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Health Governance & Reproductive health
perspective in Bangladesh
Md Nazmul Alam
Save the Children International
Bangladesh health scenario at a glance• Population - 152.5 Million
• Density – 946/sqm
• Life expectancy – 67 years
• Income / capita – 848$
• Health exp./ capita – 23$
• TFR – 2.3
• Infant Mortality Rate – 43 per 1000
• Under 5 Mortality rate – 53 per 1000
• No. of registered physicians- 53,063
• Estimated no. of doctors available in the country - 43,537
• Doctors working under MOHFW - 38%
• Doctors working in private sector - 58%
• Registered diploma nurses - 26,899
• Estimated no. of nurses available in the country - 15,023
• Under 5 Mortality rate – 53 per 1000
• Maternal mortality rate – 194 per 100000
• Child malnutrition – 47%
• Immunization – 86%
• Assistance at Delivery
• Skilled - 12%
• Unskilled – 53%
• Birth at health facility – 29%
• CPR – 61.2%
country - 15,023
• No. registered mid -wives - 23, 472
• Population per physician – 3269 (Current population / available registered physicians)
• Population per bed - 1738 (Hospital beds: under MOHFW + Regd. private hospitals)
Source: MOHFW Health Bulletin 2011
Source: BDHS 2011
Health system structure in Bangladesh
Ministry of Health &
Family Welfare
Director General of Health Service
Director General of Family Planning
Directorate of Nursing service
Directorate of Drug Administration
Facilities Services
7 Division Medical College – (21 Public, 44 Private) Specialized Hospitals (38)
64 Districts
Districts hospitals (61) Outdoor and indoor service (50-250 beds), laboratory and ambulance services
Maternal and Child Welfare Center (95) Emergency Obstetric Care and other services.
481 Upazila
Upazila Health Complex (460) Outpatient, inpatient services (31-50 beds), diagnostics service with
Health Service Delivery System in Bangladesh
Upazila beds), diagnostics service with operative treatments.
4498 Unions
Union Health and Family Welfare Center (2500)
Outpatient service – Family planning, maternal and child health, communicable disease control, clinical care etc
Rural Sub center (1449)
40482 Wards
Community Health Clinic (9722) Family planning, immunization, common disease treatment and referral, communicable disease control
Split Autonomous Administrative Health System
Governance & Health – A historical review
The Alma Ata Declaration (06-12 September, 1978) 1978) –– Alma Ata, USSRAlma Ata, USSR
To protect and promote health
Health For All
Express urgent actions from:
Emphasized on
“ Primary Health Care” (District Health system)Express urgent actions from:
- All governments - All health and development workers- The world community
(District Health system)With substantial
“Community Involvement” for universal,
preventive and curative services
1980 Debt crisis &
SAP
1990 Health Sector
Reform
Governance & Health Governance – A quick glance
Governance -
is about rules (both formal, embodied in institutions –democratic elections, parliaments, courts, sectoral ministries and informal- reflected in behavioral patterns -trust, reciprocity, civic-mindedness) that distribute roles and responsibilities among societal actors and that shape the interactions among them.
Health Governance -
is the approach for sustainable delivery of quality health services by the political leadership to the community especially to those who have little or no resources
what is Health Governance!
Rules that govern roles/responsibilities and interactions among:Beneficiaries/service users,
Political and government decision-makers, and
• Health Governance includes - mechanisms, processes, institutionsthrough which people articulate their interests, exercise their rights and obligations and for those in government to serve the people well, and for the civil society and the private sector to actively engage those in government.
Political and government decision-makers, and
Health service providers (public, private, nonprofit)
To determine/ ensure: (which) Health policies pursued,
(what types of) Services provided,
(how) Health resource allocation and use,
(Assess) Distribution of costs,
(Reaching to) Recipients of services and benefits,
(How come better) Health outcomes can be achieved.
Interactive agencies in Health Governance
Linkage of Health Governance Actors
Relationship within the actors
III. Relation between state and Providers (A contract-like connection)
a. From State to Providers: Policymakers specify objectives,
procedures, and standards; provideresources and support; and exerciseoversight relative to providers
In exchange for resources, providerscarry out the agreed-upon desires and
II. Relation between providers and citizens (Consider as ‘heart’ of health system)
I. Relation between state and Citizens Citizens will express needs, preferences, and
demands to politicians, policymakers, and public officials.
State will response to client/citizen needs, preferences and demands
carry out the agreed-upon desires anddirectives of the policymakers
b. From Providers to State: Regular reporting of information for
monitoring purpose
Maintain political, performance, and financial accountability
Provide data for policymaking to pursue evidence-based policy formulation
citizens (Consider as ‘heart’ of health system)
Clients/citizens convey their needs and demands and their level of satisfaction – directly to service providers,
Service Providers in turn offer a mix of quality services that satisfy needs and demands.
This relation is a balancing board of –
Power negotiation
Information irregularities
Capacity gaps
Accountability failures
Inequities
Health care personnel comparison- urban & Rural
Regional comparison of Qualified Health care personnel Per 10,000 people
Bangladesh Health Governance: Issues and Challenges• Lack of people’s voice and Accountability within the system• Weak Monitoring and Regulatory Framework • Centralized administration with limited understanding of demand• Poor Management of Drug and Equipments• Staffing and Absenteeism • Mismanagement in Health Care Service Delivery• Weak Management and Coordination Network
Ways to Forward: • The health care system in Bangladesh operates within a complex political administrative
environment.
The politicized administrative structure at health sector is the root mis-governance• The politicized administrative structure at health sector is the root mis-governance
• Strengthening of health service system planning and management
• Accountability and transparency is an important factor for all sectors.
• Improvement in the logistics of drug supplies and equipment to health facilities at district and lower levels;
• Strong and effective referral system within the health institutions
• Engage quality human resources for health sector;
• Systematic regular maintenance of existing health facilities;
• universal access to basic healthcare and services of acceptable quality;
• Improvement in medical education;
• Strong policy and regulatory framework.
Access to Health Care Services in Bangladesh
• Access to health services depends on availability and affordability of services;
• availability of physicians,
• health centres, and hospitals
• Referral system etc.
• Citizens with lower income and living in rural area do not have much accessibility as health facilities
• Both public and private sector are distributed in an unjust way.• Both public and private sector are distributed in an unjust way.
• Delivery of services also varied depending on the level of income (rich and poor), which is evident in discriminatory access to services.
• The poor in Bangladesh bear higher health risks and suffer the burden of excess mortality and morbidity.
• The poorest households are likely to use health care services and are less willing to pay for improved services compared to other socio-economic groups (Jahan and Salehin, 2006).
Reproductive Health
• Reproductive Health
• implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.
• It also implies
• To be informed of and to have access to safe, effective, affordable and acceptable methods of birth control and family planning;
To have access to appropriate health care services of sexual & reproductive • To have access to appropriate health care services of sexual & reproductive medicine and
• To have implementation of health education programs to stress the importance of safe pregnancy and safe childbirth
Few facts on world wide Maternal health
• Worldwide, 1000 women die every day due to complications during pregnancy and childbirth - up to 358 000 women per year
• Four main killers cause around 70% of maternal deaths worldwide: • severe bleeding,• infections,• unsafe abortion, and • hypertensive disorders (pre-eclampsia and eclampsia)
• More than 136 million women give birth a year. About 20 million of them experience pregnancy-related illness after childbirth
• Developing world has 90% birth through adolescent mother aging between 16-19 yearsyears
• Of the 1000 women who die every day, 570 live in sub-Saharan Africa, 300 in South Asia and five in high-income countries.
• 46% of women are attended by a trained midwife, nurse or doctor during childbirth• In developing countries, the percentage of women who have at least four antenatal
care visits during pregnancy ranges from 34% for rural women to 67% for urban women
• About 18 million unsafe abortions are carried out in developing countries every year, resulting in 46 000 maternal deaths
• By 2015 another 330 000 midwives are needed to achieve universal coverage of mothers with skilled birth attendance
(Ref: http://www.who.int/features/factfiles/maternal_health/en/index.html)
Few facts on Maternal Health in Bangladesh
• Bangladesh was one of eleven countries that were responsible for approximately 65% of maternal deaths around the world (WHO 2010)
• Since 2002 Bangladesh has reduced maternal mortality by 40% (BRAC 2011)
• Average age at marriage is 16 and average age of birth is 19.
• Bangladesh is facing a severe health care worker shortage
• In 2001 less than 18% of births were attended by medically trained personnel.
• In 2011 only 29% of births took place at a health care facility.
• The lack of skilled providers at health clinics explain over 60% of deaths • The lack of skilled providers at health clinics explain over 60% of deaths during childbirth and 40% of post-partum hemorrhage death.
• 80% of maternal deaths occur at home.
• The challenges of maternal health differ for Bangladesh’s urban and rural populations
• Urban areas contain about 15% of the population but 35% of doctors and 30% of nurses.
• Rural women bear on average one more child than their urban counterparts.
• In 2007, 36% of women living in urban areas had a skilled provider present during childbirth compared to only 13% of women living in rural areas.
Comparison maternal mortality survey Bangladesh
BMMS 2010 BMMS 2001
Factors of effects health service utilization
service delivery
Gender Inequality
Health Beliefs
Health Service Utilization
service delivery system factors
Factors of effects health service utilization (Contd……1)
Social norms in developing countries - childbirth to be seen as a normal event, or even a test for women to endure on their own.
Markovic et al., (2005) shows women uncomfortable discussing their health problems with their husbands or senior male members of the household and postpone care-seeking until the benefits of early intervention have been lost
Afsana et al., (2000) found blame was placed on women who needed to ask for assistance or have delivery in a facility, as they intentionally done something for attention and assistance.
A study in Uganda shows “the woman who delivers herself was said to be highly A study in Uganda shows “the woman who delivers herself was said to be highly respected” (Kymuhendo, 2003)
Many study reveals the primary reason for low utilization of health services are;
distance from a health facility
transportation problems
costs of services including informal charges
opportunity costs from time lost
perceived low-quality care in facilities, or
cultural barriers to professional health-seeking ( stigma, fear, inability for women to travel alone, or to be seen by male doctors
Factors of effects health service utilization (Contd……2)
• In Bangladesh too many alternative healthcare providers get involved when problems are perceived.
• Elderly women in the house mostly take decisions regarding maternal health and as they have not received any facilities they have less interest in it.
• In many cases household chores become a barrier for women to go and take medical services . A comparative study (Parkhurst et al. 2006) between Uganda and Bangladesh revealed Ugandan husbands are more liberal taking over household work in contrast of Bangladeshi husband.
• Same study findings briefs, in Ugandan cases, it was almost always the husband or close family networks who supported the decision and action to use a facility for delivery.
• But in Bangladesh, in most cases, husband in the rural do not interfere with the decision of elder female members in this regards. Also no much choice is taken from family members of the female.
• Formal education and relative wealth are positively associated with the utilization of maternal and child health services (Amin et al. 2010).
• Socio-economic status and husband’s occupation is correlated with modern health service utilization (Chakraborty et al. 2003)
Key actions to improve Reproductive Health outcomes
• Increase school enrollment of girls.
• Strengthen employment prospects for girls and women.
• Educate and raise awareness on the impact of early marriage, child-bearing and reproductive health choices.
• Increase advocacy and community participation, and involve men in supporting women’s health and wellbeing.
• Improve and expand recruitment and training of community health workers, skilled birth attendants, etc. particularly in areas where formal health care skilled birth attendants, etc. particularly in areas where formal health care infrastructure is lacking.
• Secure reproductive health commodities and strengthen supply chain management.
• Sustainability of Maternal Health Interventions need to be ensured;
• Institutionalizing community-level interventions within government structure
• Going through social norm and value change
Ref: Bangladesh Reproductive Health at a glance (2011)
How Health governance can help Reproductive Health
• State must have maternal health strategies that focus on strengthening the primary health care system
• Emergency obstetric care (EmOC), focusing on the primary level where critical planning, budgeting, and implementation decisions are made
• Multiple stakeholders should be involved including bureaucrats, public health officials and other individuals and organizations to change policy formulation and implementation in favor of better maternal health i.e.
• Ensure skilled birth attendance (Quality & quantity)
• Transportation system for patient living in distance
• Accountability paying hospital bills or entering in hospitals for treatment
• Strong collaboration and referral between organization across the nation
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