More money, thanks. But what’s next?
Never in the history of budget placement in this country has there been so much of excitement and interest. People from different walks of life were waiting eagerly to listen to the finance minister. The reason—what breath of fresh air does he bring to the pandemic flustered populace through smart and appropriate allocation? The reaction to the budget thus far has been mixed. This is not entirely unexpected as no budget can satisfy everyone.
While the additional money allocated for health is not enough (and is perhaps never enough), this at least demonstrates that the government is attuned to the expectations. The other good news is that the sectors which are closely related to tackling the effects and after-effects of Covid-19 such as education, agriculture, safety nets, etc. have also seen a boost in their allocations. However, why the environment, forest and climate change sector got a cold treatment is not understandable, particularly when good health cannot be achieved without ensuring a good environment. The case of arsenic in both drinking water and agriculture chain is a case in point.
The devil is in the details, goes the idiom. Here too, we need to know more details. The simple question is: "Well, we have the additional money which is great, but how and where will this be used?" If it is "business as usual", then it's just old wine in a new bottle, with some additional allocations to the existing heads including misappropriation.
As the saying goes, never let a good crisis go to waste, we must use the Covid-19 as an impetus for bigger and better actions. "As a result of the learnings from the present pandemic, the health sector will be refurbished and the budget will include initiatives in this regard," the finance minister told a news channel two days ago. The question, again, how is the government going to "refurbish" the health sector and what new "initiatives" are they going to take? In my opinion, we are past the point of refurbishment and it is time to consider a complete overhaul.
The minister in his budget speech mentioned seven areas where "reforms" would be implemented. Unfortunately, the health sector did not appear in the list. Does this mean that these tall words are only lip service and lacklustre of what kind of "refurbishment" is expected?
We hope not. On the contrary, we do hope that the government understands and appreciates the opportunity created by this unprecedented crisis and go for a total reform of the sector that will galvanise us towards the dream of Vision 2041. Experts have been deliberating on the immediate steps to trigger the reform process. There is quite a remarkable unison in the way they have been thinking about it. Some of these are discussed in the following.
Formation of a Permanent National Health Commission: As a first step, the government should form, through an Act of Parliament, a high-level Permanent Health Commission to decide on the roadmap to achieving the vision for health. The government has committed time and again in various global forums to achieving Universal Health Coverage (UHC). Universal Health Coverage, as we know, is achieved when everyone can access health services they need without suffering financial hardship. To be headed by an individual of repute, s/he should have a good and holistic understanding of public's health and the factors that affect and is affected by it. It is critical that the head should have enough clout and status (a cabinet minister status). Commissioners should be drawn from people with expertise in related areas including public health, medicine, economics, finance, business, gender, politics, and civil society.
Making the health sector accountable: An important measure to increase the accountability of the health sector is to set up an independent National Health Security Office (NHSO) whose task would be to act as the financier of the health sector. This office would be the holder of the entire health sector budget and disburse to different sub-sectors (such as hospitals, primary health care, related institutions) based on population needs and demands. The Office would monitor the expenditures through strict regimes of internal audits and monitoring. This would be an autonomous Office headed by an individual with the rank of a senior secretary. This would do away with the current faulty system where both the purchaser and provider of the services is the Ministry of Health and Family Welfare (MoHFW).
Management and governance are the keys: Much has been written about the poor management of our health systems, both public and private. Examples galore on the poor delivery of health services by the public system. Absenteeism is the name of the game and in any given time, not even two thirds of the relevant staff are found in facilities which require their presence 24/7. Such an issue of management has to be seen from both the supply as well as the demand side perspectives. I don't think we have discussed it enough, let alone addressed the root cause of why such management and governance failures happen. Same goes with the private sector healthcare where the absence of regulatory enforcements is turning the sub-sector into an uncontrollable monster.
A moratorium on infrastructure building: A major source of spending in the MoHFW is the infrastructure. It is well known that not all the infrastructure are made based on sound rationale and that concomitant funds are not made available to utilise and maintain the infrastructure in the expected ways. A moratorium on building new infrastructure should be enforced for the next two years. Such a measure would free up substantial funds to invest in other areas of immediate concerns.
Re-emphasise primary health care and community participation: The primary health care (PHC) has been a subject of systematic neglect. The building of Community Clinics (and Union and Upazila level centres) has brought the infrastructure close to people, not the care. There is a perennial shortage of healthcare workers, equipment and essential drugs which make these less popular destinations in care seeking, particularly for the poor. If the PHC was strong, we wouldn't have seen such a big pressure on our hospitals during these last days. Similarly, there is no alternative to community participation in healthcare and its management. Many of us have written on the value of a "whole of the society approach" in combatting the Covid crisis.
Revamp planning, research and data systems: Any reform or even maintaining the status quo to a certain level of quality delivery, appropriate, relevant, and timely availability of quality data is a sine qua non. A number of institutions in the public sector are vested with this role of collecting, analysing and publishing the data. Unfortunately none of them have played their expected role in addressing the Covid crisis. The issues which plague these institutions include leadership, bureaucratic dilly-dallying, lack of capacity and inadequate financing. The government (and the above proposed National Commission) should review the role of each and every such institution and take steps to activate them so that they can perform their role in the Covid crisis as well as in the new post-Covid health systems.
Initiating the above reforms will require commitment from the highest office. We have seen in the past 10 years that the present government can deliver if they want to. It has been proven in a number of cases, including the construction of the Padma Bridge and power generation. This can also be done in the case of health. As has been shown in many countries, leaders doing such reforms as UHC become national heroes. Undertaking such a reform is very befitting in the context of celebrating Mujib-borsho and the golden jubilee of our independence.
Mushtaque Chowdhury is professor, Columbia University Mailman School of Public Health and Convener, Bangladesh Health Watch.