Community Health Clinics: Are there Alternatives?
The "Health and Population Sector Programme" strategy recommended, among other things, establishment of "Community Health Clinics" - one for 6000 people. This is a classical population to health facility ratio but experienced public health planners and practitioners might agree that this criterion has outlived its validity and utility. The government is planning to build about 13000 community clinics "to provide medical care to the common people at their door steps". This indeed is a laudable enterprise. But is this feasible? Local and global experience points to the need to carefully examine and evaluate the actual performance of population-based and widely dispersed health facilities usually built at high capital cost. The assumption that once created these will produce the desired services that are acceptable, accessible, and affordable has often been not true. Doubts also remain if such schemes are cost-effective or sustainable.
The strategy of population and geography based provision of health facilities was highly favoured by national development planners in many emerging countries after the Second World War. In most cases, however, it proved costly to build and maintain; more importantly, it proved difficult to keep the numerous health centres running efficiently with optimum output due to several reasons including inadequate recurring budget, poor management, staff with low morale and motivation. In the present trend of globalisation with dominant free market economy, central planning is not in tune with realities or demands of the economy and the market. Central planning was born and nurtured within a system of liberal welfare oriented command economy. Socialised government planning of public service provisions was its natural ally. Time and events, however, proved it ineffective and redundant. Without the means and ways, the public sector is unable to support provision of many economic and social goods and services.
Planning health facilities by population numbers is conceptually obsolete and operationally not practical. Take the example of Thana Health Complexes in Bangladesh - a grandiose government scheme characterised by heavy capital cost but not by the ability to generate and allocate the recurrent cost budget sufficient to make each THC function optimally and deliver services of acceptable quality or adequate quantity. Public confidence is lacking and most of these remain under-performing and under-utilised.
The strategy of setting up and running thousands of health facilities scattered throughout the country, therefore, needs re-examination in the light of past experience and current dynamics of creation and operation of public services. It is doubtful if yet another grand scheme of establishing 13000 or more Community Clinics will achieve much more than perhaps further over burdening the government health recurring budget. In a market economy regime, the government is required to perform a facilitatory or enabling function to let the people and the market determine many personal and public services. Lessons need to be learnt from the past similar schemes by objectively evaluating the results. Strong evidence need to be produced based on the economics of the medical care market and the client perceptions of their needs and priorities and their preferred access and use of available services. For example, the issue of community-based autonomous or self-managed primary care insurance has not been seriously and exhaustively assessed.
Yet it is the duty of the State in a professedly liberal democracy to provide equitable access to public services. The issue is not if the State has a role but what that role is and how best to play that role. For example, arranging medical care for each citizen at the door step is no longer the business of the government - not even by the government of the rich countries let alone by that of a poor country like Bangladesh. At best such extra-ordinary commitments will not be met, at worst the public will become sceptical of all government commitments. The latter is probably already the case. On the other hand, government can spend its limited resources in providing an array of essential public health services for example, healthy environment, safe drinking water and good sanitation, essential drugs of good quality at affordable cost, set and enforce minimum standards and norms of medical care, medical and allied health professional education, safe and hygienic food supply and distribution, information and education on health and public hygiene, in addition to other essential functions such as prevention and control of epidemic communicable diseases that threaten public health, and adhere to the international health obligations.
Rather than commit heavy capital expenditure by creating huge health infrastructure without means to make these produce the level or type of care that the client has ability to utilise or has confidence in, it would be more rational and produce higher health returns if government spent its limited resources preferentially and effectively on selected public health functions and to give some subsidised care, as part of social safety net, for the very poor. It makes very good sense to produce efficient and effective and urgently needed public health services that bring greater good for the greatest number of people, and assure their continuity and quality. It also enhances equity and social justice which are so necessary in health. In the writer's view, government need not and cannot afford to invest scarce public resources in yet more grand experiments of proven inefficiency, however politically attractive and socially redeeming that may appear to be.
As a foot note, the writer wishes to state that there are alternative pathways to the destination of equitable and reasonable health care including personal medical care; population coverage can be effectively enhanced not just by setting up more buildings/clinics. New ways of doing things with imagination, enterprise, and innovative thinking and actions, new partnerships and alliances in the civil society - all of these need to be explored objectively and rationally. For example, the State could facilitate the growth of Group Family Practices in small towns, city suburbs, rural communities, especially in the under-served regions. These and other means of expanding access and availability are more competitive and more compatible with the market economy.
Government can, and should, produce incentives through judicious health policy that promotes and supports wide distribution of health and medical care without necessarily assuming the burden of creating and running those services at a cost which it cannot afford. Also, the present misguided priority to invest in tertiary care and specialisation of practice which evidently benefit few may be dropped. What the country needs more is more quality and affordable primary care which addresses effectively more than three fourths of the needs of the population and not more tertiary care in a paradoxical situation where the private providers compete with the public facilities. Creating health infrastructure - usually at great capital cost - does not mean that these produce health services that are appropriate, acceptable, or even affordable.
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