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Friday, 12 August 2011

On reading the Health Policy: some reflections...

The economic consequences of ill health for the poor households, especially the bottom 15-20% is well documented in Bangladesh. Therefore, improving the ability of the health system to reach the poor/disadvantaged populations is essential to mitigate the income-erosion effect of ill-health and facilitate poverty alleviation in Bangladesh. To maximize this poverty-alleviation effect, health interventions need to be designed according to the needs and priorities of the poor and the disadvantaged. Whatever we decide, should be based on evidence and not wishful thinking.
Where do the poor go for treatment? Who are the main providers of health care? Studies on health-seeking behaviour of the disadvantaged population in rural areas (demand-side perspective) as well as the recently conducted study on the de-facto composition of the health care providers in Bangladesh (supply-side perspective) give us some clue: 
a.                      a.  Self-care[1] is around 30-40%
    1. When people do go to a provider, the first contact is with an informal provider (20-30%)— (drug shops attendants and the Village doctors[2] ).
    2. Semi-qualified para-professionals (medical assistants, mid-wives) and community health workers (CHWs)[3] are main provider of formal allopathic care in more than 25% of illness episodes.
    3. Qualified modern providers (physicians, dentists, nurses) constitute only 5% of the entire providers.
What can be done/should be done?  These issues (including governance issues) are touched by the Health Policy somewhat, but the solutions are not adequately presented. Here are our suggestions:

    1. Self-care is regarded by the WHO as ‘a primary public health resource in the health care system’. To use this resource to its full potential, its integration as an essential, informed and efficient component of the primary health care and as a cost-effective complement to the formal healthcare, is long overdue in Bangladesh.
    2. Given the shortage of supply of qualified health care professionals in Bangladesh, the importance of unqualified/semi-qualified practitioners as major providers of healthcare to the poor should be recognized by the public sector, and their capacity developed in a planned way so as to ensure that the poor and the disadvantaged get an acceptable level of care, at least in the short-term, until supply side constraints can be alleviated. Studies from Vietnam, Laos, and Thailand and Nepal show that education and training efforts are necessary to change practice of irrational and harmful use of drugs by these providers, besides managerial and regulatory interventions.
    3. The education and training system for producing health manpower should be geared towards producing more technologists and nurses than physicians. In the present system, many of the tasks of the nurses are done by the physicians and many of the tasks of the clerks are done by the nurses. This should be changed (e.g., appointment of ward clerks in in-door health facilities who will maintain the inventory of materials in the wards instead of the nurses) so that the doctors and the nurses can devote most of their time for the care of the patients.
    4. The education curriculums for physicians and nurses should be reorganized in such a way that the students get acquainted with the health problems and health systems of the country early in their education. The culture of responsiveness and empathy towards patients should be pro-actively nurtured throughout the period of education and in-service training. The internship should be extended for six more months for hands on training in the rural upazila health facilities.
    5. Creating an enabling environment at the upazila level and mapping a career path is absolutely necessary for retention of doctors and nurses at the rural areas. Performance-based assessment of the health workers should apply reward and punishment for improving the attendance and quality of care provided.
3.  Good governance and accountability? For transparency and accountability, the health systems in the upazila level and below should come under jurisdiction of the Local Government and the community. Health systems should be decentralized and reorganized around the District health system. All common specialties should be present and functional at this level. The upazilas should be functionally linked to the district health system and act as first referral point for the union centres and community clinics.
4.  User-fees, rational use of essential drugs, controlling price and quality
1.   Evidence exists that implementation of ‘user-fees’ is not poor-friendly: ‘they raise little money, rarely meet their stated efficiency and equity goals. They are often associated with reduced use of services, especially by the poor and vulnerable; failure to complete treatment; and delays in seeking treatment’.
2.      Good quality Essential Drugs for common illnesses (as listed in the national EDL) at an affordable price should be made available at the PHC level facilities, especially the public sector facilities throughout the country---that’s the basic minimum expected by the people from the pharmaceutical and health establishment of the country 38 years after independence! Measures should be taken to motivate and convince the medical profession about the necessity of the rational use of essential drugs at the PHC facilities including avoidance of polypharmacy, overuse and misuse of antibiotics, generic prescribing and prescribing from the national EDL. Policy makers should also think how the consulting time can be increased for quality provider-patient interaction
3.      Regulatory supervision by the DDA (with imposition of sanctions as necessary) should be strengthened for controlling the quality and price of the drugs. Both human resource and technical capacity (e.g., establishment of drug testing labs) need to be developed for this to take effect. Further, the DDA can collaborate with consumer interest groups (e.g., Consumers’ Association of Bangladesh) in order to device a price control mechanism and identifying fake or counterfeit drugs.
4.      Education and training combined with managerial and regulatory interventions are needed to rationalize drug dispensing at more than 80,000 unlicensed Drug shops in the country as well public and private sector health facilities; proper labeling of drugs dispensed, and counseling patients/attendants on dosage and side-effects are also needed.

[1] defined as any treatment used without a physician’s prescription or direct recommendation by a healthcare professional including the decision not to treat
[2] majority (Rural Medical Practioners, RMPs) have three to six months training from semi-formal, unregulated private organizations of doubtful quality. Few (Palli Chikitsoks) have had one year training from a short-lived Govt. programme in the early ‘80s (PC training programme) which stopped in 1982 
[3] who have varying duration of formal training in public or NGO institutions

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