Why the public sector health providers don’t deliver enough: The other side of the story

People’s perception of public sector health services in Bangladesh is not good as has been shown in repeated studies over the years, both small scale studies as well as large scale surveys. Long waiting time, misbehavior of the providers, exclusion of marginalized groups (e.g., destitute, eunuchs etc.), lack of privacy, not explaining the problem and management to the clients etc. are some of the complaints frequently made. One of the main complaints is related to the responsiveness of the health system and healthcare providers towards consumer of health services. A healthcare provider without the right attitude and motivation is highly unlikely to provide services that will satisfy clients. But then, why it is so? What’s their side of the story?

This issue has been explored in a recent study where the researchers conducted in-depth discussion with healthcare providers (doctors, nurses, technicians) and managers to elicit their perspectives. The providers unanimously mentioned lack of infrastructure (physical and human) and supplies as the sole reason behind poor behaviour to the clients and services delivered. The doctors in addition mentioned about unfair treatment by the administration which fail to recognize good work and reward it e.g., through incentives such as promotion.

All the providers rather complained about the never-ending complaints of the patients and bad behaviour of the patients’ caregivers. They thought that the patients expectations were too high, not conforming to the limitations of the infrastructure. A blame game was very common: patients don’t need explanation because they are illiterate; they cannot be satisfied easily because their demands are unrealistic; the working condition is responsible for the ills, and the doctors and nurses don’t need to change their attitude etc. etc.

So what is the way out? Obviously, accountability of the providers to the consumers of services and improving responsiveness to the patient’s woes count. A recent review of literature on the issue found four principal mechanisms to tackle the problem: decentralization of health services and a mechanism for community participation, access to quality information for the consumers, informed community groups facilitating consumer action, and scaling up NGOs operation to improve access.

Evidence exists for positive effects on provider behaviour from decentralization coupled with supportive measures for community participation. This may be due to the fact that decentralization facilitates responsiveness from local officials against consumer demands, which if left to decentralization alone, won’t be effective.

Information asymmetry is one of the reasons which deter consumers to effectively challenge the providers. To remove this, consumers need access to quality health information. Studies have shown how this may lead to a positive impact in making the consumers’ voices heard and make the providers accountable.

Next, collective action by an aware and informed consumer group may act as a pressure group for the providers to behave properly. This collective consumer action may act through breaking the inertia inherent in traditional community with respect to health issues of public interest.

Finally, research has shown the effectiveness of NGOs in healthcare provision, playing supplementary and complementary roles to the government health system, and found it to be equitable and of quality, especially for the poor. What is needed is the scaling up of the interventions to sufficient degree so as to have a macro level impact.

These and other issue need further exploration to design appropriate interventions for improving provider responsiveness and accountability to the consumers of healthcare services in Bangladesh.

Source: 1) Cockcroft A et al. Health services reform in Bangladesh: hearing the views of health workers and their professional bodies. BMC Health Services Research 2011;11(Suppl. 2):S8.

2) Berlan D and Shiffman J. Holding health providers in developing countries accountable to consumers: a systhesis of relevant scholarship. Health Policy and Planning doi:10.1093/heapol/czr036