In recent times Bangladesh has made remarkable attainment in health service delivery. Delivering maternal and child health services has improved over the last decade. In terms of providing primary health care the country has made important strides and most of the health indicators show steady gains and the health status of the population has improved. A combination of evidence-based technical and social interventions led to improved maternal and child health outcomes enabling Bangladesh to reach Millennium Development Goal with a 40 percent reduction in the maternal mortality rate in less than a decade.
According to our constitution, it is the constitutional obligation of the government to ensure healthcare for all its citizen. Regarding healthcare, the constitution of Bangladesh documented in article 15, "It shall be a fundamental responsibility of the State ... securing to its citizens the provision of the basic necessities of life, including food, clothing, shelter, education and medical care". For public health and morality the provision of the constitution in article 18 (1) is: "The State shall regard the raising of the level of nutrition and the improvement of public health as moving its primary duties ..."
Bangladesh has achieved impressive improvements in population health status by achieving MDG by reducing child death before the 2015 target, and rapidly improving on other key indicators including maternal death, immunization coverage, and survival from some infectious diseases including malaria, tuberculosis, and diarrhoea. Presently, number of steps has been taken by the government to improve quality of services, especially to reach the poor and the disadvantaged. Initiatives for development of new health policy, revitalization of primary health care by making all community clinics functional with required human resource, supplies and logistics, recruitment and appropriate deployment of human resource for health and gradual extension of e-health services to the rural areas are some of the examples for health development in the- country. The Government of Bangladesh adopted a national strategy focused on improving maternal health with an emphasis on improving emergency obstetric care services in order to reduce maternal mortality. The government enhanced referral systems for pregnancy complications and improved overall quality of care - with a special initiative on retaining existing government community health workers to become community skilled birth attendants.
Amidst of good progress in improving health outcomes Bangladesh remains one of the countries with the highest level of malnutrition among the developing countries, with children and women the most affected. Neonatal mortality appears hard nut to crack, so also skilled attendance at birth, child marriage and teenage pregnancy. Challenges remain in the overall health care governance system in terms of quality of care and equity, especially for pregnant women and adolescents in poor communities. Bangladesh has one of the highest rates of adolescent motherhood in the world - with 28 percent of adolescents bearing at least one child. Nearly 85 percent of births take place in the home - outside a healthcare facility or with the aid of trained healthcare professional such as a doctor, midwife, or skilled birth attendant - making access to emergency care difficult, if not impossible, and life threatening to both mother and child.
Main issues and challenges in health service delivery include proper management of the huge network of field and facility based services at different levels including community clinics throughout the country. There are some critical challenges for the maternal and child health care system needed to be addressed immediately. Firstly, lack of coordination across two different departments for implementing maternal and child health-care service delivery in rural and urban areas i.e. DGHS and DGFP; secondly, critical shortage of trained health service providers with appropriate skill-mix in the public sector and widespread increase in unregulated informal providers for an alternative source of care; thirdly, low annual allocation to health in the government budget ; fourthly lack of equipment and inadequate health infrastructure and finally, inequitable access to health services between urban and rural areas including variable health financing mechanisms, which have slowed achieving universal health coverage.
The key actors in health system of Bangladesh are: Government, Local Government Institutions, private sector, NGOs and donor agencies. Government, Local Government Institutions, private sector and NGOs are engaged in service delivery, donors play a key role in financing and planning health programmes. The public sector is mandated not only to set policy and regulations but also to provide comprehensive health services and to manage financing and employment of health staff. The Government regulates the functions of public, private and NGO providers through various acts and legislation. It delivers services through its nationwide infrastructure by employing doctors, dentists, nurses, pharmacists and a huge number of auxiliary health workers. However the quality of services at government facilities is quite low, due mainly to insufficient resources, institutional limitations and absenteeism or negligence of providers.
Over 45 years after independence in 1971 the health system of Bangladesh has gone through a number of reforms and established an extensive health infrastructure in the public and private sectors. Local governments have a large and growing role in national health care, and they must be included in any plans for implementing reforms.
On the other hand, public sector hospitals and medical sub-centers have failed due to absenteeism or negligence by government doctors and health staff. So ensuring accountability through increased supervision by local authority can improve the quality of service delivery. Therefore the Local Government Institutions in Bangladesh can play vital role in improving healthcare system especially in maternal and child health care service.
Local Governments in Bangladesh have been mandated by law to work on improving health care service. According to Local Government (City Corporation) Act, 2009 and Local Government (Municipalities) Act, 2009, city corporations and municipalities are responsible to provide primary health care to city dwellers. Local governments in rural areas such as Upazilla Parishad and Union Parishad are also mandated by their law to supervise healthcare service delivery in rural areas. As per Upazila Parishad Act 2009, Upazila Health and Family Planning Officer must work under Upazila Chairman and he is accountable to Upazila Parishad for all kind of health service at Upazila level. According to Union Parishad Act 2009, there is a Standing Committee on Health and Family Planning headed by UP Chairman at Union level and Councilor at ward level. The major function is to monitor health service rendered by Union health sub-centers and create mass awareness in rural areas.
Links between health and development have long been acknowledged. It is generally recognized that securing a certain level of health-related development is a prerequisite for the overall economic development. Health plays a critical role in achieving particular development outcomes; conversely, development strategies can also have significant positive and negative impacts on the health of populations. Development of an effective, coordinated and synergistic public sector health care delivery system through collaboration with local government institutions can make a huge impact in improving health service delivery system in Bangladesh.r (PID-UNICEF Feature)
Saleh Ahmed Mujaffor is Deputy Secretary, Ministry of Public Administration