Bangladesh Health care system and reproductive health

1. nazmul.alam@savethechildren.org
Health Governance &
Reproductive health
perspective in Bangladesh
Md Nazmul Alam
Save the Children International
<nazmul.alam@savethechildren.org>

2. Bangladesh health scenario at a glance
• Population - 152.5 Million
• Density – 946/sqm
• Life expectancy – 67 years
• Income / capita – 848$
• Health exp./ capita – 23$
• TFR – 2.3
• Infant Mortality Rate – 43 per 1000
• Under 5 Mortality rate – 53 per 1000
• No. of registered physicians- 53,063
• Estimated no. of doctors available in the
country - 43,537
• Doctors working under MOHFW - 38%
• Doctors working in private sector - 58%
• Registered diploma nurses - 26,899
• Estimated no. of nurses available in the
country - 15,023
• Maternal mortality rate – 194 per
100000
• Child malnutrition – 47%
• Immunization – 86%
• Assistance at Delivery
• Skilled - 12%
• Unskilled – 53%
• Birth at health facility – 29%
• CPR – 61.2%
• No. registered mid -wives - 23, 472
• Population per physician – 3269 (Current
population / available registered
physicians)
• Population per bed - 1738 (Hospital beds:
under MOHFW + Regd. private hospitals)
Source: MOHFW Health Bulletin 2011
Source: BDHS 2011

3. Health system structure in Bangladesh
Ministry of Health &
Family Welfare
Director General of
Health Service
Director General of
Family Planning
Directorate of
Nursing service
Directorate of Drug
Administration

4. Health Service Delivery System in Bangladesh
Facilities Services
7 Division Medical College – (21 Public, 44 Private) Specialized Hospitals (38)
64
Districts
Districts hospitals (61) Outdoor and indoor service (50-250
beds), laboratory and ambulance
services
Maternal and Child Welfare Center (95) Emergency Obstetric Care and other
services.
481
Upazila
Upazila Health Complex (460) Outpatient, inpatient services (31-50
beds), diagnostics service with
operative treatments.
4498
Unions
Union Health and Family Welfare Center
(2500)
Outpatient service – Family planning,
maternal and child health,
communicable disease control,
Rural Sub center (1449) clinical care etc
40482
Wards
Community Health Clinic (9722) Family planning, immunization,
common disease treatment and
referral, communicable disease
control

5. Split Autonomous Administrative Health System

6. Governance & Health – A historical review
Health For All
The Alma Ata Declaration (06-12 September, 11997788)) – AAllmmaa AAttaa,, UUSSSSRR
To protect and promote health
Express urgent actions from:
Emphasized on
“ Primary Health Care”
(District Health system)
- All governments
- All health and development workers
- The world community
With substantial
“Community Involvement” for
universal,
preventive and curative services
1980
Debt crisis &
SAP
1990
Health
Sector
Reform

7. Governance & Health Governance – A quick glance
 Governance -
is about rules (both formal, embodied in institutions –
democratic elections, parliaments, courts, sectoral
ministries and informal- reflected in behavioral patterns -
trust, reciprocity, civic-mindedness) that distribute roles
and responsibilities among societal actors and that shape
the interactions among them.
 Health Governance -
is the approach for sustainable delivery of quality health
services by the political leadership to the community
especially to those who have little or no resources

8. what is Health Governance!
• Health Governance includes - mechanisms, processes, institutions
through which people articulate their interests, exercise their rights
and obligations and for those in government to serve the people well,
and for the civil society and the private sector to actively engage
those in government.
 Rules that govern roles/responsibilities and interactions among:
Beneficiaries/service users,
Political and government decision-makers, and
Health service providers (public, private, nonprofit)
To determine/ ensure:
 (which) Health policies pursued,
 (what types of) Services provided,
 (how) Health resource allocation and use,
 (Assess) Distribution of costs,
 (Reaching to) Recipients of services and benefits,
 (How come better) Health outcomes can be achieved.

9. Interactive agencies in Health Governance

10. Linkage of Health Governance Actors

11. Relationship within the actors
III. Relation between state and
Providers (A contract-like connection)
a. From State to Providers:
 Policymakers specify objectives,
procedures, and standards; provide
resources and support; and exercise
oversight relative to providers
 In exchange for resources, providers
carry out the agreed-upon desires and
I. Relation between state and Citizens
 Citizens will express needs, preferences, and
demands to politicians, policymakers, and
public officials.
 State will response to client/citizen needs,
preferences and demands
II. Relation between providers and
citizens (Consider as ‘heart’ of health system)
directives of the policymakers
b. From Providers to State:
 Regular reporting of information for
monitoring purpose
 Maintain political, performance, and
financial accountability
 Provide data for policymaking to pursue
evidence-based policy formulation
 Clients/citizens convey their needs and demands
and their level of satisfaction – directly to service
providers,
 Service Providers in turn offer a mix of quality
services that satisfy needs and demands.
 This relation is a balancing board of –
 Power negotiation
 Information irregularities
 Capacity gaps
 Accountability failures
 Inequities

12. Health care personnel comparison- urban & Rural

13. Regional comparison of Qualified Health care personnel
Per 10,000 people

14. Bangladesh Health Governance: Issues and Challenges
• Lack of people’s voice and Accountability within the system
• Weak Monitoring and Regulatory Framework
• Centralized administration with limited understanding of demand
• Poor Management of Drug and Equipments
• Staffing and Absenteeism
• Mismanagement in Health Care Service Delivery
• Weak Management and Coordination Network
Ways to Forward:
• The health care system in Bangladesh operates within a complex political administrative
environment.
The politicized • aaddmmiinniissttrraattiivvee ssttrruuccttuurree aatt hheeaalltthh sseeccttoorr iiss tthhee rroooott mmiiss--ggoovveerrnnaannccee
• Strengthening of health service system planning and management
• Accountability and transparency is an important factor for all sectors.
• Improvement in the logistics of drug supplies and equipment to health facilities at district and
lower levels;
• Strong and effective referral system within the health institutions
• Engage quality human resources for health sector;
• Systematic regular maintenance of existing health facilities;
• universal access to basic healthcare and services of acceptable quality;
• Improvement in medical education;
• Strong policy and regulatory framework.

15. Access to Health Care Services in Bangladesh
• Access to health services depends on availability and affordability of services;
• availability of physicians,
• health centres, and hospitals
• Referral system etc.
• Citizens with lower income and living in rural area do not have much accessibility
as health facilities
• BBootthh ppuubblliicc aanndd pprriivvaattee sseeccttoorr aarree ddiissttrriibbuutteedd iinn aann uunnjjuusstt wwaayy..
• Delivery of services also varied depending on the level of income (rich and poor),
which is evident in discriminatory access to services.
• The poor in Bangladesh bear higher health risks and suffer the burden of excess
mortality and morbidity.
• The poorest households are likely to use health care services and are less willing
to pay for improved services compared to other socio-economic groups (Jahan
and Salehin, 2006).

16. Reproductive Health
• Reproductive Health
• implies that people are able to have a responsible, satisfying and safe sex life and that
they have the capability to reproduce and the freedom to decide if, when and how often
to do so.
• It also implies
• To be informed of and to have access to safe, effective, affordable and acceptable
methods of birth control and family planning;
To • hhaavvee aacccceessss ttoo aapppprroopprriiaattee hheeaalltthh ccaarree sseerrvviicceess ooff sseexxuuaall && rreepprroodduuccttiivvee
medicine and
• To have implementation of health education programs to stress the importance
of safe pregnancy and safe childbirth

17. Few facts on world wide Maternal health
• Worldwide, 1000 women die every day due to complications during pregnancy and
childbirth - up to 358 000 women per year
• Four main killers cause around 70% of maternal deaths worldwide:
• severe bleeding,
• infections,
• unsafe abortion, and
• hypertensive disorders (pre-eclampsia and eclampsia)
• More than 136 million women give birth a year. About 20 million of them experience
pregnancy-related illness after childbirth
• Developing world has 90% birth through adolescent mother aging between 16-19
years
• Of the 1000 women who die every day, 570 live in sub-Saharan Africa, 300 in South
Asia and five in high-income countries.
• 46% of women are attended by a trained midwife, nurse or doctor during childbirth
• In developing countries, the percentage of women who have at least four antenatal
care visits during pregnancy ranges from 34% for rural women to 67% for urban
women
• About 18 million unsafe abortions are carried out in developing countries every year,
resulting in 46 000 maternal deaths
• By 2015 another 330 000 midwives are needed to achieve universal coverage of
mothers with skilled birth attendance
(Ref: http://www.who.int/features/factfiles/maternal_health/en/index.html)

18. Few facts on Maternal Health in Bangladesh
• Bangladesh was one of eleven countries that were responsible for
approximately 65% of maternal deaths around the world (WHO 2010)
• Since 2002 Bangladesh has reduced maternal mortality by 40% (BRAC 2011)
• Average age at marriage is 16 and average age of birth is 19.
• Bangladesh is facing a severe health care worker shortage
• In 2001 less than 18% of births were attended by medically trained
personnel.
• In 2011 only 29% of births took place at a health care facility.
• TThhee llaacckk ooff sskkiilllleedd pprroovviiddeerrss aatt hheeaalltthh cclliinniiccss eexxppllaaiinn oovveerr 6600%% ooff ddeeaatthhss
during childbirth and 40% of post-partum hemorrhage death.
• 80% of maternal deaths occur at home.
• The challenges of maternal health differ for Bangladesh’s urban and rural
populations
• Urban areas contain about 15% of the population but 35% of doctors and 30%
of nurses.
• Rural women bear on average one more child than their urban counterparts.
• In 2007, 36% of women living in urban areas had a skilled provider present
during childbirth compared to only 13% of women living in rural areas.

20. Comparison maternal mortality survey Bangladesh
BMMS 2010 BMMS 2001

21. Factors of effects health service utilization
service delivery
Gender
Inequality
Health
Beliefs
system factors
Health Service Utilization

22. Factors of effects health service utilization (Contd……1)
Social norms in developing countries - childbirth to be seen as a normal event, or
even a test for women to endure on their own.
 Markovic et al., (2005) shows women uncomfortable discussing their health
problems with their husbands or senior male members of the household and
postpone care-seeking until the benefits of early intervention have been lost
Afsana et al., (2000) found blame was placed on women who needed to ask for
assistance or have delivery in a facility, as they intentionally done something for
attention and assistance.
AA ssttuuddyy iinn UUggaannddaa sshhoowwss ““tthhee wwoommaann wwhhoo ddeelliivveerrss hheerrsseellff wwaass ssaaiidd ttoo bbee hhiigghhllyy
respected” (Kymuhendo, 2003)
Many study reveals the primary reason for low utilization of health services are;
distance from a health facility
transportation problems
costs of services including informal charges
opportunity costs from time lost
perceived low-quality care in facilities, or
cultural barriers to professional health-seeking ( stigma, fear, inability for women to
travel alone, or to be seen by male doctors

23. Factors of effects health service utilization (Contd……2)
• In Bangladesh too many alternative healthcare providers get involved when
problems are perceived.
• Elderly women in the house mostly take decisions regarding maternal health and
as they have not received any facilities they have less interest in it.
• In many cases household chores become a barrier for women to go and take
medical services . A comparative study (Parkhurst et al. 2006) between Uganda
and Bangladesh revealed Ugandan husbands are more liberal taking over
household work in contrast of Bangladeshi husband.
• Same study findings briefs, in Ugandan cases, it was almost always the husband
or close family networks who supported the decision and action to use a facility
for delivery.
• But in Bangladesh, in most cases, husband in the rural do not interfere with the
decision of elder female members in this regards. Also no much choice is taken from
family members of the female.
• Formal education and relative wealth are positively associated with the
utilization of maternal and child health services (Amin et al. 2010).
• Socio-economic status and husband’s occupation is correlated with modern
health service utilization (Chakraborty et al. 2003)

24. Key actions to improve Reproductive Health outcomes
• Increase school enrollment of girls.
• Strengthen employment prospects for girls and women.
• Educate and raise awareness on the impact of early marriage, child-bearing and
reproductive health choices.
• Increase advocacy and community participation, and involve men in supporting
women’s health and wellbeing.
• Improve and expand recruitment and training of community health workers,
sskkiilllleedd bbiirrtthh aatttteennddaannttss,, eettcc.. ppaarrttiiccuullaarrllyy iinn aarreeaass wwhheerree ffoorrmmaall hheeaalltthh ccaarree
infrastructure is lacking.
• Secure reproductive health commodities and strengthen supply chain
management.
• Sustainability of Maternal Health Interventions need to be ensured;
• Institutionalizing community-level interventions within government structure
• Going through social norm and value change
Ref: Bangladesh Reproductive Health at a glance (2011)

25. How Health governance can help Reproductive Health
• State must have maternal health strategies that focus on strengthening the
primary health care system
• Emergency obstetric care (EmOC), focusing on the primary level where critical
planning, budgeting, and implementation decisions are made
• Multiple stakeholders should be involved including bureaucrats, public
health officials and other individuals and organizations to change policy
formulation and implementation in favor of better maternal health i.e.
• Ensure skilled birth attendance (Quality & quantity)
• Transportation system for patient living in distance
• Accountability paying hospital bills or entering in hospitals for treatment
• Strong collaboration and referral between organization across the nation

26. TThhaannkk yyoouu