& 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

Health policy: Essentials and remedial measures

DR. LAILUN NAHAR
A POLICY means a plan of action, or a statement of ideas proposed or adopted by a government. But the Health Policy adopted by our past government was only theoretical. In the theoretical health policy passed on 14-082000, the emphasis was on providing basic medical services to all classes of people with particular attention towards poor, and women and children.
Almost all countries of the world have their formal health policy. In our country, the Development Plan for each five year period commenced since 1973. And this health policy has been passed the in fifth five-year plan, extending from July 1998 to June 2003. In the fourth five year plan there were 125 development projects. In fifth five-year plan all have been merged into a single Health Population Sector Programme (HPSP). The HPSP comprises Operational Plans. The programme includes: Provision of Essential Service Package (ESP); Steps to unify, restructure, and decentralize the service; Integrated support system; Improved hospital services; Establishment of
sectorwise programme management; Strengthening policy and regulatory framework; Strengthening other services of public health importance.
Among the operational plans there is only one related to Human Resource Development, termed as Human Resource Management (HRM). The HRM plan only includes matters concerning the appointment, transfer, promotion, deputation and retirement of staff. Surely, there should be some measure to elicit the goodwill and sustained spirit of health manpower to work toward the national goal and objectives, as said by the noted health policy professional, Kenneth Lee. And the eminent health economist, Anne Mill states that financial remuneration is important but not the sole motivator for health manpower. According to her, there should be some measures to strengthen the determination and high level of performance and productivity of staff . There is no such measure to develop goodwill and spirit of our health manpower in our country. Kenneth S Warren (LSHTM,97) says, there is a need for useful transfer of knowledge across the interface between biomedical science research and the health care community. But, in our country only those from biomedical science are taken into account for promotion and those qualified from health care community treated as simple MBBS.
Being a doctor and qualified in Health Policy, I have a real concern about the generally bad impression
of Bangladeshi doctors' attitudes. I feel very strongly that this impression should be changed, and that there should be a good attitude, goodwill and a spirit of dedicated service by doctors toward patients. And as the private sector is dominating gradually, I'll highlight some measures to help our citizens in the private medical sector.
Human resource: Doctors' development
Human Resource Management is merely responsible for much routine work, in authorizing appointment, transfer, promotion, deputation and retirement. We do not see any effort to encourage medical students and doctors in moral, intellectual or global aspects. Socrates has said "I don't want to teach them, I want to make them think". Philosophically, only monetary benefit from private practice is in place for doctors. There is no stimulus to encourage doctors to think about the moral value of the profession or to do something innovative! New thoughts and ideas, new actions and reactions, intention and discoveries are crucial to force a change. The notion about life to doctors, their mode, mentality, tone, temperament, ambition and demand should be valued. They should get an environment which encourages them to develop mentally and intellectually.
Enthusiasm is the root of spiritual health. But in our country, neither medical students are provided with any media to stimulate their enthusiasm nor does our government do any thing towards developing our human resources, until the declaration of the historical Health Policy. No medium exists in our country to explore the potential of our high IQ health professionals ! Medical students have to run their life on theoretical classes in the morning and practical classes in the evening. Health professionals are busy with their job in the morning and private business in the evening. Such a tremendous workload is not required in any other discipline. They cannot afford time for their family; and experience deprivation
from social, cultural, religious or political environment.
Considering the above weakness, I would like to propose the following steps.
For medical students at the time of admission: It is essential to promote their knowledge and enthusiasm in medical science as well as in social, cultural, and religious aspects of life. Students admitted to medical colleges should be provided with a brochure. It should explain which subjects are taught respectively in different years, the system of examinations, the pass levels, the importance of practical and theoretical classes, and introduce the teachers in each department. One day inauguration ceremony in medical college auditorium should include presenting them with the brochure. In the ceremony, the Principal of the medical college, Director of the Medical College Hospital, and Heads of Department should introduce themselves, explain in brief the importance of the subjects and introduce those matters included in the brochure. A Half day visit to all wards, clinical and other departments, the library, computer lab, canteen etc. should be included. The Committee of BMDC can lead the proposal for the brochure. The Principals of all Medical Colleges sit together and decide the format.
For medical students, during study: Include an English language course and supply computer with med-line, provide daily newspapers, and periodicals at hostel premises to broaden their outlook. I strongly propose commencement of a one hour TV programme on health, and medical discoveries, perhaps on Friday evening. These measures would help them develop in several aspects.
Doctors should be provided with a prospectus: Doctors should be provided with a prospectus of the health sector along with the MBBS certificate. The prospectus should include the rules and regulations of public and private sectors; composition of the sectors; all facilities for them in future, including foreign employment; and the objective of providing them with the certificate. A one day conference at a medical college should provide them with the prospectus. The Principals of Medical Colleges, Principals of Post Graduate Institutes, and the Committee of BMDC should decide upon the proposed prospectus.
Because of the existence of the two directorates under MOHFW and different job responsibilities, two separate brochures for doctors ought to be developed and should be issued along with their appointment letter. The brochures should include their job description, the job responsibility of different posts, criteria for promotion, their authority, the structure of the directorate and all directors' responsibility, government service rules, and the doctors' different associations with their aims and objectives.
Frequently, we come across different pieces of information about the health sector in our country. But we have no definite source to know these clearly. GOB /MOHFW should commence publication of monthly or quarterly newsletter, termed "Health Service in Bangladesh" and supply them to all public facilities. The booklet should inform what is going on in the sector. The Publishers Association should sit with BMDC, the Joint Secretary Administration MOHFW, Directors of all Postgraduate Institutes, Directors of all Medical Colleges and Director DGHS and Director DGFP to plan this publication. It should include Joint Secretary from Ministry of Information as well.
Private health service
Private services are accessible to the richer section of society. Because of very low ratio of doctors, no competitive market is possible in the private sector. Patients rush to doctors only on reputation, behaviour and amount of charges. It takes even a month to get a follow-up visit to a specialist doctor, for an outdoor service. As staff at medical clinics consist of owners and directors from among medical college professors, patients prefer to attend private
clinics to get proper attention.
In our country, the quality of health service depends entirely on judgment of physicians and providers, in both the public and private sector. No information exists about the facilities and services available, nor about the prediction of expenditure. .Patients lack legal support for protecting them from bad medical practice. On the other hand, private clinic owners face problem in regulatory environment. The administrative structure for licencing and monitoring is very weak. The quality of administrative officials is low and there is no time limit for licencing. A file may halt for about 4 to 6 months without any specific reason. Owners face problems and harassment during the registration process. They have to pay unofficial fees to the inspecting officers visiting the facilities. Some have complained of paying toll to local mastans.
There are 620 private clinics in Bangladesh, 75 per cent of which are owned by medical doctors. These constituted 36 per cent of the estimated total in-patient care beds in Bangladesh. The Licence is given on the basis of 1982 Ordinance, where the conditions are entirely input based. No mention or scope for monitoring the quality of clinical care and cost are provided in the ordinance. Therefore, the quality of service and cost of service to consumers depend only on the providers' judgment. There is a fundamental need to overhaul our attitude to the quality of care. Greater attention to the quality of health outcomes and quality of services could require a change in practitioners' attitude as much as change in the attitude of regulator.
Suggested Solutions: In considering the matter of private health services, we have also to think about health specialist institutions and future health specialists. A successful politician, the prime minister of Singapore, Lue Kuan Yew has said "for maximum use of optimum potential, a country needs to structure its society and policy via maximum use of international capital, management skill, marketing skill, technology and knowledge". We should look into use of international market, management skill and knowledge of doctors to obtain their potential.
Because of the gradual establishment of specialist institutions, a good number of specialists are taught in Bangladesh. The World Health Report 2000 has identified that a health system can have plentiful human resources, with excellent knowledge and skill, but still face impending crisis if future health needs prorities and available resources are not taken into account.
There is an urgent need to amend 'the 1982 Ordinance'. The new ordinance should include i. Employment of an Executive Officer at every facility, with B.Sc. qualification and having a minimum of two months' management training. ii. Publication of a brochure. The brochure would help consumers to know the facilities available and the expected cost. Specialist doctors should form Professional Associations such as an "Orthopedic Society.". Such associations are important for our citizens. They would help the specialists to set standards of professional practice and to decide the standard service charges for both outdoor visit and indoor services.
The authority responsible for the licensing of private service faciliies should ensure an appropriate time for licensing. The quality of investigating officers should be at a level that "he can have an understanding of the sector as well as our social, religious and political state".
Role of the media
The media can play an important role in motivating the doctors and creating awareness amongst the general citizens. In Thailand the media have played a vital role in this respect. The media can also help reduce the existing difference between general elite and doctors. This reduced gap can help to withdraw the patients from hospitals abroad, of which our government is more concerned.
It is very disappointing that there is little or no media approach to generate self-criticism in our doctors. Our government along with donors only think of monetary inducements, but never of the role of media. The objective should be to develop an encouraging environment as well as self-criticism among doctors. !
Both TV and print media should combine their effort. TV should allow one hour programme between 5pm to 6 pm or 4 pm to 5 pm, depending on the days and hours of work. TV programme may include interviews with Line Directors of operational plans, Directors of post-graduate institutes and with DGHS and DGFP; also with the Director MCH of DGFP and with newly graduated MBBS doctors on their first appointment. The TV can develop awareness against HIV/AIDS and teach citizens the key points in maintaining a healthy life-style, healthy diet, and healthy environment. Our print media can play more important role to publicise modern global developments in the health sector for doctors and general public. It can provide the means for doctors' to reply to questions raised by readers.
E-health
I do wish to emphasize the role of EHealth today in the world and its potential for doctors in my country. It has been estimated that 15 per cent to 25 per cent of the contents of the Internet deal with health in the world. E-health is applicable to many different aspects of health. But considering economic condition, language barrier and political state of our country I wish to suggest that E-Health be applied for medical education and administrative management. E-Health is far more about management and policy than about medicine and technology. And we are aware that knowledge of management is very poor in our health sector. Hence E-Health can be an important component of improvement of management in the health sector.
Research shows that physicians are among the least sophisticated users of IT and the Internet. But considering financial state of doctors, government as well as private entrepreneurs should come forward. I'm very happy to introduce one such project termed "Engender Health" in our country. We hope it to be launched soon.
As our government is committed to implement IT in our country, computers should be supplied to all 13 medical colleges. There should be a computer lab in each medical college. All Departmental heads should be supplied with an Internet connection. It would then be their duty to collect teaching material for students, save on a floppy and install in hard discs, for respective
class students. They should keep themselves up to date with global progress in their respective disciplines. According to the government's commitment no extra expenditure from MOHFW would be required.
Improved administrative management can be achieved in the health sector by taking advantage of computer technology. By considering inconvenience of health manpower, I would insist to use computer at personnel section of MOHFW, DGHS and DGFP. Simple keeping the CV of manpower at the personnel section would help the manpower as well as administration during posting, transfer, promotion and other related matters. It should be responsibility of management to avoid possible corruption and illegal usage.
Besides the above, I would like to identify some miscellaneous potential to expand our health service. First, there are about 2500 to 3000 garment factories in cities, where the majority of staff are rural women. Our government can oblige the BGMEA to ensure outdoor service and dissemination of the knowledge of important health information like healthy diet, healthy environment, preventive services provided by GOB. Secondly college students between the age of 18 and
24 years can be provided with necessary knowledge to prevent HIV/AIDS. IDA assistance on HIV/AIDS is US $40m, so there should be no problem with financing. Third, all TFPO can attend two months' health services management course before taking the charge. And similarly a two months' management course should be undertaken by all fresh post graduate doctors. Such a measure would tremendously improve the service at 460 THCs and all private clinics. Fourth, there are more than 9000 private practitioners in our country. Our government including private practice certificate authority can oblige them with the dissemination of important health information at their practice premises. Fifthly, we should include doctors with medical service discipline along with those from biomedical discipline, during promotion.
I hope our policy makers will weigh up the suggestions and proceed to serve our nation better. Government should give them fixed time to implement. I hope our policy makers and planners would put a budget to the Planning Commission in June 2002 which will significantly help doctors' as well as citizens.
Dr. Lailun Nahar is MSC Health Policy, Planning and Financing (HPPF).