& çâÌæÚUæð´ ·¤è ¥ôÚU Îð¹Ùæ ÁæÚUè ÚU¹ð´ ¥ÍæüÌ ¥ÂÙð ÜÿØ ÂÚU ŠØæÙ ÚU¹ð´Ð ãæÚU Ù ×æÙð´, €UØô´ç·¤ ·¤æ× ·¤ÚUÙð âð ¥æÂ·¤ô ©gðàØ ·¤è Âýæç# ãôÌè ãñ ¥õÚU ÁèßÙ ·¤æ ¹æÜèÂÙ ÎêÚU ãôÌæ ãñÐ ÖÜð ãè ÁèßÙ ×ð´ ç·¤ÌÙè Öè ·¤çÆÙæ§ü €UØô´ Ù ¥æ°, çÁ™ææâæ ¥õÚU ©ˆâæã ÕÙæ° ÚU¹ð´Ð ŠØæÙ ÚU¹ð´, ÜÿØ ã×ðàææ ¥æÂ·Ô¤ Âæâ ãôÌð ãñ´ çÁ‹ãð´ ÂæÙð ·Ô¤ çÜ° ÂýØæâ ¥æÂ ·¤Öè Öè àæéM¤ ·¤ÚU â·¤Ìð ãñ´Ð

How to Develop Health Policy

by Dr K M Raahid
▼ ▼ hvfng tn rural area* and a Gro* a National Product (ONPI per capita of (USS 186). Bangladesh present. a untaue situation and poae* a big challenge to policy maker* and planner*. Nonetheless.
of a health polity for Bangladesh, a vital issue of national importance, can no longer be delayed, because formulation of health
development plan* and
translation of such plans Into action In a cohesive and con tinuous manner Is very much dej>endent on a formal health
Health and Development
The South Asia subcontinent has a centuries-old her Hage of health sciences, and a* such tn addition to the allopathic system of medicine, traditional systems of medicine are widely practiced particularly amongst the rural communities Although the allopathic system of medicine has made major Impact on the approaches to health care and the pattern of development of health services Infrastructure, there exists scope for further development and integration of traditional system of medicine Into the delivery of primary health care services
Development Is a process of economic growth plus social change As a process tt may be considered as a means to achieve well being. On the other hand, well being can be considered us a slate. wherein the individual or society enjoys a sustained higher level of living which from an economic standpoint Implies the capacity to pay for and consume goods and services and the availability of the same.
In a developing country like Bangladesh, the low levels of living cause low output and efficiency of labour which In turn are among the causes of low Income. The relationship between health and development can be considered as health Is both a means and an end to development'. In the analysis of social system, health falls under levels of living As such, tt Is affected by change In other components of the levels of living (e.g. nutrition, food consumption, education, housing conditions of work, clothing, recreations etc.).
All countries — developing and developed — have the de sire to move from their present level to the next higher level of development. To be able to do this ft is necessary to analyze conditions, such as. income or output, conditions of production, levels of living. attitudes, Institutional condition* and policies. The relationship* of these conditions with each other are so close that changes in one almost always lead to changes in other*.
A plea for higher allocation to health sector and other related sectors contributing lo positive health is based on the stipulation that investment in health while generally considered consumption Investment' are clearly also production In-vestment.' Attention to major health problems affecting rural K, urban slum dwellers and ur forces, particularly women and children will result tn more productive population. Just as sophisticated curative medical facilities have been developed In response to urban-elite demand and have paid political dividends, so too the primary health care will ebeit political support front its special target groups. This large number could amount to considerable political clout.
Health Scenario of Bangladesh
Il Is well-known that In a developing or underdeveloped country It is difficult lo cor-
rectly assess the status of health development due to the fact that the health information system there is In the process of development. However, the socio-economic scenario of Bangladesh may be characterized by high birth rate, high morbidity and mortality rates, high rate of population growth, low adult literacy rate (34 as against 91 in Sri Lanka and 86 in Myanmar) and low per capita Income.
The health development efforts made during the past three successive Five-Year Plan periods have brought about some improvement In health status and health care services. The life expectancy at birth Increased from 50 years In 1985 to 55 years In 1989. the infant mortality rate (per 1000 live births) declined from 125 in 1985 to 110 tn 1989 while the maternal mortality rate did not show any significant change. The crude birth rate ( per 1OOO pop.) declined from 39 in 1985 to 36 In 1989. and the crude death rate ( per 1OOO pop) came down from 15 in 1985 to 13 tn 1989.
While some improvement la obvious from the above statis lie* there to still a tong way lo go to reach an acceptable k-wl of health statu* of the population.
This will be apparent from a comparison of the health sta tus of the people of Bangladesh with those of a few neighbouring countries which are shown tn the tabte.
Malnutrition to widespread in Bangladesh. and about 78% of all the households are defi dent In calorie intake. Studies have Indicated that nearly 50% of the children suffer from malnutrition. Nutritional intake over the years has declined from 2094 kcl in 1975 to 1900 kcl in 1989. Prevalence of vitamin A deficiency (night blindness, xc-rophlhalmai). iron deficiency anaemia, iodine deficiency goitre, protein-calorie deficiency are on the Increase.
Morbidity and mortality due to communicable diseases are still very high: predominant amongst cause* of morbidity are diarrhoeal diseases, acute respiratory Infections, tubcreu-
losis, tetanus, intestinal worm Infestation*, and some parasitic diseases (Malaria and Kalazar). Among the non-communicable diseases, diabetes. cancer, mental Illnesses and drug dependence are on the increase.
Health care facilities
The primary health care facilities so far developed have been able to cover only around 55% of the population of the country and the availability of essential drugs and vaccines for public health services has reached nearly 50% of the total requirement.
Out of a total of 460 Upzilas, 351 Upazilas have so far been covered by Upazlla Health Complexes (according to plan each Upazlla will have one Health Complex). At the Union level. 1317 Health Sub-Centres/Rural Dispensaries (under the Health Services) and 2383 Health and Family Welfare Centres (under Family Planning Services) are operating. However, there are anomalies In the distribution and functioning of these Instllutions at the periphery While in each of the 2*7 Union* both the above inotttutlona are functioning there are nearly 979 Unions where none of these facilities exist. In the Sub Centre, the emphasis is on the delivery of health care services whereas the HFWC* concentrate mostly on the family planning
Amongst the front-line community health workers, there are 21,000 Health Assistants (HA* employed by Health Service* and 23,500 Family Welfare Assistant (FWAs) employed by the Family Planning Service* operating al the ward level. Tht* mean* that for about 1OOO houses there exist one HA and for about 850 houses one FWA. Thus a fairly large number of work force is available al the community level
Around 34,000 hospital bed* (27.050 under public sector) for a population of 106 million gives a hospital bed population ratio of 1:3176. Nearly 21,000 doctors and 11,000 nurses have so for graduated in the country, thus
giving doctor population ratio of 1:5,143 and nurse-popula lion ratio of about J:10.000. However, these ratio* will look further gloomy if we lake into account the loss due lo emigration. retirement, and death; but unfortunately these figures are not available
With regard lo the strong thenlng of health infras truclure tn support of delivery of primary health care, it will appear from the above that lots remain to be accomplished In the near future tn order lo achieve the cherished goal of 'Health for All by the Year 2000.'
Decision-making in Health Development
In the communities there are various groups with differing values and views some of which may clash with others. But these do not pose a significant obstacle in the determination of policies and programme since the Improvement of the well-being, reduction of mortality and/or morbidity arc acceptable to all groups although slated in dif-ferent way*. However, when deciding approaches lo achieve these objectives prove* conflicting, rational decision is a difficult matter.
Over the past decades, there has been a rapid growth tn knowledge and technology so much so that existing ones may become obsolete tn a short period. Technologic^ that arc developed may be complex and/or expensive. This would require proper choice of what to adopt or apply considering the capacity to absorb them and the feasibility of their application. If the pol icy makers and planner* Insist on adopting such expensive technologies as a measure of progress, this may lead to depletion of scarce resources that are so vital for the delivery of primary health care. Ill con reived. ID-planned and Inadequately supported super specialised services are Ineffective. and frustrating both the consumer* and service provider* Moreover, ft is not rational to Invest the scarce resource* towards high-tech-nology service* while the Infant and maternal mortality rales In Bangladesh arc still very high as compared lo those in other countries. Il seem* that the public kector In a developing country like Bangladesh ha* no other alter native but to put more empha-*1* on the preventive and pro-motivc aspect* of health care at the present lime rather than Investing heavily on the curative service*
One must realize that tn a developing country, while II I* difficult lo increase resources, tt Is *ttll possible lo Improve the health scenario by making optimum use of available re souret s biised on the principle of efficiency and effectiveness. Political decision makers do not always sub •cribc lo utilizing political pressure a* the sole basis of their action They loo, as other managers, require facts. want to understand Implication* of their decisions. So. it Is the responsibility of the bureaucrat* and technocrats to keep (he politicians well informed about UFA strategy to which the country is committed. In the formulation of a national health policy correct assess ment of the health and health services situation, identification of priorities, definition of objectives and selection of appropriate programmes and projects to tackle such priority health problems are very im port ant steps.
(The writer is a former medical officer of World Health Organisation)