's development is totally out of control. But even private healthcare is also centralised. You can only find good ones in the city areas.

Allegations are prevalent. The root-level health sector lacks manpower. Many posts of the upazila hospitals remain vacant. Local arrangements can be done here. It is also true that often many expensive logistics are brought in but they [manpower or hospital officials at the upazila level hospitals] do not know how to use them. Maintenance is not proper.

You have to remember that doctors alone do not cure ailments. Logistics is very necessary. However good the doctors are, logistical deficits will impact the efficiency of the healthcare system.

Our cadre service is huge. Only a few people are taking all the decisions. That's not going to solve the problem. Moreover, the procurement process is not good enough. Logistical decentralisation and supervision are needed. Sitting in Dhaka, they are interested in procurement because there is money. 

Our hospitals are all the same, except the very specialised hospitals. However, community healthcare, union hospitals, thana health centres, districts hospitals – these things are not defined. What services will be available in what kind of hospitals are not defined. Also, people remain unaware of what services are available in which hospitals. 

Budget allocation for healthcare is considerably low in comparison with our neighbouring countries. Bangladesh is far behind in this respect than the standard set by WHO. Why do you think the government fails to allocate an adequate portion?

The commitment to the health sector is a big reason. There is no clear directive from the government on how the sector should be run, especially the public sector. Only the rich, the affluent class can avail the benefits of the private sector benefits. Poor people do not go there. Only the upper class can take the benefit of the private sector. Poor people have little access to good care.

In the last FY 2021-22, the budget allocation for health was only 0.95% of GDP. The World Health Organisation sets the standard figure of at least 3-5% of GDP as a minimum requirement for a country to perform well.

Bangladesh's allocation is too low. Less priority is given to medicare. Although during the Covid-19 pandemic, more than Tk20,000 crore was allocated, this constitutes an exception. Because it is not routinely given.

However, there are many "in-between" lines. For example, in the armed forces, the treatment and medical-related facilities are provided from the health budget. That does not come from the military budget. 

To make it people-friendly, there need to be significant changes. The government's commitment to providing quality healthcare must be clarified and necessary measures should be implemented. Conflicts of interest need to be evaded.