Anomalies in district hospitals

WITH a very low income and high population, Bangladesh has outpaced many of its peers in social development indicators of similar per capita GDP. Improvements in some health indicators are remarkable, especially in reducing child mortality rate. Bangladesh has made dramatic advances and received the United Nations MDG award for being on track for reducing infant and child mortality.

However, this overall progress in the health sector has not been equally realised throughout the country, rather regional variations are high in terms of achievement of MDGs. According to a UNDP report published in 2009, some regions are lagging behind in terms of achieving the MDG targets whereas some are doing well. It is the same at Upazila level, according to a World Bank study conducted in 2012.

A recent study by the Brac Institute of Governance and Development (BIGD) looked at this regional disparity to see how district hospitals are doing in terms of performance. It looked at three most essential aspects of health governance -- availability of physicians, availability of nurses and proportion of equipments necessary for hospitals to operate. Based on these, it ranked the districts to see the variations in terms of performance. The BIGD study made a simple index out of these three variables to see the state of service delivery of a particular hospital.

It was found that there is mismatch among districts in terms of number of physicians filled in as a percentage of sanctioned positions. On average, only 60% of total sanctioned positions in district level health facilities are filled, even though variations are pronounced when compared among districts. There is a high urban bias -- district hospitals in Dhaka and Chittagong, for example, have 99% and 87% positions filled. Percentages of filled positions of physicians are 82, 71 and 60 in Rangpur, Khulna and Sylhet, respectively. Of major urban districts, Rajshahi and Barisal are lagging behind with only 56-57% of the sanctioned positions filled.

However, when all the districts are ranked, there is a striking disparity -- while it is almost 99% for Dhaka, it is only 22% for Panchagarh. Generally speaking, all the districts of Barisal and Rangpur division, except district headquarters, are below the national average, whereas half of the districts of Rajhshai and Sylhet divisions stand below the national average. Habiganj and Sylhet districts are marginally above the national average. In Dhaka division, most districts have higher rate of physicians filled in compared to national average, whereas the exceptions are Faridpur, Gopalganj, Narshingdi and Netrokona. In Chittagong division, all the districts except Cox's Bazaar and Noakhali and three hill districts stand above the national average.  

When the filled-in positions of nurses are considered, the national average suggests that district level health facilities are even less equipped in terms of nurses -- only 42% of total positions are filled, and the distribution is more equal throughout the country. Dhaka, Chittagong and Sylhet divisions have 48% positions filled, followed by Khulna (38%), Rajshahi (36 %), Rangpur (65%) and Barisal (35%). However, the disparities between districts are lower compared to physician allocation -- one likely reason is that nurses have relatively lesser scope to engage in private practice compared to physicians.  

When it comes to percentage of equipment functioning, not
all the urban districts are doing well. Dhaka as a district along with its immediate neighbourhood has the highest numbers of functional ECG and x-ray machines and colorimeter, with a divisional average of 77%. In comparison, most of the districts under Rajshahi and Rangpur division are performing poorly in this regard. The overall performance of equipment functionality is also low in Sylhet and Barisal division. Bhola is again a poor performer with 28% functional equipments. Chittagong and Noakhali are doing badly in maintaining their equipments.

Looking at the overall performance aggregating all three aspects, it is seen that there are strong variations in hospital performance. A few districts, including Dhaka and its neighborhood (Narayanganj, Gazipur and Manikganj), get better allocation of physicians and nurses and more equipment, whereas remote districts like Panchagarh, Patuakhali and Bhola remain the laggard performers. Distance and transport facilities apparently affect the allocation of hospital input. Patuakhali, for instance, is the remotest region in terms of distance from the capital and some coastal regions in terms of transport facilities, which limits people's access to services of doctors, nurses and medical equipments.

The study assumed that if district hospitals are well resourced and well maintained then they are better governed and will be able to give better service delivery. Here only one aspect of service delivery is considered, the performance of outpatient department (OPD) of a hospital in terms of number of patients served. It used equipment functionality as a single variable of governance performance. The quantitative result of the study shows that the relationship between OPD service delivery and equipments functionality is positive and significant, i.e. with better equipment functionality more OPD patients can be served.

It was also revealed that OPD service is positively and significantly related with physician posts filled in, so hospitals that have more physicians available can serve more outdoor patients. Nonetheless, there is a positive relationship between nurses' positions filled in and OPD service delivery, but it is comparatively less significant.

Generally, districts which have better input are performing better, however, Satkhira is an exception which, with minimum allocation of equipment and manpower, is maintaining a top rank in OPD. In contrast, when the lagging districts are considered, a few districts show clear association between manpower and equipments. Patuakhali, Bhola and Sunamganj are clearly lagging behind due to low allocation of manpower and equipments.

That said, regional variations in districts in terms of hospital input allocation are uneven, and this is affecting the overall performance of Bangladesh's healthcare system. Even though the country is progressing well in achieving health related MGD related targets, it still far behind in ensuring parity in resource allocation among the districts. Looking at the findings one can urge to policy makers to look into these issues more seriously. Upgradation of resources in remotest districts is crucial to avoid people's suffering, especially in districts like Patuakhali, Bhola, Sunamganj and Panchagarh. More worryingly, in some districts, resources are not translated into better service delivery, which calls for prudent management of resources.

The writers are Senior Research Associate and Research Associate at the BRAC Institute of Governance and Development (BIGD, respectively.