I quote Dr K M M Rahman in The Dally Star "The doctors have received the highest education available in the country, and that is also with a highest subsidy from the state. Many of them have received higher education in developed countries of the world, where medical ethics are strictly followed. Besides, many doctors and other medical staff have been serving different developing but prosperous countries, with name and fame. How on earth^ then, these people could engage themselves in stich’ un-

scrupulous activities in ouf ewn. country?" (A Lonely Death at DMCH, 23-2-97) The answer lies as I have come to realize, in my friend Prof James R Killingworth's comment that the major constraints facing even the health professional who is aware of the highest standards of care, committed to raising those of Bangladesh through example, personal sacrifices and struggle with traditional interests, are not specific medical practice patterns, but. rather institutional and policy development problems that impede the advancement of sys-

tem-wide standards of care.

Bangladesh, as we know, occupies 144000 sq. km. of land inhabited by nearly 120 million and is the most densely populated country in the world (World Bank 1995: World Development Report 1995: Workers in an integrating world. Qx-,/ord University press.) with an .adult literacy rate'of 36.4 pier, Arent arid "ah estimated GDPUbf

those of mortality and morbidity indicate that the development of health in Bangladesh is a sluggish process. Infant mortality is at an unacceptable level of 81.8 per thousand live births, life expectancy at birth is 58.1 years for males and 57.6 for females. Ross and co-work-ers report that a woman surviving the age of 49 in a marital union is likely to go through almost five pregnancies, 90 per cent of these births take place at home conducted mostly by untrained and unskilled ignorant

relations or neighbours. Six out of 100 women face pregnancy related deaths, a figure a hundred times greater than that in a developed country.

The Government of Bangladesh aims to offer health for all by the year. 2000 To achieve this objective we need to determine the health needs (both normative and felt needs) of our nation and the demand for health with relevance to income status, cost and accessibility. We also need to determine the sources and the quantity of health care financing and alternative and additional sources of finance which could be made available through revenue generation, insurance, pre-payment and other mechanisms. We have to address how our health system can best be organised.

The public health sector is facing daunting problems. The

existing government facilities suffer from a vast array of difficulties ranging from inadequate sanitation and hygienic water supply to the lack of equipment, supplies, and adequately trained staff. Poor service, lack of drugs and essential supplies and distance from home fail to attract over three-quarter of the rural people from attending government health centres. The government of Bangladesh has a dual system of health service delivery resulting in underutilization of its facilities and personnel. The public health sector has to be redesigned and restructured to enhance productivity and efficiency.

Over the years private and NGO providers have made gradually increased contributions to the health sector in Bangladesh. Information is required about the size, dislribu-

tion and service characteristics of the private and NGO providers and then policies have to be formulated whether to support prlvate/NGO sector or not and if so how and to what extent should they be supported. Ways are to be designed to evaluate and monitor the activities of the private and the NGO sectors which should complement the public health system in this country.

A National Health Policy must be developed to ensire equity. while protecting the vulnerable individuals of the society who are most likely to suffer ill-health and are also least able to afford health care. Health manpower development is another key area which should receive prominence in health policy. Improvement in the curriculum in medical training institutes and provision of structured training thereafter will also be needed to bring benefit to health profes-

sionals and the patients equally. The medical curriculum must include, amongst other, communication skills so that patients are treated with courtesy, dignity and respect and not with contempt.

The present Government in Bangladesh appears to be heading in the right direction. High powered committees have been constituted to formulate a National Health Policy. They should carefully and systematically address healthcare con-;Bumplion, the overall health care delivery system, patient rights, resource deficits, resource mobilization and utilization. health facility, efficiency. cost-effectiveness, education, accountability and training of health professionals. the public-private regulatory framework and the evaluation and monitoring of healthcare quality. And finally while changing policy for these areas, the National Health Policy should also take into consideration the economic, historic and cultural background of Bangladesh so that the objective of health for all can be brought within realistic reach.