Key Issues to Health Governance in Bangladesh

Paper to be presented to the International Conference on

Challenges of Governance in South Asia in Kathmandu, Nepal
December 15-16, 2008

Presented by: Fardaus Ara

Department of Public Administration, Rajshahi University.
Assistant Professor, Department of Public Administration,
Rajshahi University, Rajshahi-6205,
Bangladesh.
E-mail: dipty777@yahoo.co.in; dipty777@hotmail.com
Telephone/fax/ mobile numbers: Tel: 0088-0721-750041/4138(Office)
Fax:
0088-0721-750064
Mobile: 008801673204600

Key Issues to Health Governance in Bangladesh

Abstract
Like other social sectors, health governance in Bangladesh is identified with poor and
inefficient service delivery. Health care provision depends on efficiently combining financial
resources, human resources, and supplies, and delivering services in a timely fashion
distributed spatially throughout the country. To ensure good governance in this sector it is
equally important that health services be delivered efficiently and health professionals are
accountable to the public and government for their action. In Bangladesh, lack of voice and
accountability; government ineffectiveness; low level of regulatory quality; weakness in
establishing rule of law; lack of transparency and, corruption -- all are impediments to good
governance in this sector. This study highlights these core issues and at the same time
recommends some policy prescriptions to ensure good governance in this sector and thus a
healthy nation.
Background:
Bangladesh, with about 149 million people in only 133,910 sq km, is one of the densely
populated countries in the world. Its problems are many and health is one of them. As a result,
poor and inadequate health services are acting as obstacles against the overall development of
this country. The goal of Health for all by the year 2000 AD was set for all the countries of
the world and to attain the goal of Primary Health Care (PHC) services was recommended as
the key approach in the international conference at Alma Ata in 1978 . As a signatory,
Bangladesh has also taken the strategy of providing health services to its citizen (Ara, 2008).
During this period, in accordance with the global change in the health policy focus and
considering national situation, government made a significant move toward primary health care
from the hospital oriented curative care. Government set a three-tier health care service
structure for the people living in the rural area, which include household level domiciliary
services, 1union level institutional services and 2thana level institutional services.
In Bangladesh, government is viewed as the primary actor in the health sector. The overall
health status in Bangladesh represents an unimpressive picture albeit some developments have
taken place in this sector during the past years. The country has adopted primary health care
policy for achieving health for all, but policy achievement in the health sector is very poor.
Social and economic inequalities exist to the highest extent in Bangladesh. Medical care is an

1
2

The lowest administrative tier of rural local government in Bangladesh.

The second tier of rural local government in Bangladesh

extremely scarce and expensive service in the country. The Government delivery system is not
efficient enough to cover the target population.
Since independence, health and fertility indicators in Bangladesh have improved substantially
with the infant mortality rate and the total fertility rate both decreasing by about 50 percent.
Despite these, the vast majority of the Bangladeshi population continues to suffer from poor
health. Life expectancy at birth is about 61 years, one of the lowest figures in Asia. The underfive mortality rate at 88 per thousand live births, which is six times higher than in Sri Lanka.
The infant mortality rate in Bangladesh was estimated by the 2000 Demographic and Health
Survey to be 66 per thousand live births and the maternal mortality ratio is estimated at 330 per
100, 000 births. A maternal mortality ratio of this magnitude is slightly less than that found in a
few countries in the world and 100 times that of developed countries (ADB, 2005).
Less than 40 % of the total population has access to modern primary health care services
beyond immunizations and family planning (Abedin, 1997 cited in Perry, 1999). Only 25% of
pregnant women receive antenatal care, and only 14% of births are attended by someone with
formal training (BBS, 1997c. cited in Perry, 1999).
Malnutrition in Bangladesh is among the highest in the world. The extent of stunting and
underweight are 45% and 48% respectively for children under five years of age, while anaemia
is prevalent among 53% of pregnant women (CPD, 2003).
According to the World Health Report 2006, Bangladesh in 2004 had 38 485 medical doctors,
20 334 registered nurses, 5 658 medical technologists, 5 743 public and environmental health
workers, and 46 202 community health workers (CHWs).
In spite of the progress made, Bangladesh has been identified as one of 57 countries with a
critical shortage of the health workforce (doctors, nurses and midwives number below 2.28 per
1000 population). The nurses to population ratio of 0.14 per 1000 and nurses to doctors ratio
of 1:1.85 are among the lowest in the world (WHO,2007).
The health care system in Bangladesh is a mix of public and private initiative. In terms of
physical infrastructure, public sector is stronger than the private sector although in terms of
coverage, the health care system of the country should be termed as a privatized one. Besides
the private sector there are some NGOs, which also play a significant role in providing health
services. All these institutions are managed and controlled under the policy guidelines of the
government (Osman, 2004).
The governments efforts to provide health facilities at the various levels, though free of cost
and managed by trained professionals, has however, not lead to desired level of use of the
services. Primary health care services are greatly underutilized, despite repeated efforts by the
government to improve these services (Jahan and Salehin, 2006).
2

Lack of voice and accountability, government ineffectiveness, low level of regulatory quality,
weakness in establishing

rule of law, lack of transparency, mismanagement by the

government, lack of adequate human and financial resources, and, corruption - all are
impediments to good governance in this sector.
This paper is an attempt to identify and assess the key health sector governance issues in the
public sector and also to address ways to improve this situation.
What is Public Health Governance?
Governance means different things to different people. In broad terms, governance can be
defined as the actions and means adopted by a society to promote collective action and deliver
collective solutions in pursuit of common goals.
Health governance concerns the actions and means adopted by a society to organize itself in
the promotion and protection of the health of its population. The rules defining such
organization, and its functioning, can again be formal (e.g. Public Health Act, International
Health Regulations) or informal (e.g. Hippocratic oath) to prescribe and proscribe behaviour
(Lee, 2000).
Public health governance invariably involves policy formulations followed by effective
management of all activities relevant for attaining health policy goals (Sobhan,1998).
Public Health Governance in Bangladesh:
Strictly speaking, health is a state of complete physical, mental and social well being and not
merely an absence of disease or infirmity so that each citizen can enjoy a socially and
economically productive life (WHO, 1978). Public health is an organized system of preventing
disease, prolonging life and promoting health and efficiency. This is ensured through the
sanitation of the environment, control of communicable diseases, education of the individual in
personal hygiene, the organization of medical and nursing services for the early diagnosis and
preventive treatment of disease, and the development of social machinery to ensure every
individual a standard of living adequate for the maintenance of health so organizing these
benefits as to enable every citizen to realize their inherent right to health and longevity. In the
broader sense of the term, public health does not merely mean providing some services through
the institutions under the control of the Ministry of Health and family Welfare (MOHFW). On
the contrary, public health covers many other things. For example, ensuring hygiene quality of
food and food items sold, controlling emissions on our roads, supplying clean and safe
drinking water to the community, managing waste/garbage disposal providing for a healthy
environment in the work place, shopping centers and /or in any other public places,

provisioning of housing and sanitation facilities to the slum dwellers and squatter population,
etc (Sobhan, 1998).
The constitutional commitment of the Government of Bangladesh is to provide basic health
and medical requirements to all people in the society. The Constitution of the Peoples
Republic of Bangladesh ensured that Health is the basic right of every citizen of the
Republic, as health is fundamental to human development. Since the achievement of
independence in 1971 through the war of liberation, discussions were held for the formulation
of the health policy at different levels.
All governments gave emphasis on health sector development through adopting various
programs in the national development plan with the purpose of building a network of primary
health care services. But achievement in this sector was never been satisfactory. Finally, in
August 2000 the national health policy has been declared by the Government of Bangladesh
with aim of ensuring better health services to all the people in the country (GOB, 2006).
Health Care Delivery System in Bangladesh:
Bangladesh inherits a health care service structure that was predominantly elite-biased, urbanfocused and curative-care-oriented. There were only 8 medical colleges, 1 post graduate
institute, 37 T.B. clinics, 151 rural health centers and 91 maternity and child welfare centers
spreading over the country in 1971 (Osman 2004). The new government of Bangladesh took
the public health issue as one of the priority concern and in 1972 approved the Thana Health
Complex Scheme, with mission to establish a health care network consisted of comprehensive
preventive and promotive health care services in rural areas (GOB 1973). In 1976 government
revised the program and planned to build 356 THCs one in each thana and 1068 sub-centers at
the union level (Khan 1988). In brief, the period from 1971 to 1980, in relation to health care
service, could be said the reorganization and reconstruction phase. The focus of this phase was,
mainly, to build the physical infrastructures like hospital and health centers, expansion of beds,
procurements of modern equipments etc. all around the country. Along with infrastructural
expansion, government initiated some significant attempts to reorganize several service
provider agencies. Since the mid 1980s the government has sought to improve its health
services and teaching institutions. The explicit goal was to build one Union Sub centre (USC)
or Health and Family Welfare Centre (HFWC) in every union (4415); one health complex in
every thana (397); and one general hospital or tertiary facility in every district (59). As of 1996,
there were 4200 USCs/HFWCs, 379 health complexes and 59 district hospitals. By 1999, there
were 460 Thana health complexes, 1362 Union Sub-Centers and 3315 Community Clinics;
there were also 15 government medical colleges and 7 postgraduate/specialized hospitals.
There are another 33 private medical and dental colleges. The total number of hospital beds
4

was 43,293 (1999), which has increased to 51, 684 in 2005. In 2005, 3.43 beds per 10,000
populations were available (WHO,2007).
Organizational Structure of Health Care Service: Health care services in Bangladesh are
delivered by public, private (for profit), non-government organizations and traditional sectors.
The public health care system is organized under the overall supervision of the Ministry of
Health and Family Welfare. The organization structure of the services is designed in alignment
of the administrative set up of the country. The entire area of Bangladesh is divided into 6
administrative divisions. Each division is further divided into districts; there are 64 districts
and 460 upazilas (sub-districts). Upazilas are the lowest administrative unit of the central
government. Each upazila consists, on an average, of 10 unions; and a union consists of 10
villages on an average. An average size of Union, in general, used to have a population of
20,000 - 25,000. The organizational structure of the public health care system in Bangladesh is
highly centralized. At the central level, the Ministry of Health and Family Welfare is the
highest government authority headed by a Cabinet Minister, responsible for to implement,
manage, coordinate and regulate national health and family planning related all activities,
programs and policies. The Secretary is the administrative head of the ministry who is assisted
by huge number of cadre and non-cadre civil servants. The MOHFW is the second largest
ministry, in terms of its manpower, in Bangladesh (Osman 2004). The ministry is divided into
two wings: Health Wing and Family Planning. Each of the wings is administrative through
separate Directorates under the ministry.
The Directorate General of Health Services (DGHS) is the key agency to implement the
national health policies and programs. It also provides input to the government for making or
changing health related decisions. The directorate is in charge of a wide range of activities
from procurement of material and manpower to supervising medical schools. The DGHS is
assisted by nine functional Directors and under each of them there are several Deputy and
Assistant Directors. Until recently, the strength of the DGHS, in total, was 702 (Osman 2004).
Like the DGHS, the Director General of Family Planning has also similar kind of
organizational structure that is dispersed in a pyramidal fashion from the national level to the
grassroots. These two wings have been running separately with their own cadre of workers
from top to the grassroots for three decades. In addition to the DGHS, the Directorate of the
Nursing Services and Directorate of Drug Administration are attached to the Health Wing of
MOHFW. These Directorates have their own office, separate workforces and are assigned to
perform various health care related activities. From the program implementation point of view,
the District is very important, in fact this is the level from where the health care services in
the small district towns and rural areas are controlled, managed and supervised. The Civil
5

Surgeon is the chief of the district health service. He runs both fixed-site and out-reach health
care

services in the district. The district health administration is responsible for supervising

and coordinating, on average, 17 Upazila Health Complexes - a 30 bed primary care hospital
with a very limited secondary level health services. The upazila health complex is administered
by the Upazila Health and Family Planning Officer. At present, there are 406 Upazila Health
Complexes in the country. On paper, the upazila level health and family planning services are
integrated. Upazila Health Complex is organized with three functional components - outpatient department, 31 bed in-patient service including 6 bed for maternal and child care and
domiciliary health care section staffed with field workers. The Union Health and Family
Welfare Center is at the bottom of the government health care structure. At present there are
4200 union health centers. Some of them, about 1300, are administered by Medical Officers
and rest are run by Medical Assistants who are assisted by 15 health and family planning
personnel in managing the static health facility and rendering domiciliary services (ibid).

Hierarchy of Health Care Delivery System of Bangladesh

Source: Islam, 2006.

Access to Health Care Services in Bangladesh:

Access to health services depends on the availability of service (i.e. the availability of
physicians, health centers, and hospitals) to the actual as well as potential users. In Bangladesh,
health facilities in both public and private sector are distributed in an unjust way, which makes
the services inaccessible to low income and rural people. Along with such unjustified
distribution of services between urban and rural areas, delivery of services also varied
depending on the level of income (rich and poor), which is evident in discriminatory access to
services. The poor in Bangladesh bear higher health risks and suffer the burden of excess
mortality and morbidity. The poor in general are more prone to illness and diseases than the
non-poor. The poorest households are likely to use health care services and are less willing to
pay for improved services compared to other socio-economic groups (Jahan and Salehin,
2006).
Public Health Governance: Issues and Challenges:
In Bangladesh public health system does not exist at its self-pose yet. Analysis of official
statistics represents an unsatisfactory scenario. The doctor-population, doctor-nurse, nursepopulation ratios remain far below the standard level. Though in terms of infrastructural health
facilities, Bangladesh is one of the well resourced countries (CPD, 2001).
Though the health sectors achievement in recent days is remarkable, still the health care
system have to go far to achieve the Millennium Development Goals. Most of the health
indicators show low rates of achievement. Causes of failure of governance as mentioning
below are responsible for these shortfalls:
i. Voice and accountability: Citizens voices and demands result in improved state
responsiveness, transparency and accountability. In reality, the state in Bangladesh like many
developing countries is not sufficiently accountable to its citizens, whose voices often remain
unheard or are simply too weak to have any influence. Voice and accountability permit
communities to be involved in decisions and oversight of health care services. In the field of
governance assessment, voice and accountability is a key indicator encapsulating a broad
range of factors, from freedom of expression and respect for civil liberties to free and fair
elections and the just rule of law (RIA, 2007).
Peoples voice in Bangladesh is rarely taken into account while making and implementing
health policies. The low confidence in government health facilities and their underutilization
are caused by weak administration, lack of oversight over them, and poor accountability

(Ahmad, 2000). Failure in enforcing a system of accountability in the health system is

weakening governance.
ii. Weak Monitoring and Regulatory Framework: The regulatory framework for monitoring
health services delivery is weak There are 45 laws related to various aspects of heath like
Epidemic Disease Act 1897, Prevention of Malaria Ordinance 1978, laws related to quality of
food, quality of drugs etc. According to the Terms of Reference (TOR) of their services the
senior officials are given the responsibility of supervising and monitoring the health activities
of their respective areas, they seldom do this (Osman, 2004).
The Bangladesh Medical and Dental Council (BMDC), established under the medical and
dental Council Act of 1980 is empowered to look after public interest by maintaining proper
standards of services and education. It has the authority to take disciplinary actions, including
temporary suspension or permanent removal of the practitioner from the register for
misconducts like issuing false certificates, disregard of personal responsibility to patients etc.
But due to the absence of a monitoring system on the activities of practitioners, it is very
difficult to implement, and there is no such evidence till now of a practitioners name being
removed from the register (Jahan and Salehin, 2006).
iii. Centralized administration: In Bangladesh, health planning is solely the responsibility of
central government. Ministry of Health controls the health care system with deconcentration of
some power at the local level. None but the higher level officials take the decisions that are
distant from policy implementation. Targets are set, activities are planned, and resources are
allocated by the Ministry without much consultation with those who know the local level
conditions. For this centralized tendency, over-targeting is a common characteristic of our
health sector plan. For example in the fourth five year plan(1990-1995), target to cover
population under essential health care as % of population was 80, where as achievement was
45; delivery assisted by trained persons (%of preg. Women) was 50 and achievement only 12;
antenatal care target was set at 60 and achievement 35(Sobhan, 1998).
The weak local government system of Bangladesh is acting as governments agents rather than
representative bodies of the community. They are accountable to the ministry rather to the
people. Centralization of authority at the Ministry acts as a major barrier to ensure
accountability in administration and to formulate a local health authority with adequate
involvement of the community.

iv. Staffing and absenteeism: Staffing is arguably the single most important element of health
care delivery as little can be achieved without it. Training of the staff, their competencies and
8

ability to function all determine whether the expected results can be achieved. Training
typically is inadequate if not well beyond that needed in Bangladesh, especially for physicians.
Among the most serious issues in Bangladesh is the high rate of absenteeism, which
undermines service delivery. Capturing low productivity and poor service poses greater
difficulties; absenteeism already reflects reduced output, and underperformance (DiTella and
Savedoff, 2001).
Bangladesh has only 18 doctors and 5 nurses per 100,000 people. The numbers are among the
lowest in the world. As compensation from public hospitals is very low and many of those
doctors and nurses try to find job in private clinics, no wonder that public hospitals experience
shortage of medical personnel. Therefore, when a patient comes for the medical help to the
public facilities, very often it is the case that hospital has no specialists with appropriate skills
or knowledge, or there is a lack of staff which can give very basic help( Rashid, Savchenko
and Hossain,2005).
Most of the public hospitals are suffering due to lack of regular staff. A report published in the
Daily Prothom Alo , dated November 22, 2008 reflects the sufferings of patients and worse
situation in the hospitals. According to the report, the Kustia General Hospital , with 250beds
has the provision of 150 doctors, are running by 26 doctors. Out of them 8 were transferred in
the last six months and no initiative was taken to fill up the vacant positions. One physician
was absent for long and another one has been suspended. It becomes very difficult to give
treatment about 450 patients on average daily. As a result patients are compelled to seek
treatment from outside.
In another case, with 109 of the 164 posts of doctors lying vacant in different health centres in
Potuakhali district, only 55 doctors are struggling to cope with health care service for about 1.7
millions people in seven upazilas in the district. On an average, one doctor is available for
every 30,000 people in the district. Dasmina upazila is running with only two doctors as 13 of
the 15 doctors posts are vacant. In Mirzzaganj upazila 12 of 15, in Kalapara 15 of 18, in
Galachipa 21of 26, in Baufal 17 of 23, in Dunki 5 of 9, in Sadar upazila 15 of 18 posts are
lying vacant. In Patuakhali General Hospital 9 out of 33 posts including that of senior surgeon
of child and ENT are vacant. Many patients are returning home without getting treatment due
to lack of doctors (The Daily Star, 24.11.08).
Absenteeism poses a chronic, but often unmeasured, problem in publicly financed health care,
and can severely limit patient access to services and suggest corruption (DiTella and Savedoff,
2001). A study conducted by UNICEF (1992) showed that our doctors spend 54 seconds per
patients at thana hospitals and rural dispensaries; they take 37 seconds per patients to dispense
medicine. The qualified doctors are more inclined to moonlight in private clinics where

government employed doctors maintain a dual obligation with their responsibilities (Sobhan,
1998).
Doctors are often criticized for neglecting their duties through absenteeism and private practice
during office hours. Such malpractice generally starts from the moment of posting of a doctor
to a rural THC or Union Health Centre. They are either unwilling to join, or they make delay
within the loopholes of the system. Given the doctors who join the THCs in rural areas, being
dissatisfied with working conditions and career prospects, lack for alternative ways of earning
extra money through private practice and provide service for lesser time than the scheduled
working hour. Neglect of duties of the paramedics and domiciliary staff has also been affecting
the policy implementation process (Osman, 2004).
No positive affirmative action is seen to resolve this problem.
v. Poor Management of Drug and Equipments: Misgovernance is prevailing in the management
of drug and equipment in the public hospitals. A huge quantity of supplied medicine and
equipment is left unutilized and unconsumed due to poor management. Very often, it is alleged
that doctors encourage the patients to purchase medicine from outside because of unawareness
of the medical officer about availability and quantum of medicine stock in the store. Moreover,
physicians are getting bribe from the private medicine suppliers. Lack of transparency in
management creates the scope for the fourth class employees of the hospitals to sell drugs of
hospital stores to outside pharmacies (Osman, 2004). Many pharmaceutical/drug shops admit
of buying medicine from the hospital staff at cheaper rate. Many private clinics admit of
procuring expensive equipment and supplies from the public sector supply system (Jahan and
Salehin, 2006).
vi. Flow of Funds: The allocated funds for health sector are scarce and also are not utilized and
managed properly. In many places, bureaucratic problems, corruption and mismanagement lead
to inadequate public funds at the point of service and the informal charging of patients. The
allocated funds are disbursed very slowly and often at a reduced level. The slow disbursement
of funds causes delayed completion and ineffective utilization of funds.
In 1993-94, the national health expenditure by both public and private sectors amounted to
3.04 percent of the GNP. It has increased to 3.4 percent in 2003. Public expenditure on health
as percentage of total expenditure on health was 36.5 percent in 1998, which has declined to
25.2 percent in 2002. Government health expenditure as percentage of the total government
expenditure was 6.9 percent in 1998 but it has also declined to 4.4 percent in 2002. In 1998, the
total government health expenditure per capita was US $ 4, which has increased to US $ 11 in
2002.

(http://www.searo.who.int/en/Section313/Section1515_6124.htm

retrieved

on

25.11.2008).
10

vii. Mismanagement in Health Care Service Delivery:

Often irregularities and poor

governance simply stem from poor management. Where incentives for strong performance
either do not exist or are undermined by ineffective management it is not surprising that
productivity and performance suffer. Low wages also lead workers to seek additional
employment outside government (Lewis: 1955).
The promotion path in Bangladesh public health sector is so long that usually it becomes time
for retirement before getting promoted to the highest level of hierarchy, which demoralizes
them. Not only the doctors, but the field workers are also the sufferers from such stagnancy of
service. There also exists a mismatch in distribution of human resources between urban and
rural areas, which have a direct impact on the policy performance (Osman, 2004).
Transfer, posting of the health professionals is another problematic area. In absence of a clear
guideline for transfer/posting, patronage and corruption is practised in this area. Most often
transfer and posting become politically motivated. There is no central training institute for
providing in service refresher training for all categories of health personnel (Osman, 2004).
viii. Weak Management and Coordination Network: The management of the tertiary health care
centers, i.e. district hospitals, medical college hospitals and referral hospitals is a major issue in
public health governance. Abuse of trade unionism by the lower level employees makes the
situation worst. Maltreatments of poor outdoor patients by the medical staff are very common.
The class III and IV employees in every district level and medial college hospitals are so
strongly organized that doctors and hospital administration appear helpless to control them.
They build homesteads in the open spaces within the hospital campus to reside and also rent
space to outsiders. Thus the whole environment of the hospitals has become unhygienic both
physically and socially. These protected slum like enclaves are safe heaven for criminals in
most of the medical college and district hospitals. Taking appropriate action against these
unauthorized occupants were never taken seriously, and if seldom planned to remove them
failed due to lack of coordination between different executive bodies of the government
(Sobhan, 1998).
Payment of unofficial fees in these hospitals is very common. While official fees are minimal,
patients are paying out substantial sums as unofficial fees, in the form of bribes and payments
to staff to ensure that they receive the services they are technically eligible to receive free of
cost (ibid).
Sanitation facilities in the public hospitals are very poor. Food supply to the patients is another
area of mismanagement and misuse of resources. Both the quality and quantity of food are
inadequate to the needs of the sick.
Lack of coordination among different levels of service creates duplication and dichotomy.
Insufficient coordination between the Ministry and health directorate has often created
11

bottlenecks and unnecessary constraints and duplication of work. Director General of Health
Services and Health Ministry both oversee the personnel matters including posting and transfer
of all class 1 Officers, resulting in dichotomy, duplication and delay in decision making (Hye,
1985 cited in Osman, 2004).
Unfortunately, there is no well defined role for the MOHFW to intervene in important health
related issues in the sectors controlled by other ministries. Nor there is any meaningful
coordination among the executive bodies, particularly ministries to monitor public health.
People suffer from lack of health services information. A well coordinated public health system
is not available to the public (Sobhan, 1998).
Moreover, the institutional arrangement for implementing health programmes in Bangladesh
seriously suffers from the absence of an effective information flow. Still the entire
administration is mostly paper based. Shortage of data for evaluating the programs and
correcting actions is difficult for this. Lack of coordination within units of Ministry of Health,
lack of coordination between different ministries, lack of sufficient ICT facilities in all levels,
inadequacy of trained manpower including inappropriate placement, inadequacy of up to date
data and often unreliable data, inadequate use of health information at policy level are acting as
impediments to good governance.
Conclusion: In regard to access and availability of quality services the public health sector
governance can not be termed as good. The health care system in Bangladesh is operating
within a complex political administrative environment. The politicized administrative structure
which lies at the root of our misgovernance reflects governance failure in the health sector.
The major steps that need to be implemented, are the strengthening planning and management
capabilities across the health service system; improvement in the logistics of drug supplies and
equipment to health facilities at district and lower levels; improvement in the production and
quality of human resources for health; a system to ensure regular maintenance and upkeep of
existing health facilities; universal access to basic healthcare and services of acceptable
quality; improvement in medical education; improvement in nutritional status, particularly of
mothers and children; prevention and control of major communicable and non-communicable
diseases; Strong policy and regulatory framework.
Existing policies need to be reviewed and revised for improving accessibility, affordability and
quality of services and for further improvements in affordability, quality and safety of drugs
and rational use of drugs. New policies on public and private sectoral mix and financing of
services need to be formulated, protection and preservation of the environment; more training
institute for graduate and postgraduate study with proper practical facilities should be
established, decentralization of management through devolution of authority and the adoption
12

and maintenance of healthy lifestyles and the development of a comprehensive people oriented
plan to improve and assure the quality of health services be provided.
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