Everything runs on certain policies, whether a state, a society, a business firm, a social organisation or even a household. But there is a formal definition of public policy. A public policy is a set of decisions that are taken through a specific decision making process. Certain people, experts on the concerned subject, are involved with it and a specific plan of action is drawn up to that end. At the same time, abstaining from taking any decision is also a part of that policy. For example, policymakers could restrain from including any subject in the policy for any vested interests, apprehension of loss, lack of knowledge or any other reason.
The composition of the first National Health Policy of Bangladesh began in the mid 80’s, during the rule of President HM Ershad. The National Drug Policy, composed during his tenure in 1982, is a precursor to all the health-related policies in Bangladesh. The drug policy was praised abroad as well. Like the drug policy, Zafrullah Chowdhury was the main architect of the first National Health Policy, proposed in 1990, as well. The main principles of the health policy was to ensure primary healthcare for the marginal people, improving audit systems to ensure accountability, managing and providing medicines efficiently, decentralisation of the health system etc. But the process was scrapped because of objections of various quarters and also the fall of Ershad.
Another initiative was taken to compose a health policy, taking lessons from the failure to compose the first health policy. The lesson was, like any other policies, it is important to gain the trust of all the stakeholders through discussions. Taking all this into consideration, the health and family welfare ministry constituted a committee in 1996 including the representatives of civic society, health professional bodies, technocrats and related administration officials. But until 2011, the first draft of the health policy could not be prepared. In 2011, Shashthya Andolan, a civil society platform on healthcare, along with a few other civic bodies managed to raise people’s awareness and also sensitise the relevant people about an advanced and pro-people health policy.
The health policy that was passed in parliament on 31 May 2011 after a long process naturally created huge public expectations. But, could the health policy that was composed with so much labour meet our demands and aspirations? And how relevant has the health policy been in combatting the ongoing COVID-19 pandemic? A more theoretical discussion on the composition of the policy and its implementation is required to get a clear answer to those questions.
By any policy, or for that matter health policy, we understand a piece of paper where it is written how the state’s healthcare system would run, who would get what and how will those be managed. But a very popular framework to analyse the health policy, known as Health Policy Triangle, said, it is not enough to understand the documents to understand any health policy. Rather, the context and process of implementation also have to be understood. Here I will detail the important issues of our health policy, things that got omitted and why there have been so many hitches and dilly dallying in its implementation.
Bangladesh health policy has a preamble, context, vision, three specific objectives, 19 main goals and 16 principles, 18 challenges and 39 plans of action to face those. The preamble begins with the much acclaimed definition of health by the WHO (World Health Organisation), which has recognised health as a physically, mentally and socially sound state, instead of considering it only as a state with an absence of any disease. The policy identified healthcare as one of the fundamental rights of human being. Health has been taken out of parochial medical state and placed in a greater context of preventive activities like pure water, proper food, and pollution-free environment. And, importance has been given on the coordination of different ministries and departments to manage all those. Considering all those factors, we cannot but accept that our health policy is sufficiently modern and visionary.
The context part of the policy has unhesitatingly accepted various discrepancies and limitations. For example, inadequacy in providing medicines, lack of manpower, administrative complexities, disorganised referral system, child malnutrition, incongruity in various health indices, inadequate care during childbirth, lack of institutional healthcare in villages, impact of climate change on health, substandard government and private healthcare, dependency on unskilled service providers, lack of medical equipment, inadequate health management and above all limited per capita expenditure in healthcare. Such detailed discussion of limitations alongside various achievements assures us that the health policymakers were at least aware of the lack of availability of services and people’s complaints in this regard.
The vision part is also sufficiently progressive. Aside from acknowledging health as a right to people, it has given due importance to equality in getting services, gender equality, and healthcare to marginal and disabled people to ensure good health. Collective development is the precondition of development in healthcare. This was also not overlooked by the policymakers. They emphasised the necessity of reducing poverty as well. Important issues like universal primary and emergency medical care, equality, standard of services, availability, and prevention of diseases, human rights and dignity have been mentioned as specific goals. It can’t be said that anything very important has been omitted.
Alongside medical treatment, public health, nutrition, primary healthcare, acquiring replacement level public-fertility, mother and child health care, use of information technology, upgrading the standard of medical education, priority in getting health information, availability of essential drugs and control of prices, and development of alternative medicines (Unani, Ayurveda and homeopathy) have been fixed as main goals in the health policy.
The 14th section of the policy talked about ensuring coordination of different ministries and departments of public health and medical care and private sectors. This suggests the health policy recognises that public health and medical care, that is clinical track, is different. But it is unfortunate that many high-ups of the health department do not realise this these days. Maybe, that’s why in all these years we did not see any different track for public health, though the COVID-19 pandemic has forced us to look into this.
The matters discussed in the principles and challenges section are still relevant even after a decade. In fact, those are highly pertinent at this point of time.
Noninfectious diseases, outbreak of new diseases and revisitation of old diseases, climate change, urban health, development and management of human resources, health research, epidemiological monitoring have been discussed in brief. The first point of the plan of action part may be mentioned. It said a national health council, headed by the head of the government, would be formed. This council would be comprised of concerned ministries, private stakeholders and relevant experts. The council would give directives to implement the health policy. After a decade of the composition of that health policy, in the wake of the pandemic, the question is – where is that national health council?
Truly, Bangladesh’s National Health Policy is a progressive policy and includes necessary issues, but the context and process of its implementation is seriously faulty. That’s why it is pertinent to inquire into the shortcomings.
At the outset of the article, I said abstaining from taking any decision is also a part of the policy. It is the call of the hour that we inquire whether that negligence to our health policy is because of any vested interest. Sri Lanka is the most advanced state in South Asia in terms of healthcare. In Sri Lanka, the preventive and remedial organisations work parallel under the health directorate. But in Bangladesh, we do not even have any system to evaluate the training of the recommended BCS cadres (health) in public health. Even, despite repeated demands of posting of public health professionals in the higher positions at the health directorate, inexperienced or noted but untrained physicians or irrelevant medical educationists are being appointed for long.
Because of the faulty appointments in BCS (health), trained health managers almost never get appointment in the health and family welfare ministry. Rather, most of the people who get appointment there have neither training nor experience to run the health sector. As a result, Bangladesh’s failure to control a pandemic situation like the outbreak of COVID-19 was nothing but inevitable. But, the responsibility of this failure is not of any individual, any department or ministry, rather the result of a lack of collective realisation about public health, and negligence to the existing health policy.
Following the outbreak of Nipah Virus, Zika fever, Chikungunya, and dengue, the outbreak of COVID-19 is not the first epidemic, nor even probably the last one. There is no alternative to include the public health in the mainstream of Bangladesh’s health sector to address the situation.
For this to happen, I am presenting five proposals: 1. Identify the public health related works in the existing structure of health sector; 2. Create necessary posts as per the international list for necessary public health related activities; 3. Create interlinked but separate career-related clearly defined steps, beginning from joining to retirement in public health sector like Sri Lanka; 4. Bring necessary and appropriate changes in undergraduate medical curriculum and related higher studies to make it suitable for careers in public health; and 5. Bring necessary infrastructural and institutional changes in the health sector to make the public health career track compact.
To implement all these, a coordinated health council has to be formed and public health related works under existing departments have to be carried out under that. I have already mentioned that the National Health Policy clearly talked about forming a National Health Council. In proper implementation of the health policy, going beyond the personal or vested quarters’ interests, lies the mantra of facing a pandemic, like COVID-19, and getting a sustainable, pro-people, efficient and strong healthcare system in the long run.
* Taufique Joarder is public health and medical health expert and executive director Public Health Foundation, Bangladesh. This article, originally published in the 22nd anniversary edition of Prothom Alo, has been rewritten in English by Shameem Reza