ENSURING HEALTH FOR ALL Bangladesh must be ready for a bold new experiment

Dr Anwar Islam

   IT WAS back in 1978 – precisely thirty-two years ago – that the World Health Organisation at its pioneering Alma Ata Conference came out with the bold idea of ensuring Health for All by 2000. At that conference, first ever held in the former Soviet Union, the WHO also came up with the idea of comprehensive community-based and community-owned primary health care as the vehicle through which the HFA goal is to be reached. Unfortunately, the WHO neither remained focused on strengthening the primary healthcare system around the world nor achieved the goal of Health for All by the target date. Following the Alma Ata Declaration it was hoped that the WHO will renew its commitment to PHC and push for comprehensive primary health care in all member countries. However, that commitment did not last long. Instead of championing the cause of PHC around the world, the WHO soon went back to designing and supporting disease-specific vertical programmes often with extra-budgetary financial contribution from rich industrialised countries. Consequently, a number of vertical disease-specific programmes made their appearance during the 1980s and 1990s. These include the Roll Back Malaria programme, the Stop TB Programme and the Global Polio Eradication Initiative.

   These vertical programmes achieved various degrees of success. However, due to neglect and lack of leadership from the WHO, the primary healthcare system remained largely under-developed throughout developing countries. On the occasion of the twenty-fifth anniversary of the Alma Ata Declaration, in 2003, the WHO carried out a global survey on the status of PHC in developing countries. The survey came out with a dismal picture of PHC in many developing countries, primarily in sub-Saharan Africa and South Asia. Although in many countries governments build buildings across rural areas to provide effective primary healthcare services, the survey found little evidence of other essential ingredients of PHC – skilled human resources for health, necessary equipment, and drugs and supplies. In other words, the presence of infrastructure did little to ensure or enhance primary health care in the absence of necessary human, financial and material resources including drugs. Needless to say, in the absence of a robust comprehensive community-based primary healthcare system the dream of ensuring Health for All remained as such – a dream. The slogan of HFA was quietly abandoned or forgotten by the WHO and other United Nations agencies. In 2001 the United Nations quietly introduced another ‘revolutionary’ goal – this time to be achieved by 2015. The Millennium Development Goals – eight in total – first adopted by the UN General Assembly in September 2000, soon emerged as the rallying cry for all development organisations and advocates. As developing countries adopted the Millennium Development Goals as their prime development benchmarks to be achieved by 2015, the rallying cry of Health for All largely vanished from the development vocabulary. 

   Well, not quite. By the turn of the millennium the World Health Organisation – and by extension other UN agencies – came under increasing pressure to get back to their original pledge and make renewed commitment to primary health care. At the start of the twenty-first century, a new grassroots-level movement emerged that drew renewed attention to the goal of Health for All. Dr Zafrullah Chowdhury, the enigmatic founder of the Gonoshasthaya Kendra, played a critical role in the establishment and growing appeal of the People’s Health Movement. The PHM prides itself in having ‘its roots deep in the grassroots people’s movement and owes its genesis to many health networks and activists who have been concerned by the growing inequities in health over the last 25 years. The PHM calls for a revitalisation of the principles of the Alma Ata Declaration which promised Health for All by the year 2000 and complete revision of international and domestic policy that has shown to impact negatively on health status and systems.’ Not surprisingly, ‘equity, ecologically sustainable development and peace are at the heart of’ the vision of the People’s Health Movement. Its vision to create a ‘better world – a world in which a healthy life for all is a reality; a world that respects, appreciates and celebrates all life and diversity; a world that enables the flowering of people’s talents and abilities to enrich each other; a world in which people’s voices guide the decisions that shape our lives....’ In other words, inspired by the spirit and the vision of the Alma Ata Declaration, the PHM is dedicated to championing the cause of equitable, sustainable and universal primary health care. 

   With a modest start, the PHM became a global phenomenon with chapters in many countries – from Latin America, to Africa, the Middle East and to Asia. Currently, a South African health activist is managing the global secretariat of the PMH. It should be noted that the first People’s Health Assembly – mirroring the World Health Assembly organised each year by the World Health Organisation – was held in Savar, Bangladesh in December 2000. A total of 1,453 participants from 75 countries were at this first People’s Health Assembly. The delegates at the assembly endorsed ‘a consensus document called the People’s Charter for Health. The charter reflects the vision, goals, principles and calls for action that unite all the members of the PHM coalition. It is the most widely endorsed consensus document on health since the Alma Ata Declaration.’ By the second People’s Health Assembly held in July 2005 in Cuenca, Ecuador, the PHM had grown into a global civil society movement with chapters in over 80 countries representing all the continents. The second People’s Health Assembly was the culmination of a process of ‘local and national reflection, discussion, debate and exchange of experiences of communities and networks as well as conferences and workshops about the aspects that influence the health and well being of everyone.’ The assembly unequivocally demanded ‘Health for All Now.’ The PHM, with a view to continuing to make their presence felt, participates in the World Health Assembly organised by the WHO each year. It also coveys its messages through various popular and scholastic publications. 

   I have discussed the PHM quite extensively simply to highlight the fact that the vision of Alma Ata and that of Health for All is still alive and well. A number of UN agencies also raised the issue of universal health care from time to time. Even the World Bank dedicated its 1993 World Development Report to ‘Investment for Health’ and called for the availability of an ‘essential package’ of health services for all. The 2001 Report of the WHO Commission on Macroeconomics and Health led by Dr Jeffrey Sachs went to the extent of costing out such an ‘essential package’ of health services and argued that with increase in overseas development assistance (as outlined by the United Nations back in 1975) it is possible to ensure basic health services for all. It should be noted that in 1975 the United Nations called for the developed industrialised nations to devote 0.75 per cent of their gross domestic product to overseas development assistance. Unfortunately, even after more than thirty-five years, few developed countries (mostly smaller Scandinavian countries) reached the target of 0.75 per cent of GDP for overseas development assistance. The wealthiest and the biggest (in terms of absolute dollars in ODA) countries like the Unites States, Japan, Germany, the United Kingdom and France are from achieving the 1975 target set by the UN. 

   In other words, although ODA is on the rise in recent years (in some cases the amount is decreasing for some developed countries due to the global economic downturn), developing countries must rely more on their own resources – and generate new resources – to ensure health for all. Two observations must be made here. The need for ‘health for all’ is much greater now than ever before. Although globalisation has produced enormous wealth in almost all countries, it has also exacerbated inequity within and across countries. Such inequity is restricting access to healthcare services for an increasingly impoverished segment of the population in many developing countries, Bangladesh not being an exception. It is also important to note that the term ‘health for all’ does not mean covering all types of health care services – from primary to tertiary level of services – for all. Increasingly, it is being recognised that the public exchequer should ensure availability of and accessibility to a ‘basic’ or ‘essential’ package of health services for all. The ‘essential package’ would differ from one country to another or even from one region to another within a country. However, the package must include all healthcare services that an individual or family would require to lead a healthy productive life. Health care is a combination of public goods, private goods and merit goods. The essential package must include all public goods (services like health education, illness prevention activities, family planning and reproductive health, maternal, newborn and child health including safe delivery and immunisation, and access to safe drinking water and sanitation) and probably some merit goods (for example, emergency accident care). Through dialogue among all stakeholders, including NGOs and civil society groups, consensus can be reached on the size and contours of the ‘essential package’. Obviously, the epidemiological and demographic characteristics would provide the essential backdrop in determining such a package.

   In Bangladesh much of this ‘essential package’ is part of the publicly-funded healthcare system. The problem is that these are not universally accessible to all. On the other hand, the publicly-funded healthcare services are not often used by a large segment of the population because of a real or perceived lack of quality. Complaints against the publicly-funded health system are numerous: lack of skilled human resources when required, lack of required equipment (or that they are ‘broken’ and non-functional. The list often includes ambulances in the upazila health complexes or in district hospitals), non-availability of drugs, and an utter lack of cleanliness. Most consumers also complain of lack of attention and/or neglect from physicians, nurses or other healthcare workers. This non-use of the public health systems has two serious implications. First, it keeps the system underutilised and, therefore, inefficient. Secondly, it deprives the public health system of potential revenues (through nominal user fees and charges) that could be used to improve the system. In other words, this underutilisation acts as a catch-22 for the publicly-funded health system. The system fails to generate resources that could improve the system; and this lack of improvement continues to fuel underutilisation. For our public health system this is indeed a critical challenge: how to increase utilisation so as to improve the quality of the system.

   The major problem is money – how to fund a universal healthcare based on the essential package? The term universality means that the identified services are available for and accessibly to every citizen irrespective of one’s place of origin or place of residence. In other words, migration or movement from one part of the country to another would not affect a citizen’s entitlement to essential healthcare services. Currently, Bangladesh spends about 3 per cent of its GDP on health care which is lower than many other developing countries with similar economic condition (i.e. similar per capita income or GDP per capita). The government can easily allocate increased resources for health care filling the resource gap to a certain extent. Nevertheless, additional resources would be required to implement universal health care. The additional resources must come through contributions from the public at large. 

   It is often asked whether people are ready or willing to pay. Our total expenditure on health is about $18 per capita per year. Almost 65 per cent of this total health expenditure is out-of-pocket expenses by individuals and families. The public exchequer contributes only 35 per cent of this total. In other words, citizens of Bangladesh are already paying a lion’s share of the total expenses on health. Are we prepared to pay more? The answer probably lies in four interrelated questions. First, what is the quality of services? Second, will services be available when needed (without unnecessary delay)? Third, is it assured that necessary drugs, equipment and other paraphernalia of health care would be there (and operational/functional) when needed? Fourth – and this is perhaps the most critical question, what would be the nature of the interaction between the service providers and consumers? Will consumers be treated with respect, and dignity? Will physicians and nurses (and other service providers) treat patients with humility respecting their rights and individuality? 

   If we can answer these questions in the affirmative, it is highly likely that the people of Bangladesh will be willing to contribute a fair share to the healthcare budget. The term ‘fair share’ means that the contribution asked from individuals and families must be tied to their financial ability. In other words, the amount of contribution to be made by individuals/families will be progressive – the amount of financial contribution will increase with increase in income. This also means that there must be a way to cover the ultra poor without any fee. The government might create a health protection fund to be managed by an independent agency to which individual/family contributions will flow. This independent health protection agency will be responsible to pool all available resources to ensure universal health care. This bold experiment could be carried out in few upazilas or districts on a pilot basis before replication throughout the country.

   Is Bangladesh ready for such a bold experiment? The convergence of the following three powerful factors seems to indicate the feasibility of such an experiment in universal health care. Bangladesh has a strong NGO sector dominated by three world-class, highly-respected non-government organisations – BRAC, GK and Grameen Bank. Their grassroots-level organisational reach and appeal could be mobilised for such universal health care. We are also blessed with a robust and increasingly penetrating private sector that thrives on the ingenuity of the individual agency of Bangladeshis across the country. Harnessing the individual agency of all Bangladeshi and the growing private sector could be a boon for universal health care. The third factor is perhaps the most important. Bangladesh has got a government that claims to be democratic, secular, progressive and pro-people. Political commitment and leadership from this government would be the most critical factor in ushering in a universal healthcare system based on a grand partnership between the people and their democratically elected government. As noted earlier, the convergence of these three factors makes it abundantly clear that the country is ready for such a bold experiment. This could prove to be the most powerful fundamental building block of ‘digital health care’ in Bangladesh so enthusiastically promised by the party in power.

   Dr Anwar Islam is associate dean and director, James P Grant School of Public Health, BRAC University

source:New age

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