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25 November, 2015 00:00 00 AM / LAST MODIFIED: 24 November, 2015 11:18:33 PM
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Health Status of Bangladesh 2015

Dr. Maswoodur Rahman Prince
Health Status of Bangladesh 2015

Bangladesh with a land area of 147,570 sq. kilometers (56,977 sq miles) and with a population of about 15 crore plus. Bangladesh territory is one of the largest deltas of the world. It is a low lying country and has borders with India on three sides, adjoining West Bengal, Tripura, Assam and Meghalaya. Only a small strip in the southeast has border with Myanmar. The country is covered with a network of rivers and canals forming a maze of interconnecting channels. Bangladesh mostly comprises floodplain areas, with scattered hills at the eastern and the northern parts.
The northern part is in the Himalayan valleys, and the southern part in the coast of the Bay of Bengal. Bangladesh is recognised as the worst victim of global climate change effects without being responsible for its under lying causes. The country manifests all the direct and indirect effects of climate change, such as global warming and sea level rise. As a result, human health has to bear enormous costs.
If we talk about health status of Bangladesh, we may mention that about 30 per cent dying patients are unable to receive services of trained physician and about 60 per cent of expectant mothers fail to receive pre-natal check up.
“Health is a right, not privilege. It needs to be delivered with equity.” Well, no denying the fact that health is a basic requirement to improve the quality of life. National economic and social developments depend a lot on the state of health services. Access to health service is also guaranteed in our constitution and is accepted as a basic human right.
However, a large number of Bangladeshis, particularly in the rural areas have little access to healthcare facilities. It may seem that access to healthcare services for the insolvents, poor and the destitute countries to remain a day dream in one hand and on the other hand private sector healthcare service delivery with most modern and advanced facilities has developed remarkably for the affluent section of the society. Even then many of those wealthy people undertake medical tourism to neighbouring countries with higher and better healthcare service such as India, Thailand, Malaysia and Singapore. Some good number of people often makes it to Australia, Japan, Europe or America.  The National Health Services Sector has been experiencing slide down even through budgetary allocation is on the rise even against resource constraints, resulting in expotential rise and multiplication of problems in the health sector. The state health services are being increasingly deteriorating due to increase in population and corruption and resulting in health services being transferred to private hands to a large extent. The Government doctors are seen devoting more time to their private practices in private chambers and or private hospital. Some of them are allegedly accepting fees for their service at the government hospitals. Negligence, avoiding responsibilities, wrong treatment, higher costs, limited facilities (especially at the public hospitals, over prescribing and unnecessary lab tests (for getting handsome kick-backs from the private labs and diagnostic centres) have landed us in crisis at the health service delivery systems.
Bangladesh, a small country with a population of 150 million plus (mid 2013) about half of which is under 15 years and nearly 38 per cent live below poverty line. Health and population statistics show that over the last forty five years infant and maternal mortality has steadily declaimed in Bangladesh and life expectancy has risen steadily. The percentage of people having access to safe drinking water and facility of sanitary means of disposal of excreta has improved. There has been remarkable rise in EPI coverage of children under one year of age between 1990 to 2010.
There has also been a reduction of death rate due to diarrhoea during last one and half decade. On the other hand the population of Bangladesh has steadily grown from 44 million in 1941, 71 million in 1974 to more than 150 million in 2012. Prevalence of communicable disease remains high. Tuberculosis and smoking related diseases are causing high morbidity and mortality. Malaria, especially malignant malaria, filariasis and leprosy remains to be continued and eradicated yet.  However leprosy and filaria eradication has made a great headway due to especial programmes taken by the directorate of health under Health and Family Welfare Ministry. With various positive developments in the health-care we still are greatly concerned as malnutrition is persisting in all age group, injury and death from accidents and all kinds of violence have been causing serious health problems including mortality. In majority cases the poor are the victims. Only about 40 per cent of the population receives some kinds of state medical care.
The improved and extended especial curative treatment facilities in private sector in recent decades are out of reach of the poor. Most astonishing fact is that the Upazila (Thana) Health Complexes (with 50 bedded hospital), established for about 2 lacs population each, receive yearly budget allocation of Tk 2,00,000 to 3,00,00 only (that is Tk 1 to 1.50 per capita per year).  
All these things which are some way or other harm the physical, mental and social health of the people in this country are attributable to a great extent to over population, corruption and lack of proper and firm political commitment.
There is no doubt that the present medical facility either in public or in private sector cannot satisfactorily cope with the requirements of patients belonging to both insolvent and rich section of society. The country is spending about Tk.12,000 crore from the public exchequer a year for the health sector. Also the private sector medical services have expanded. Despite all these growth and advancement, millions of people of the country have no access to minimum secondary and tertiary level medical care because of their limited financial abilities and or poverty.
Conditions of Upazila Health Complexes established to take health services to the poor rural people are in a pitiable state. Absence of doctors, inadequate supply of medicines and dressings, unsuitable and rusted medical equipment and unserviceable machines have turned most of them into deserted places. More people die from lack of treatment than those who had treatment in those rural centres. On the other hand specialised hospitals and institutions with super specialities, both in public and private sectors, are being established exclusively in metropolis, cities and big towns. In the capital are all the specialised public institutions such as Kidney, Cardiovascular, Mental health, Opthalmology, Trauma and Orthopedics rehabilitation, Cancer, Public health, Preventive and social medicines and diseases of chest and hospitals, equipped with all sophisticated machines and equipment and also specially trained manpower. There are also multispeciality hospitals and cardiac care hospitals, all in the capital such as Apollo (multinational), Square hospital, United, LabAid hospitals. Then there are a few modernised and speciality hospitals such as BIRDEM (mainly Diabetes and Endocrine disease care), Ibrahim Cardiac, Modern Hospital, LabAid Cardiac, Popular Hospital, Ibne Sina Hospital, Islami Bank Hospital, Holy Family Red Cresent Hospital, National Hospital, National Heart Foundation Hospital (Cardiac). Then there are hospitals for cancer care and research such as Ahsania Mission Cancer Hospital, Delta Oncology Hospital etc. There are also large number of private medical college hospitals and diagnostic centres in and around Dhaka Metropolis, fitted with sophisticated equipment, instruments and trained manpower which allure patients from the public sector medical college hospitals and institutes. This greatly hampers healthcare for the poor and destitute at public sector joints. Sophisticated diagnostic procedures are out of reach for the urban poor as the government cannot provide these sophisticated procedures free of cost because the machines and accessories are extremely costly and the price must be reimbursed by people using the facilities. So is the case with heart disease diagnostic procedures and operations/interventions, cancer diagnosis procedures, treatment such as surgical removal of tumours, radiotherapy and chemotherapy.
All these procedures and treatments are extremely costly and very much out of reach for the low income group of people and the poor rural people such as marginal farmers/cultivators or agricultural or industrial workers, day labourers, construction workers, vendors and petty shop keepers, menials and so much and so forth. They cannot get any help from the public institutions, even they cannot dream of such healthcare.
If ill luck would have it and they suffer from heart disease, cancer or kidney failure, they die without any healthcare. Some rural people, who even want to get some treatment at the cost of selling their home and hearth may not avail such opportunity because of unavailability of facilities around his usual place of residence i.e rural areas. Primary healthcare and mother and childcare i.e, reproductive healthcare is grossly neglected and hardly accessible in the rural areas though palpable advancement is seen in the highly institutionalised city and urban areas.  Surprisingly enough, reasonably good infrastructure with adequate skilled human resources, are available in the shape of Upazila (Thana) Health Complex Hospitals and Union Health Centres/dispensaries.


However, only one third of the Union Health Centres are presently manned by an MBBS doctor. The government has created more than 4000 posts for MBBS doctor. Once recruited, these doctors have been posted to the available union health centres. Unfortunately, the healthcare facilities in the rural and upazila area remain very much under utilised due to absence and negligence of doctors and their private practice (service in the exchange of fee) at the place of their work during and after office hours, lack of referrals due to lack of proper communications or absence of ambulance, inadequate supply of medicines or no supply at all and workout instruments and investigation facilities etc. it is no wonder that more than 70 per cent deliveries are done at home and that too by mostly untrained relatives or illiterate and barely experienced rural and so called midwives who have hardly any knowledge about hygiene and asepsis. Occasionally caesarean sections are done at the UHC, if and when EOC made available there (a few UHC’s have provision of EOC presently and OT is made serviceable with availability of Obstetrician and Gynae surgeon, anaesthetist and of course blood transfusion arrangement).  
Well, besides EOC at the secondary healthcare in the rural setting is very much a positive & encouraging development, there are of course many positive developments in the health sector of the country also. These developments are evident such as the total fertility rate (TFR) has come down from 63 in 1971 to 2.40 in 2008. The contraceptive prevalence rate (CPR) has gone up from 7.7 in 1975 to 57+ in 2008. The average longevity has improved quite a lot from 56 in 1990 to 66.78 in 2008 and 68+ in 2014. In 1993 the doctor and population ratio was 1:10,740 in 2015 the doctor/population ratio has come to 1:12,690 (The WHO standard is 1:1400). In 1993 the doctor nurse ratio was 10:1 and it is 2.5:1 in 2011 while WHO standard is 1:3. During 2001 the number of hospital beds stood at 45607 while the number of hospital beds in 2010 has risen 79,199. From these figures an improvement in the health sector is perceivable. To add more on the positive aspects we may mention that there are more than 4000 NGOs running about 170 small and/or medium hospitals with about 4500 nos. of beds. Number of public sector medical colleges with academic hospitals has risen from 5 in the pre-liberation period to 33 by 2014. In the private sector there was not a single private medical college with academic hospital in the pre-liberation days.     
 Today (in 2014) we find that there are 67 private medical colleges with academic hospitals throughout the country. All these development in the private sector occurred between 1975 to 2014. However, it is unfortunate that quality of education and training in many of these private medical colleges and hospital remain questionable due to dirth of qualified and experienced full time and regular teaching staffs including faculty. It is no wonder that due to scarcity of quality teachers, mostly teachers of basic subjects (pre-clinical) are simultaneously teaching in more than one or two colleges each. This also tells upon the standard of education. Then, among other things many private medical colleges do not have proper library and laboratory, necessary equipment and other training aids.
As for some positive sectors we have made some advancement also in the clinical side. We have witnessed the installation of most modern and sophisticated diagnostic equipment, surgical gadgets and other advanced technologies such as Cath Labs, MRI, PET Scan, Bone Scan, CT scanners, CT scan units 16, 32, 64 & 128 slices, Ultrasonography machines, Colour dopplers, Stress thaleum test equipment with Gamma Camera, various advanced coronary care and interventions such as Coronary Artery Angiogram, Angioplasty and Stenting, Coronary Artery Bypass Grafting updated procedures such as awake surgery, beating heart and minimally invasive bypass surgery, faco surgery with artificial lens implantations, kidney and liver transplants (that too from live donors)etc.
We have good number, though not enough for a population of 16 crore, of experienced and  skilled manpower, advanced health service devices and technologies, but what we lack are equal distribution of resources and unquestioned sincerity of the service providers. Pro-people primary healthcare service is not properly implemented within the well knit rural health care infrastructure. Added to these infrastructures about 6000 community clinics were established during 1998-2001 under HPSP programme which has been rejuvenated during the HNPSP Programme. Each community clinic meant to serve 6000 people’s cluster at the grass root delivering primary healthcare and reproductive healthcare. Manned by a health assistant, each community clinic started serving the people. However, subsequent govt. in 2002 stopped the functioning of the community clinics. After the general election in 2008, the new government re-introduced community clinics under HNPSP and already established 12,557 community clinics and put them into service. However, all these well knit rural health service facilities remain highly under used due to lack of commitment and lack of proper utilisation of the facilities, maintenance and proper management.   An ambitious five-year Health and Population Sector Programme (HPSP) was undertaken with World Bank assistance and prescription starting in 1997. The programme ending in 2003, has not been able to see any measurable success. On the other hand, the HPSP programme’s efforts to deliver health and family welfare services from unified platform has jeopardized family planning service and it became platued for a considerable period of time till unification was undone under a new health and family welfare, nutrition sector programme (HNPSP, 2003-2012).
Recently concluded, the Health, Nutrition and Population Sector Programme (HNPSP) under the ministry of Health and Family Welfare (MoHFW) has 38 operational plans (OPs) and 18 projects (the projects include 11 investment projects, 5 technical assistance projects and one JDCF project).  The above health indicators and statistics show that we have achieved considerably in the health field. However lot more remains to be done. All our developments will go in vain unless we can develop a sustainable primary health service delivery on a solid footing and make it accessible to all irrespective of cast, creed, sex, colour or culture. We have progressed reasonably in attaining Millennium Development Goals (MDGs)by the end of the year 2015 in the health related sector. However much remains to be done. We must put lot of thrust to cut down maternal mortality and child mortality to achieve millennium development goal. For this we have to put more and more emphasis on reproductive health and MCH. If run and managed properly with adequate human and other resources the community clinics may go a long way in delivery of primary healthcare at the grass root level.

The writer is Editor, Stethoscope of The Independent

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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