May 24, 2013 | 01:12 PM (BD Time)
24 May, 2013 Friday
Building a health care services structure
With severe pain from hernia, Abul Kalam, 35, cried on his bed at the Chittagong General Hospital (CGH). Doctors had twice fixed schedules for his operation. But every time the operation had to be postponed because there was no electricity at that time. Having lost two dates, doctors, nurses and Kalam waited on the third occasion for electricity. Kalam was lucky on the third turn. He returned home after the long waited surgery under proper lights. Established in 1901 over an area of more than eight acres of land, 150-bed Chittagong General Hospital is the oldest in the region. Years of neglect and lack of investment have now left the hospital in tatters. The x-ray machine, ultra sonogram machine, ECG, pathology, blood bank, morgue and preservation of important drugs instantly become inoperative due to lack of power. There is a consultant in the ophthalmology unit but there is no other doctor or technician in the unit. On the other hand, orthopedics patients cannot get any treatment in the department as the post of the consultant of orthopedics is lying vacant. Though it is a hospital with 150 beds but the present human resource can only provide treatment to the patients of 80 beds. At present 88 posts of first class medical officers, five second class, 121 third class and 74 fourth class posts are lying vacant.
Narayanganj General Hospital has virtually become a centre of irregularities as the patients who come to the hospital for treatment have to suffer a lot every day. They alleged that the specialist doctors arrive at the hospital late and leave the hospital much before the end of office hours. The doctors also frequently refer the patients to hospitals in Dhaka, even in minor cases. The doctors also send their patients to private diagnostic centers for various pathological tests, although the hospital has facilities for such tests.
Amid acute shortage of manpower and accommodation, hospitals and health complexes in Patuakhali district are struggling to provide medical service for about 17 lakh people in seven upazilas. A staggering 142 of the 183 posts of doctors are lying vacant in the district. Only two doctors are serving at the ward while posts of a few others including that of the senior surgeon are lying vacant. So, this is an overall review of 3 different places which representing the overall health care crisis & shortages of Bangladesh.
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. In short, it is the infrastructure through which the desired services to the intended population are delivered. Home care of a sick baby, health care in private sectors, behavior change programs, vector-control campaigns, health insurance and financing are all integral part of the system. It includes inter-sectoral actions through comprehensive approach to ensure family, community and country health. Health service delivery, workforce, information, products, financing and stewardship are the six building blocks for strengthening of the health system in a country. Current status and future challenges of the system in Bangladesh can be conceptualized within the gamut of the six building blocks. The World Bank says more than 60% of Bangladeshis, about 80m people, have no access to modern health services other than immunization and family planning. In a new report, the bank also says malnutrition and deaths of women from childbirth are among the highest in the world. Two thirds of children under five are under-nourished. About 60% of children under six are stunted. And more than a third of new born babies weigh less than they should.
The government says that, it plans to open 13,000 community clinics around the country but there are few doctors to staff them. Health Minister Sheikh Fazlul Karim Selim says the government is trying to recruit 1,000 more doctors to improve the health care on offer. The population is expected to double to 250 million by the year 2035. And it is feared that HIV and Aids will reach epidemic proportions in the next few years. The present government has taken steps to revitalize PHC services by making the community clinics operational. These community clinics, one for every 6000 rural populations, were constructed in 2000-2001; but were not used for service delivery. These service points have some unique characteristics. They are managed by a Community Clinic Management Group which includes local public leaders and representatives. The policy in this regard is to place the responsibility for the health of the people in the hands of the people themselves. A quick assessment of the community clinics, supported by WHO in 2009, showed that with the expansion of the health-care facilities to the peripheral level, the distribution of health-care inputs and their utilization became more equitable and the utilization rate of these facilities was almost universal.
Private health care facility lacks seriously to serve the need of the large number of least privileged section living in the slums. In other words such facility especially caters to the well to do sections of the society only. From cost point of view, clinics which have better diagnostics facility and scope, better than average services are found to have higher establishment cost and monthly expenditure. Modern treatment facility like CT Scan, laparoscopy, laser therapy, incubator, ventilator, dialysis etc. are used by only 14% of the clinics and such clinics are concentrated in comparatively posh areas of the city where treatment cost are higher and therefore which is out of the reach of the middle and lower middle income groups. Moreover, absence of ambulance facility in most of the clinics is also a reason for poor health care delivery system.
There were approximately five physicians and two nurses per 10 000, the ratio of nurse to physician being only 0.4(i.e. 2.5 times more doctor than nurses). There were around 12 unqualified village doctors and 11 salespeople at drug retail outlets per 10 000, the latter being uniformly spread across the country Thus, there were about 2.5 times more village doctors and 2 times more drug store salespeople than were physicians who provide treatment/curative services to the population. Also, there were twice as many CHWs from the NGO sector per 10 000 population than from the government sector and an overwhelming number of traditional birth attendants (TBAs) and/or trained traditional birth attendants (TTBAs). The TBAs/TTBAs were involved in providing delivery-related services at home only.
The countries of WHO's South-East Asia Region also face several common health workforce related problems and issues concerning shortage, skill-mix, migration, work environment, knowledge-base and other areas amply articulated in the 'Dhaka Declaration'. Bangladesh is no exception in this regard and it is one of the countries with 'severe shortages' of health workers. Given the shortage of supply of qualified health care providers in Bangladesh, patients, especially the poor and the disadvantaged, mostly seek health care from the nonqualified providers in the informal sector.
The informal health care providers (not registered with any government regulatory body) are categorized into the following groups:
1) Semi-qualified allopathic providers:
b. Community health workers (CHWs)
2) Unqualified allopathic providers:
a. The village doctors (also known as rural medical practitioner, RMP
b. Drug store salespeople:
3) Traditional healers: 'Kabiraj'
4) Traditional birth attendants:
Bangladesh is declared by WHO as one of the 58 crisis countries facing an acute HRH crisis. On the other hand, the increase in the number of unqualified allopathic providers
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