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The health of the nation

Barkat-e-Khuda
Bangladesh is one of the most populous countries in the world, with a population of over!45 million people. With an annual population growth rate of about 1.5 %, around two million people are annually added to the country's population.
Bangladesh is one of the poorest countries in the world, with a per capita income of S695. There is high inequity in income distribution. Around 40 % of the population lives below the poverty line.
Bangladesh has achieved marked improvements in terms of school enrollment and reduction/ elimination of gender disparities; however, there has been a gradual decline in overall quality of education at different levels
There has been improvement in several health indicators, resulting in increase in life expectancy. However, neonatal mortality and maternal mortality rates are still unacceptably high.
There has been a considerable slowing down in the rate of increase in the contraceptive prevalence rate (CPR) over the last decade, resulting in a near stagnation in fertility decline.
Malnutrition remains a major area of concern, especially among young children, adolescents, and pregnant mothers.
Budget
The budget and the ADP have been presented in the context of change and challenges -- the Vision 2021 and the MDGs. The total public expenditure budget of Taka 113,819 crores is 20.9% higher than the revised budget of the last fiscal year. The ADP of Taka 30. 500 crores is 32.6 % higher than the revised ADP of the past fiscal year.
However, there are at least two major challenges: (0 facing the adverse effects of global recession on the Bangladesh econ-onn i id .u weak investment outlook.
A third major challenge relates io the weak implementation capacity of the government. What is required is a major reform in public administration, giving priority to capacity’ building and efficiency and getting rid of political favor and patronage with a view to bringing about: (a) improvement in administrative efficiency and negotiation skills, and (b) timely disbursement and quality implementation of funds.
Another major concern relates to absence of specific targets for the specific fiscal year rather than identification of medium-term and long-term targets. That being so, it will not be possible to monitor the success and/or failures in the different sectors over the budget year!
The growth target has been set at 5.5%, the lowest target in the last six years. Also, the investment target as percentage of GDP is low. How will the government be able to deliver its promises with such low growth and investment targets?
The budget has proposed several social safety net and employment generation programs. The overall goal is to bring
down poverty rate 15% by 2021. However, what lessons have been learned from our as well as other countries' past experience regarding the leakages and/or abuse of these programs? Also, how far realistic is the target of bringing down poverty to only 15% by 2021?
The budget deficit is estimated to be Taka 34,358 crores (within 5% of GDP. of which 2% will come from external sources and 3% from domestic sources). Given the global recession and the fact that the
World Bank and the ADB have raised objections to some of the amendments proposed in the Public Procurement Policy (there are some indications of resolution to such problems), how much of the external funding will be actually forthcoming? By borrowing from the banks, the government will limit the access of the private sector to bank loans.
Health
Ensuring adequate health services for all is one of the principal commitments of the government. In accordance with the current need, the government has started reviewing the Health Policy, developing a pragmatic population policy, updating the 2005 Drug Policy setting up of 13,500 community clinics; and revitalising pri-
mary health care services, mother and child care, family planning services, sanitation, cleanliness, prevention of diarrhea, balanced food and nutrition.
Given that the policies are already there, how much more revision is required, and how much time will be used up in the process? Therefore, more important is to ensure efficient and timely implementation of the existing policies, while the work of "reviewing" is underway.
By when will community clinics be set up across the country, especially in inaccessible areas? How will the different types of services delivered -- separately by the Directorate of Health Services (DGHS) and the Directorate of Family Planning (DGFP) or will such services be provided under a unified service delivery system?
Unified service delivery system will not only reduce duplication and overlap, but
also save costs, in addition to addressing some of the staff shortage problems.
Existing maternal health voucher program will be expanded to 45 upazilas from 33 now for ensuring health services to the poor and helpless would-be mothers by preventing maternal mortality and improving maternal health.
The target is to reduce the infant mortality rate from 52 to 15 and maternal mortality from 2.9% to 1.5% by 2021.Given that the program has been in operation for several years, what are the lessons learned? Given that over 70% of the infant mortality is on account of neonatal mortality which has declined rather at quite a slow pace, how realistic is the target of such a sharp reduction in infant mortality by 2021?
Also, the MDG goal of reduction in under-5 mortality seems doubtful, given the still high neonatal mortality. Given that only 18% of births are attended by medically trained providers and only 15% of births take place at a health facility, how realistic is the target relating to reduction in maternal mortality by 2021? Also, the MDG goal relating to maternal mortality is impossible!
The budget speech notes "the fundamental weakness of family planning as lack of adequate manpower and the government's failure to meet the demands of die people." Agreed, but there are so many other pressing problems as well like staff absenteeism, lack of trained manpower, lack of proper monitoring and supervision, tension between DGHS and DGFP as well as between medical and non-medical staff of DGFP, absence of clear career planning, stockouts, etc.
In addition, and quite importantly, the erosion in political will and commitment since the 1990s, putting the problem of overpopulation in the back burner, needs to be reversed if the problem of overpopulation is to be adequately addressed.
The target is to achieve 80% CPR by 2021. However, given the trend, it is doubtful. Moreover, only eight countries have achieved a CPR of 80% or more. A CPR of around 70-72% should be enough to achieve replacement level fertility, which Bangladesh has consistently failed to achieve since the mid-1980s. Achieving a CPR of 70-72% is, in itself, a gigantic task without a considerable strengthening of the family planning program in the country, let alone achieving a CPR target of 80 %. Therefore, what is the use of setting
unachievable targets?
The target is to ensure quality nutritional demand for 85% of the population by 2021. The NNP will be extended to 123 upazilas within the budget period and subsequently all upazilas will be brought under the NNP Given the high levels of malnutrition, especially among the children, adolescents and pregnant women, how feasible is the above target? What arc the lessons learned from the ongoing NNP? By when will all upazilas of the country be brought under die NNP? When will the NNP be mainstreamed in the overall health sector?
Hospitals at upazila and district levels will be modernised and upgraded to render better hospital-based services to the patients. Also, several new medical colleges, health technology institutes and nursing institutes will be set up; several nursing institutes will be upgraded to nursing colleges; and reconstruction and
modernisation of old medical colleges and hospitals will be a priority program.
However, will all of the above be accomplished within the budget period? If yes, have the required resources been allocated? Also, has the Ministry of Health and Family Welfare (MOHFW) prepared the necessary plans and does it have the necessary capacity to complete the above activities by June 2010? Further, there is no mention about public-private partnerships (PPP) in the above activities.
The aim is to turn the pharmaceutical sector into a viable export-oriented one by attaining self-sufficiency in producing quality medicine for domestic needs and a surplus to enhance export earnings. The Drug Policy 2005 will be made more
pragmatic, and the Department of Drug Administration would be modernised. When will the "more pragmatic" Drug Policy be finalised? When will the Department of Drug Administration be modernised and its capacity developed? Further, why is there no mention of PPP in the pharmaceutical sector?
The budget speech refers to the process of formulating policies relating to determination of user fees and collection and distribution of user fees, as well as government and NGO efforts to be taken to undertake training programs for paramedics, nurses, and midwives. Neither any specific timeline has been provided for accomplishing the above activities nor any specific number has been provided relating to the number of personnel who will be trained and by when?
The overall health sector has over the years been identified as one of the "priority" sectors. However, this has consistently not been reflected in financial allocations. Only l%oftheGDPhasbeen allocated to the health sector against the WHO target of 5% of GDP. Only 6.15% of the total budget has been allocated to the health sector, which, in per capita terms, comes to a meagre amount of Taka 482.7 as against the WHO optimum suggested expenditure of $34 per capita per year.
The amount is quite insufficient to be able to ensure "adequate health service for all," let alone be able to achieve the MDG targets. Unless the financial allocation is increased to a desired level, achiev-ing the MDG targets by 2015 will remain a wishful thinking and the various goals set in the budget speech will fall far short of achievements.
Conclusion
For timely and efficient implementation of the budget, what is required is a major reform in public administration, giving priority to capacity building and efficiency and getting rid of political favor and patronage with a view to bringing about: (a) improvement in administrative efficiency and negotiation skills, and (b) timely disbursement and quality imple-^ menthtiMVoffunds.n bouclq")
Within the health sector, nutrition has received the lowest priority, followed by family planning. The family planning program is in need of additional funding and considerable strengthening, also true of the health program. Also, greater thrust should be given to underserved areas, urban slums and disadvantaged population groups. The NNP should be scaled up nationally, and eventually mainstreamed in the overall health program.
Adequate investment in the health sector is not only justifiable on its own grounds but also because of its other indirect benefits in terms of productivity gains and overall reduced health expenditures as well as reduced demand for additional resources to provide for additional food, shelter, clothing, education, health care and employment for the growing population. In addition to increased investment in the health sector, greater importance should be given to investing in the women.
Barkat-e-Khuda, Ph D. is Professor of Economics. Dhaka
University, Dhaka