Governance accountability. The need for greater accountability

Governance
and Leadership is one of the important building blocks of health system defined
by World Health Organization. This is considered as the basement if the total
health system is considered as a house.

Figure 9.1. Health system building blocks represented as house. (Source: Lancet
2009, The National Academies Press, www.nap.edu/read/18256/chapter/20#509)

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 In a WHO publication named Monitoring the
Building Blocks of Health System: A Handbook of Indicators and Their
Measurement Strategies it is written that, “Leadership and governance in
building a health system involve ensuring that strategic policy frameworks
exist and are combined with effective oversight, coalition-building,
regulation, attention to system design and accountability. The need for greater
accountability arises both from increased funding and a growing demand to
demonstrate results. Accountability is therefore an intrinsic aspect of
governance that concerns the management of relationships between various
stakeholders in health, including individuals, households, communities, firms,
governments, nongovernmental organizations, private firms and other entities
that have the responsibility to finance, monitor, deliver and use health
services . Accountability involves, in particular:

 • Delegation or an understanding (either
implicit or explicit) of how services are supplied;

 • Financing to ensure that adequate resources
are available to deliver essential services;


Performance around the actual supply of services;


Receipt of relevant information to evaluate or monitor performance;

 • Enforcement, such as imposition of sanctions
or the provision of rewards for performance. ”

 

Over
the past decades the successive governments of Bangladesh have taken various
steps to develop the health services. The steps included developing
infrastructure, expanding health services down to the grassroots, increasing
the number of health professionals and health workforce, introducing modern equipment
and establishing specialized institutions. Bangladesh has so far achieved
remarkable progress in respect to reduction of crude birth rate, death rate,
maternal mortality rate, child mortality rate, fertility rate and increase of
life expectancy.

However,
despite the above successes, governance challenges in this sector exist that
hinder further achievements.

 

 

Health
system strengthening and good governance:

In
2007 the World Health Organization (WHO) proposed a framework describing health
systems in terms of six core components or “building blocks”. Strengthening a health system means initiating
activities in the six internationally accepted core HSS functions of the
building blocks.

Leadership
or governance is an obligatory component for strengthening health system.
Governance in health is a cross-cutting theme, intimately connected with issues
surrounding accountability. In the context of health systems strengthening, it
is an integral part of the health system components discussed in earlier
sections of this handbook. Despite consensus on the importance of leadership
and governance in improving health outcomes, they remain inadequately monitored
and evaluated.

 

SDG
and implementation challenges in Bangladesh (vision 2030):

Attainment
of SDGs will require a strong and effective institutional mechanism involving
all stakeholders including public representatives (central and local),
government (executive and bureaucracy), private sector, civil society,
knowledge community, and development partners. Here mandatory efficacious
leadership is necessary to bring them all together.

 

Good
governance is an imperative prerequisite for Bangladesh:

For
the poor, the availability and quality of public health services is of great
importance. Where public services are inadequate, the poor will resort to
private services but with a considerable negative impact on the family’s
disposable income. When government resources for health are constrained, good
management of health services is particularly important to sustain health care
access for the poor, at least to a minimum package of primary care and referral
services.

The
reasons for governance deficit in health sector include absence, limitations,
and lack of implementation of laws, and also lack of transparency,
accountability, responsiveness and oversight. Other reasons include
politicization, lack of long-term planning, limitations of infrastructure and
inadequate of budgetary allocation. Moreover, irregularities and corruptions
also create impact on the governance in health sector.

 

 

Proposed
indicators for health systems governance by WHO:

A
composite governance policy index, comprising 10 rules-based
indicators that cover health policies for different disease interventions1 and
health system aspects, is presented. The index provides a summary measure of
governance quality from a rules-based perspective. The indicators assess whether
countries have policies, regulations and strategies in place to promote good
leadership and governance in the health sector, but do not aim to assess
enforcement.

Policy index Sum of the scores of
10 indicators:

1a.
Existence of an up-to-date national health strategy linked to national needs
and priorities

1b.
Existence and year of last update of a published national medicines policy

1c.
Existence of policies on medicines procurement that specify the most
cost-effective medicines in the right quantities; open, competitive bidding of
suppliers of quality products

1d.
Tuberculosis—existence of a national strategic plan for tuberculosis that
reflects the six principal components of the Stop-TB strategy as outlined in
the Global Plan to Stop TB 2006–2015

1e.
Malaria—existence of a national malaria strategy or policy that includes drug
efficacy monitoring, vector control and insecticide resistance monitoring

1f.
HIV/AIDS—completion of the UNGASS National Composite Policy Index questionnaire
for HIV/AIDS

1g.
Maternal health—existence of a comprehensive reproductive health policy
consistent with the ICPD action plan

1h.
Child health—existence of an updated comprehensive, multiyear plan for
childhood immunization

1i.
Existence of key health sector documents that are disseminated regularly (such
as budget documents, annual performance reviews and health indicators)

1j.
Existence of mechanisms, such as surveys, for obtaining opportune client input
on appropriate, timely and effective access to health services.

A1 

 

 

 Governance Challenges in the Health Sector in
Bangladesh:

Existing challenges that we are fronting:

·        
Limitations
and Challenges with regard to Policies and Laws and Implementation

·        
Limitations
of Financial Management

·        
Limitations
with regard to Human Resource

·        
Infrastructure
and Logistics

·        
Access
to information

·        
Servicing,
maintenance and others

 

Combating all these short coming
still Bangladesh has set landmark in many health indicators and already being
exemplifying to many countries. As recognitions of such achievements,
Bangladesh received an UN award for its remarkable achievements in attaining
the Millennium Development Goals particularly for reducing the child mortality
rate (MDGs-4), and received the Best Immunization Performance Award by Global
Alliance for Vaccines and Immunization (GAVI).

 

 GOAL AND OBJECTIVES OF THE NATIONAL HEALTH
POLICY 2011:

To overcome existing challenges
and to create a regulatory framework National Health Policy 2011 was
implemented which aimed at

First: To make necessary basic medical
utilities reach people of all upazilla and develop the health and nutrition
status of the people.

Second: To develop system to ensure
easy and sustained availability of health services.

Third: To ensure optimum quality,
acceptance and availability of primary health care and governmental medial
services.

Fourth: To reduce the intensity of
malnutrition among people and implement effective and integrated programs for
improving nutrition status.

Fifth: To undertake programs for
reducing the rates of child and maternal mortality.

Sixth: To adopt satisfactory measures
for ensuring improved maternal and child health and install facilities for safe
and hygienic child delivery.

Seventh: To improve overall reproductive
health resources and services

Eighth: To ensure the presence of
full-time doctors, nurses and other officers/staff, provide and maintain
necessary equipment and supplies at each of the upazilla health complexes and
Union Health and Family Welfare Centers (UHFWCs)

Ninth: To devise necessary ways and
means to make optimum usage of available opportunities in government hospitals
and the health service system.

Tenth: To formulate specific policies
for medical colleges and private clinics, and to introduce laws and regulation.

Eleventh: To strengthen and expedite the
family planning program with the objective of attaining the target of Replacement
Level of Fertility

Twelfth: To explore ways to make the
family planning program more acceptable, easily available and effective among
the extremely poor and low-income communities

Thirteenth: To arrange special health
services for the mentally retarded, the physically disabled and elderly
populations

Fourteenth: To determine ways to make
family planning and health management more accountable and cost-effective by
equipping it with more skilled manpower

Fifteenth: To introduce systems for
treatment of all types of complicated diseases in the country, and minimize the
need for foreign travel for medical treatment abroad.

Ministry of Health and family
welfare and success story in Health Governance:

Ministry of Health & Family
Welfare seeks to create conditions whereby the people of Bangladesh have the
opportunity to reach and maintain the highest attainable level of people
health. It is a vision that recognizes health as a fundamental human right and
therefore the need to promote health and reduce suffering in the spirit of
social justice. It performs

Policy
regarding Health and Family Planning
Public
Healtth

·        
Registration
of births and deaths.

·        
Adulteration
of foodstuffs and other goods relating to health.

·        
Control
of epidemics and prevention of infectious and contagious diseases and
contagious diseases and quarantine isolation.

·        
Health
insurance.

·        
Standardization
and quality control of foot, water and other health related commodities.

·        
Regulations
for medical professions and standard.

·        
Administration
of medical institutions and coordination and determination of standards in
institutions for higher medical education or research.

·        
Control
of drugs

·        
Countersigning
of medical bills of the persons holding non-profitable offices.

·        
Reimbursement
of customs duty on gifts on non-consumable medical stores received from abroad.

·        
Preparation
of schemes relating to family planning and their submission to the prime
Minister or the Cabinet through Planning Commission.

·        
Co-ordination
and evaluation of all executive functions relating to projects and programmers.

·        
Preparation
and co-ordinations of activities relating to family planning through other
Ministries/Divisions and offices.

·        
Survey,
monitoring evaluation and compilation statistics of field activities in matters
relating to family planning.

·        
Activities
relating to maternity and child health centers.

·        
Administration
of B.C.S. (Health).

·        
Administration
of B.C.S. (Family Planning).

·        
Post
Mortem examination of dead bodies.

·        
All
matters relating to administration of morgues.

·        
Secretariat
administration including financial matters.

·        
Administration
and control of subordinate offices and organizations under this Ministry.

·        
Liaison
with International Organizations and matters relating to treaties and
agreements with other countries and world bodies relating to subjects allotted
to this Ministry.

·        
All
laws on subjects allotted to this Ministry.

·        
Inquiries
and statistics on any of the subjects allotted to this Ministry.

·        
Fees
in respect of any of the subjects allotted to this Ministry except fees taken
in courts.

 

Some of the recent implemented
laws and act in health sector through MOHFW are

·        
Medical
Education-1: Chittagong Medical Law, 2016.

·        
Medical
Education-1: Rajshahi Medical Law, 2016.

·        
Bangladesh
Medical & Dental Council Act, 2010

·        
BANGABANDHU
SHEIKH MUJIB MEDICAL UNIVERSITY ACT, 1998

·        
The
Drugs (Control) (Amendment) Act, Ordinance, 2006

·        
The
Smoking and Usnig of Tobacco Products (Control) Act, 2005

 

Health
Legislation in Bangladesh:

Health Legislation in Bangladesh
can be divided into six groups, namely,

(1) Vital registration,

(2) Communicable disease control,

 (3)Food and drugs control,

 (4) Medical education,

 (5) Health practice and

 (6) Environmental health (source: Healthcare
Laws in Bangladesh by Dr BELAL HUSAIN JOY)

Hierarchy
of Personnel in the Ministry of Health and Family Welfare:

Honorable Minister for Health and
Family Welfare is the supreme authority in the Ministry. The Minister is
assisted by Honorable State Minister. As the principal executive of the
Ministry, the Secretary works with a team of officials including Additional
Secretary, Joint Secretaries/Joint Chiefs, Deputy Secretaries/Deputy Chiefs,  Senior Assistant Secretaries/Senior Assistant
Chiefs and so on.

Executing
Authorities:

The executing authorities under
the MoHFW are:

·        
Directorate
General of Health Services (DGHS),

·        
Directorate
General of Family Planning,

·        
Directorate
General of Drug Administration (DGDA),

·        
 Directorate of Nursing Services (DNS),

·        
Health
Engineering Department,

·        
Transport
& Equipment Maintenance Organization (TEMO),

·        
National
Electro-Medical & Engineering Workshop (NEMEW), Essential Drug Company
Limited (EDCL) and

·        
 Revitalization of Community Health Care
initiatives in Bangladesh (Community Clinics Project).  

Regulatory
bodies:

The regulatory bodies under the
MoHFW include:

1.     
Bangladesh
Medical and Dental Council.

2.     
Bangladesh
Nursing Council

3.     
State
Medical Faculty (SMF)

4.     
 Homeo, Unani and Ayurvedic Board

5.     
Bangladesh
Pharmacy Council.

 

 

Regulations
of Healthcare Professionals:

Healthcare practitioners have
been generally brought under:

(i)                
TheMedical and Dental Council Act, 1980, (qualifications andregistration of medical practitioners and dentists);

(ii)              
The
Bangladesh Nursing Council Ordinance, 1983, (qualifications
andregistration); 

(iii)            
The Bangladesh Homoeopathic Practitioners
Ordinance, 1983, (regulation of the qualifications and registration
of  practitioners);

(iv)            
The Bangladesh Unani and AyurvedicPractitioners
Ordinance, 1983,(regulation of the qualifications and registration of practitioners).

(v)              
 In addition to them, The MedicalPractice and Private Clinics and Laboratories (Regulations)Ordinance, 1982 was enforced to regulate medical practice andfunctions of private clinic and laboratories i.e., charges ,maintenance
of chambers & registers, license to establish private clinic, inspection
etc.

(vi)            
Bangladesh
Medical and Dental Council hasits own Code of Medical Ethics, under which any practitioner convicted
of false pretenses, forgery, fraud, theft, indecent behavior or
assault, is liable to disciplinary action by the Council. (source: Healthcare
Laws in Bangladesh by Dr BELAL HUSAIN JOY)

 

Laws
for Medical Negligence & Legal Remedies:

To administer and monitor the
healthcare services another set of substantial laws are also in action, they
are: Constitutional Law, Law of Contract 1872, Penal Code 1860, Code of
Criminal Procedure1898, The Limitation Act 1908, Consumer Rights Protection
Ordinance 2007, The Fatal Accident Act 1855, The Law of Evidence1872, Law of
Tort (we have limited tort law in our country) and so on.

 

 

Recommendations

a) Laws and Rules

1. New laws should be enacted and
existing laws should be reformed-

? Punishment against any
violation of laws by private health facilities should be increased

? Consultation fees and charges of
pathological investigations should be fixed based on realistic

criteria

2. The draft law on private
healthcare services should be finalized in consultation with the relevant

stakeholders and should be
enacted as a law.

b) Budgetary Allocation

3. Allocation for the health
sector should be increased in the national budget.

4. In the overall allocation,
allocation for development expenditure should also be increased along

with that for non-development
expenditure

c) Human Resource Management

5. Immediate steps need to be
taken to fill-up vacant positions of Civil Surgeon, Deputy Civil

Surgeon, Superintendent, UHFPO,
Medical Technologists, Anesthetists, and Senior Consultants

etc.

6. Lengthy procedure to recruit
manpower should be reformed. Quick measures should be taken

involving hospital authorities,
Health Directorate, Health Ministry, Ministry of Establishment and

Finance to recruit manpower based
on a need assessment.

7. Influences of the health
professional bodies in line with political considerations in recruitment,

promotion, transfer of doctors
should be stopped.

8. A fair selection process
should be ensured for training based on seniority, merit, and

performance.

9. Monitoring and supervision
should be strengthened to ensure the presence of health assistant at

community clinics and to stop
stealing of government medicines.

d) Health Services

10. Advice and Information Desk
should be introduced in all hospitals; an information board that

includes citizens’ charter,
directions of wards/departments should be hung at the entrance of the

hospitals.

11. Effective law should be
adopted to prevent (and to punish for) death of a patient due to doctor’s

negligence and ensured its
application.

12. List of registered doctors
along with their qualifications should be published on the website of

BMDC and an SMS system should be
in place to respond to any inquiry about registered doctors.

13. To ensure the presence of
doctors in duty locations-

·        
?
Livable residence facility should be ensured;

·        
?
Special hardship allowance should be introduced for the doctors who would be
posted in

remote areas and for working on
holidays.

14. Health Management Committee
should be made active and concerned Member of the Parliament

should take proactive initiative
to make committee meeting regular.

e) Procurement, Repair, and
Maintenance

15. E-tendering process should be
introduced to ensure transparency in selecting suppliers for

procurement.

16. Standard Operational
Procedures (SOP) should be developed to determine types of services,

manpower, equipments and
infrastructure or other necessary things for providing services based

on the level of health facility

17. Hospital authorities should
be allowed to spend at least 50% of user fees for maintaining their

emergency requirements.

 

Finally
it can be said that there are significant efforts and laudable achievements of
the government in the development of the health sector. However, the
achievements could have been higher if there were less limitations,
irregularities and corruption. It is observed that there are lacks of long-term
planning in terms of human resource management (recruitment, transfer and
promotion), procurement management, control and supervision, and ensuring
transparency and accountability. The monitoring and supervising system for
public and private healthcare institutions is not strong. Moreover, the
institutionalization of corruption in this sector particularly with regard to
administrative and service-providing aspects is observed.(  literature: Governance Challenges in the
Health Sector and the Way Outs)

 A1WHO
suggested to discard this as no work has been done on this though it is
mentioned in their health system framework handbook

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