ABINA Faiz Rashid's discussion on health sector reform (DS, Sept 7) has prompted me to share some of my

thoughts about considering health as a part of the broader socioeconomic and political condition in an attempt at improving the health status of the population of Bangladesh.

In her article, Dr. Rashid rightly stated: "If we truly want to see improvements in the health of poor women and men in Bangladesh, we need a more radical and broader based approach to health, where social and economic justice need to be an integral part of medicine and public health intervention." This article elaborates the "broader-based approach" by explaining how socio-economic and political condition of the country influence the health condition of the population and puts forward some suggestions for the policy-makers.

Neither "health" nor "health policy" can be studied in isolation from the influence of socio- economic and political conditions. The common concern of health policy is how to organise, how to finance, and how to assure the quality of health services for the entire population. Varieties of social and economic factors have influence on health in addition to medicine. Likewise, health policy Is also influenced by many different forces in society. National allocation of resources for health, patterns of distribution of health services, and provider- purchaser relationships depend on the socio-political and economic conditions of the country.

Social factors

Over-population, inequity, and economic discrimination are the main features of the social structure of Bangladesh, and have obvious influence over the health policy. Due to a high population growth rate, the population of Bangladesh is predominantly young with 12.6 per cent of the population under four years of age and 38.7 per cent under 14. This age structure of the society causes overburdening of the health budget as this section becomes frequently ill and needs more care.

On the other hand, Bangladesh society is inegalitarian in its nature. The majority of people are assetless and living below subsistence level while the small privileged section

live in urban areas. In rural areas, land ownership is skewed towards the top 10 per cent of rural households and the majority of people are landless and frequently opt for urban areas for employment and survival. The large influx of migrants from rural areas to urban areas leading to increase of slum dwellers every year causes a tremendous pressure on the available primary health service in urban areas.

In urban areas, government hospitals, dispensaries, and private and voluntary clinics provide health care services. Amongst them, the poorer section of the population opt for government hospitals. The government hospitals have failed to cope with the increase in the city population. Due to the overcrowded condition of the government hospitals, the private sector has emerged as a significant source of alternative care for the relatively well-off section in the urban areas. Rapid urban growth has resulted in severe shortages of water, sanitation, and sewerage facilities, which threatens the overall health condition of urban areas. Massive poverty is another dominant feature of Bangladesh society, and is the main determinant of ill health. Poverty is reflected in the health situation of the people in the form of malnutrition of children under five (58 per cent), prevalence of iodine deficiency disorder (69 per cent of the population), anemia (73 per cent of children under five and 74 percentofadult women).

Poverty has made the people unaware of their own rights. They have little time to concentrate on health and related matters: on, the

contrary, the affluent people have enough to spend on health care and maintenance. People are also unwilling to visit government dispensaries due to poverty related reasons, which leaves the existing facilities underutilised. The poor prefer to seek care from traditional healers or doctors without degrees, due to economic reasons.

Economic factors

The slow rate of economic growth coupled with high population growth rate has produced a negative real growth in government health budgets and in per capita health expenditure. Low income causes deterioration in the diet and nutritional status of the poor and reduces their ability to pay for medical care. Thus macro-economic factors influence resource scarcity at the national as well as individual level. Inability of individuals to pay is the reflection of the overall poor economic condition.

Poor economic conditions have also made health policy exclusively prone to external Influence. Poor economic condition of the newly independent Bangladesh made It highly dependent on rhe external superpowers for the survival of almost all the sectors of socio- economic life including the health sector. Aid dependency has put the country in a relatively weak bargaining position and macle the donors influential over the pi-olicies of the government. Such externally decided policy fails to meet the local needs as donors do riot really grasp the inherent problems of the host country due to culture distance.

’pie recent past Hpalth,andPopu-

lation Sector Programme (HPSP) is worth mentioning here. The HPSP was a unified Health and Population Sector Project formulated in 1998 in consultation with the donor agencies and stakeholders to reform the health and population sector with a view to providing a package of essential health care services and to curb population growth. Before the introduction of FT PSP the modality of health service delivery at the community level was doorstep services.

With a view tci expanding access to basic services through the HPSP, the donor agencies helped the government to shift from home delivery to community based one-stop services hurriedly, without careful experimentation as well as not taking the views of the beneficiaries whether they would avail the services if the services are provided from the community clinics. The result is that government has failed to implement it as was pronounced. The poor dienic from rural areas were deprived from home delivery services as well as from the proposed community clinic. Political factors

The political system of the country coupled with unaccountable and unrepresentative government has a direct influence over health policy. Lack of an accountable government has made the policy-makers free to make unattainable commitments to achieve temporary gains as they are not answerable to anybody for their failure. "Health for all by the year 2000" is an example of such policy commitment. In addition, due to lack of representative government, peoples’ representatives! who have!

close contact with the community, do not get a chance to design the policy.

Political instability has eroded the power of the legislature through constant discontinuity and the inexperience and inefficiencies, the most initial step should be to design a pro-poor policy. It is observed that the policy-makers have conceived pro-poor policy as merely extending the health infrastructure to the grass roots (setting up of community clinics, satellite clinics, etc).

Along with the setting up of these establishments budgetary allocation for medicine and maintenance of these establishments should also be increased so that the poor can be provided with quality care. Moreover, given the inegalitarian social structure, as the poor do not have any alternative to the public service, the poor should be given priority in health spending in the form of subsidy. In this regard the Malaysian and Costa Rican example could be followed.

According to a World Development Report: "In Malaysia, the government has followed a propoor policy since the 1970s, with the lowest income groups receiving a larger share of public subsidies for health than the middle class and the wealthy."

Similarly, Costa* Rica has also succeeded in ensuring equal access to all through its pro-poor policy in health spending. The equity issue should be paid serious attention to address the problems of inegalitarian society. Equity refers to need-based distribution of Services irrespective of income or location. Policy measures ensuring equity are necessary.

Unaccountable and unrepresentative form of government has long been affecting the implementation of the health policy of Bangladesh. Introducing local level health administration through decentralisation is a prerequisite to overcoming this limitation.

Thana health authorities should be formed which should act directly under the control of the District Health Authority instead of the Ministry. These local bodies should be given adequate authority to monitor the functions of the professionals in order to make them truly accountable and to design the health programmes as per their need.

Last, but not least, programmes should not be undertaken whimsically under the pressure of donors, rather the contextual realities should be thoroughly examined and studied before adopting any overseas prescription. Otherwise, programmes, however well designed they may be, will continue to fail to produce the desired results.

Dr. Ferdous Arfina Osman is an Associate Professor, Department of Public Administration, University of Chittagong.