Bangladesh is a mostly rural, developing country of South Asia, located on the northern shore of the Bay of Bengal, covering 147,570 square km. People of this country are known as hardworking, with proven capability to preserve mental strength in the event of unexpected extensive loss due to natural calamities, such as floods, cyclones, epidemics, etc. But, their basic needs have remained unfulfilled. Health is a basic requirement to improve the quality of life. National economic and social development depends on the status of a country's health facilities. A health care system reflects the socio-economic and technological development of a country and is also a measure of the responsibilities a community or government assumes for its people's health care. The effectiveness of a health system depends on the availability and accessibility of services in a form which the people are able to understand, accept and utilize.
The Government of Bangladesh is constitutionally committed to "the supply of basic medical requirements to all levels of the people in the society" and the "improvement of nutrition status of the people and public health status" (Bangladesh Constitution, Article-18). The health service functions were initially restricted to curative services. With the development of modern science and technology, health services emphasize primitive and preventive rather than curative health care. Yet, a large number of people of Bangladesh, particularly in rural areas, remain with no or little access to health care facilities. It would be critical for making progress in Bangladesh's health services to improve the people's participation in the health sector. The Government therefore seeks to create conditions whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health. Bangladesh has a good infrastructure for delivering primary health care, but the full potential of this infrastructure has due to lack of adequate logistics never been utilized.
Statement of research problems:
Health service is one of the fundamental rights of the people. It is the constitutional liability of the state to ensure adequate health service delivery to the people (Bangladesh Constitution, Artcle-18). However, in the case of Bangladesh, the state is not able to deliver door to door health service as yet. There are various reasons responsible for this condition.
One of the main reasons is that Bangladesh is an overpopulated country. It is a difficult task for the government to ensure health services for its population of about 160 million people. In 1978, the World Health Organization (WHO) declared "Health for All by the year 2020" in the Alma Ata Declaration. However, this grand vision of primary health care for all has not yet been achieved in Bangladesh. To the contrary, despite some progress, Bangladesh remains a country where poverty prevails at its gravest rate, income inequality is enormous, and the effective literacy rate is low. Basic primary health care services are not accessed equally and the marginalized people of rural Bangladesh are treated in a highly discriminatory nature to access health facilities.
There are already a number of awareness programs focusing on health issues that are being implemented by the development agencies in rural Bangladesh. In spite of some very rare exceptions, all the health awareness programs have aimed at improving the knowledge level on health and hygiene issues. They have not been aimed at promoting the right for all to have access to primary health care facilities.
Local government is the latest decentralized administrative unit of Bangladesh. The main purpose of local government is to provide on service provision in general. When it comes to the health sector, it is apparent that health facilities are brought down to the local level but actual devolution is lacking as decisions on policy, finance and administration are in the hands of the central government. Complete devolution of power to the local level may not have worked to the benefit of common people in Bangladesh because of the risk of elite capture and weak capability of the local-level workers in policy formulation, design and delivery of health services. It is a known fact that there is mismanagement, lack of proper coordination and accountability in the health administration. Ex-ray machine and ambulances are out of the order most of the time. Uncontrolled trade union is one of the main reasons for this. Thus it becomes a difficult for the administration to take action against their corrupt practices and irregularity in the services. Taking more money for ticket from out-door patient, absence of senior doctors in the out-door department, corruption in admission of in-door patient, lack of sympathy for patients among the doctors and nurses make the health service inaccessible to the beneficiaries. From various observations it has become clear that the Government is not able to provide service as well as people's participation in the public health service of Bangladesh even at the basic level.
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.
The weak local government system of Bangladesh is acting as government's 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.
Rationale of study:
As a Masters in Political Science student it is very essential to do some research to go depth of any related topic. As health is one of the five basic needs of a human being so is necessary to make sure that every human is getting health services. It is the duty of the local government who ensures the basic needs of the people. As political science is also related to government as a student I need to do research on a topic which is closely related to people. And health is one of them.
Objectives:
To understand the rule of local government in health care service in Bangladesh. Specific Objectives are:
To map the healthcare providers and the health care centers in the area;
To assess the nature and quality of services of the healthcare providers;
To assess the interaction between informal and formal health care systems;
To assess the health seeking behaviour of the villagers, especially of the poor, and to identify the factors influencing their behaviour;
To map the local government institutes of the study area;
To assess the role of elected representatives in health matters.
Literature review:
Bangladesh has a health system which is dominated by the public sector. Like in many other developing countries, the Bangladesh health system also went through a series of reforms. It will be interesting to review the evolution of the reforms that took place in the country over the past two decades, and how different events and interests played particular roles in this. Bangladesh has a chequered history of introducing reforms in its health sector. We inherited a hospital based health system and it was not until the days of malaria and smallpox eradication and mass education of oral rehydration therapy that the people started seeing some fruits of public health.
The Ministry of Health and Family Welfare in Bangladesh has two separate line directorates. With the posting of Family Welfare Assistants under the separate Family Planning Division, and Health Assistants under the Health Division, the division or schism within the Ministry of Health took a firm root. There were two wings: Health Wing and Family Planning Wing. This division increasingly became very overt and divisive with one wing looking at the other with adversity and mistrust. This is still continuing, and threatening the reform that was undertaken in the 1990s.
The first reform in a real sense was attempted in 1989 by the then Military Government of General Ershad, with the professional and intellectual backing of some non-governmental organizations. One of the most radical and revolutionary propositions in this new health policy was the devolution of the affairs and authority of Health to the local government. The medical community led by Bangladesh Medical Association reacted vehemently against it, which ultimately led to the downfall of the Ershad government and scrapping of the policy.
In 1996, a new government was voted to power. With support of and pressures from the donors, the new government decided to do some reform in the health and family welfare (planning) sector. The essential elements of the reform were: unification of the two wings of health and family planning, and integration of activities from a project or vertical mode to a programme or health system mode.
Another important change was the provision of health services under an Essential Services Package or ESP which included among others things Reproductive Health, Child health and others. It also attempted some decentralization in the form of de-concentration and delegation. The aim of the latter was to delegate power and responsibility to the sub-district level. The new role for the Ministry was articulated as policy and strategy formulation, regulation and legislation. The role given to the Directorate was standard setting, performance review, overseeing and providing budgets to districts. However, the government hasn't been able to implement much in this. The districts have been given some authority of higher spending and this is said to be working well. A decentralized system of local level planning was also introduced, with the upazilas given authority to priorities investments based on local need and community participation.
Unfortunately very little of this and other decentralizations have taken place so far. In a few upazilas where this was tried, both positive and negative results have been reported. The other element of the new reform was the setting up of Community Clinics (one for every 6000 population). This was a one-step facility to provide ESP and done with the aim of bringing healthcare closer to the people. However, there were lots of questions raised about it as well. Some complained that it was done with a motive to distribute political influence. Others questioned the wisdom of this: when the health centres above this (e.g. unions) were not functioning well what is the point in investing so much on this? The other criticism was that the setting up of it led to stopping of home visits by family planning and health field workers. However, the idea was to run the community clinics jointly by government and local people, thus ensuring community participation. It remains to be seen how much of this is done in reality. Lately, the government is thinking of handing over the management of some of these clinics to NGOs.
For safe motherhood, the new programme envisaged creation of a new cadre of community midwives by training the existing Family Welfare Assistants for a further period of six months. Questions are being raised on the wisdom of this, as many of these workers will be retiring soon. Access to skilled birth attendants in the country is only about 15 percent as revealed by the Bangladesh Demographic and Health Surveys and there is a huge inequity in this with most of the services being enjoyed by the well-to-do sections of the community.
The challenge is how the access to skilled birth attendants and emergency obstetric care can be increased in the country as a whole and for every group in the population, particularly the disadvantaged sections. Fortunately, the inequity in access to clinical contraceptive devices is much less. Although there were questions about some of the elements of the reforms, it is probably too early to see any positive or negative impacts. Moreover, it was only a partial reform. About 85% of the population turns to private providers but there hasn't been any move to regulate them through the reform.
In 2001 the government that initiated this reform was voted out of power. The new government decided to take a new look at this. Some of the cadre of workers, who were dissatisfied and not taken on board with the reform, particularly the family planning workers who through their unions thought that they were sidetracked and ignored, influenced the new government to put the reforms on hold.
There is a kind of a stalemate and indecisions now. A new programme with the inclusion of nutrition, titled Health Nutrition and Population Sector Programme, is being designed, which, the government claims, will take care of the flaws in the previous programme. It has already suspended the unification of the two wings but has not, fortunately, disrupted other changes.
It thus appears that reforms of the kind happening in Bangladesh is influenced by many factors such as political agenda, and professional unionism, and done in haste without much preparation and without a long-term vision. The Bangladesh health system is passing through an interesting phase of evolution. Monitoring the process of the reform and its impacts, particularly on the disadvantaged sections of the community, are necessary through well-designed and focused research studies.
According to the Alma-Ata conference in 1978, people's participation was described not as an optional extra but as an essential component of primary health care (PHC). Despite being an essential component of Bangladesh's PHC approach, the people's involvement in PHC is still very much at an experimental stage in Bangladesh. Excluding a few initiatives of non-governmental organizations (NGOs) that were adopted shortly after independence, there is little experience with people's participation in Bangladesh's health sector. The following literature summarizes some of the main experiences at the national and international levels.
Salahuddin, Ali, Alam and Ali (1988) stated that Bangladesh, being a poor country with scarce resources, cannot afford to provide sophisticated medical care to the entire population. Emphasis is therefore given to primary health care covering the unnerved and undeserved population with the minimum cost in the shortest time.
Mahmud (2004) explored people's perceptions and reality about participation in newly opened spaces within the Bangladesh public health care delivery system.
The empirical Bangladesh's National Health Policy (2000) envisages a participatory approach to caring for people's health, at least at the local level. It calls for the decentralization of services and the participation of the local population and local government institutions in the policy development, financing, and monitoring of health services. In reality, however, such participation is far from adequate. Consequently, decisions at the national level have been made in a non-participatory manner. Of course, the ordinary people have no scope of participating in the national decision-making processes regarding how health services should be delivered to them. Regardless of the quality of service they receive, the absence of participation itself constitutes a violation of the people's right to health.
Uzochukwu, Akpala and Onwujekwe (2009) assessed the perceptions and practices of health workers and households in relation to community participation in the Bamako Initiative (BI) program. The study was conducted in the Oji River local government area of South-East Nigeria, where the BI program has been operational since 1993.
Coelho (2008) examined the experience of municipal and district health councils in the city of São Paulo in the light of the literature on citizen participation in Brazil. This literature has attributed the success or failure of participatory mechanisms either to the degree of civil society involvement or to the level of commitment to such mechanisms on the part of the political authorities.
Hoque and Hoque (1994) evaluated the NGOs' water and sanitation programs in Bangladesh's rural areas. The rural villagers were provided hand pumps, latrines, and hygienic education. Interviews were conducted with the women users, women pump projects.
The study shows that there were problems of people's participation, hygienic practices as well as effective use and maintenance of hand pumps and latrines. The study points out that there should be effective measures for the sustainability of water and sanitation projects.
Chowdhury (2005) reviewed Bangladesh's health sector reform and concluded that these reforms are influenced by many factors and that the main problems are related to political agenda, professional unionism, and that they are done in haste without much preparation and without a long-term vision..
Research questions:
Despite being a vital issue for the welfare state, there is no research work regarding the development of health service in Bangladesh. The present study makes a preliminary effort at understanding the health service in Bangladesh. It explores health services by focusing on the health status and health service delivery by the local government and asks the following five questions:
How do policy factors work of health services? What are the factors involved here and how do they impact health services?
Does organizational capacity and policy issues of government impact on public health service of Bangladesh?
How the financial support and bureaucrats' impacts policy formulation and implementation in public health service of Bangladesh?
What are the barriers to participate in health services of Bangladesh? How to overcome these barriers to ensure the public health services?
What is the role of the elected representatives of the local government regarding health issues in general and of the poor in particular?
Hypothesis:
Hypothesis 1:
Local government can solve health care services problems by taking the quality decisions about proper health care services.
Hypothesis 2:
Local government can solve health care services problems by mapping out the core problems and proper utilization of the resources.
Hypothesis 3:
Local government can solve health care services problems by using proper decentralization power available for them.
Theoretical and Conceptual framework:
The research can be completed by using:
decentralization power of local government;
policy factors work of health services;
organizational capacity and policy issues of government impact on public health service of Bangladesh;
financial support and bureaucrats' impacts on policy formulation and implementation in public health service of Bangladesh?
Research method:
Research Methodology can be divided into three separate ways for making the research proposal effective. These three methods are exploratory, descriptive, analytical and predictive methods. As this rule of local government in health care in Bangladesh itself is a broad topic, in this case Descriptive method will be most effective. Descriptive method is generally used to identify & clarify elements of the subject by analyzing every aspect of the collecting data.
For this method Quantitative data collection is the most effective one here. Under quantitative method of design & methodology some important factors has to be considered:
Emphasize on collecting data regarding health sector of Bangladesh.
Concentrating on measuring scale or range of inefficiency local government facing for health care in Bangladesh.
Sources & Acquisition of data:
Primary data:
Primary data is a collection of data from different sources which is not yet been used by any people as a subject or not yet processed by any management. It is also known as raw data which is relatively same. Here, to get a statistics from the survey we can use computer or analysis by the experts.
Secondary data:
Secondary data is already established by some other person not by the person who is using this data. We will collect secondary data from the different website available in internet. We will also try to find data from the different countries health care system.
Operational definition:
This study will use a definition of health care service based on the framework provided by local government of Bangladesh. The main focus will be on the total health care service of Bangladesh whether it public or private sector, formal or informal sector. The definition of adequate or good quality will be based on local standards. Benchmarks formulated for inputs, laboratory examination and prophylactic and treatment approaches during antenatal care will critically review and transpose into measurable elements each describing an attribute.
Research area:
As our research topic is Role of Local Government in Health Care Service in Bangladesh, so the research area is total Bangladesh health care services. But it is not possible to cover whole country within the limited time so we will cover few medical centres for collecting the primary data and publications from the local government about health care to collect the secondary data.
Population:
Recent (2007-2010) estimates of Bangladesh's population range from 150 to 164 million and it is the 7th most populous nation in the world. It is also one of the most densely populated countries in the world. A striking contrast is offered by Russia which has a similar population spread over a land area that is 120 times larger than Bangladesh. Bangladesh's population growth was among the highest in the world in the 1960s and 1970s, when the country swelled from 50 to 90 million. With the promotion of birth control in the 1980s, the growth rate has slowed. The population is relatively young, with 60% being 25 or younger and only 3% being 63 or older. Life expectancy is 63 years for both males and females.
Health and education levels remain relatively low, although they have improved recently as poverty levels have decreased. Most Bangladeshis continue to live on subsistence farming in rural villages. Health problems abound, springing from poor water quality and prevalence of infectious diseases. The water crisis is acute, with widespread bacterial contamination of surface water and arsenic contamination of groundwater. Common diseases include malaria, leptospirosis and dengue. The literacy rate in Bangladesh rose to 53.5% in 2007. There is a gender gap, as literacy rates among women are 81.9% those among men, but this is disappearing in the younger generation. Among the most successful literacy programs are the Food for education (FFE) introduced in 1993, and a stipend program for women at the primary and secondary levels.
Sampling:
Quantitative data analysis method will be used for arranging the data:
Random sampling:
It doesn't mean (Jon cunwin-'Quantitative methods for business) haphazard selection. It means each member of the population has some calculable chances of being selected, not always equal chances as we see. It also means the converse that there is no one in the identified population who could not be selected when the sample is set up. Random sampling gives chance to every individual to be selected.
Cluster sampling:
Some population has groups or cluster which adequately represent the population as a whole for the purpose of survey. It can be said that pupils from a particular school would have many experience in common with pupils from a particular school that the errors in one file vary to another file.
Quota sampling:
The most usual form of non random sampling is the Quota sampling. In this case varies characteristics of the population identified as important for the purpose of survey.
Judgmental sampling:
In judgmental sampling there is no group of people select by the surveyor to take chance or judge. This method is normally used when sample size is small & researcher wants to use the local knowledge.
Convenience sampling:
As the name suggests a sample is selected on the basis that it is easy to obtain & does the job. Convenience sampling is a quick& low costs solution. It may be convenient to select our friends or a particular enquiry.
Form of presentation:
At the time of presentation, some graphs, charts & related tables of health service of Bangladesh will be shown to analyze the topic. Charts from varies economic or business journals is very much essential for presenting in a better or clear way.
Data collection process:
Interview method:
Focus group interview- A Focus (Mahhotra & John -2002) group is an interview piloted by a most trained people with great experience with few people. The moderator leads the discussions. The main purpose of focus group is to gain insights by listening to a group of people from the appropriate target market talk about the issues of interest to the researches. Focus group is the most important aspect in a qualitative research. The group size should be 8-10.
Depth interview- A depth interview is an interview where the communication is one to one where both can feel free to give interview which can go though them in depth. It is totally different from the focus group interview which is taken on a group. It is also unstructured. But it is done by person to person which is a better idea to conduct a survey. It is generally take by the high level skilled professionals. It naturally takes half an hour to one hour. The advantages of doing this interview are it goes deeper discussion that focus group interview. Both can freely exchange their views which are not possible in focus group interview method. Here respondents always feel free to answer the questions with their own observations in word where questions are also free.
Survey method:
The survey method is obtaining information is based on the questioning of respondents. Respondents are asked a variety of questions regarding their behavior, intentions, attitudes, awareness, motivations, demographic & lifestyle characteristics. The size of the survey will enable statistical analysis to be applied to any hypothesis. The questions may be asked verbally, written, computer systems.
It involves separate questionnaires to a willing & a co-operative responds. The respondents require some questions to answer which questions are prepared by the surveyor before questioning the respondents. This method has several advantages which are in this method questionnaire is simple to administrator; data obtained are reliable because the respondents are limited to the alternative stated.
The use of fixed respond questions reduces the variability in the result that may be caused by the differences in the interviewers. Finally coding, analysis & interpretation are simple. It has different types-Central location Personal interview, Telephone interview, electronic interview, mail interview. Central location Personal interview, this research methodology is characterized by basing the survey. This survey is located in a place where the targeted people are mostly available.
Observation methods:
This method records the pattern of behaviour of the people, their attitudes and gestures in a proper way or we can say in a methodological way. The observers or the surveyors do not directly feel the people attitude and they do not even directly communicate with them. Generally information is recorded or collected from the past occurrence. Observation method may be structured or unstructured, direct or indirect. Techniques such as ethnography & case study methods are involved here to find the certain types of information.
Experimentations:
In most scientific enquiry (Peter-2000) research is primarily centered about controlled experiments in which efforts are made to hold conditions constant thus enables the effect of a particular sector of variables to be studied & measured. Any change observed to have taken place in the in the test of situation is measured, statistically tested by the measure of significance. According the result of test the change may be held to attributable to the intervention of the independent variables.
For this research In-depth interview is the most appropriate one. Because depth interview is an interview where the communication is one to one where both can feel free to give interview which can go though them in depth. It is totally different from the focus group interview which is taken on a group. It is also unstructured. But it is done by person to person which is a better idea to conduct a survey. It is generally take by the high level skilled professionals. It naturally takes half an hour to one hour. The advantages of doing this interview are it goes deeper discussion that focus group interview.
Data collection techniques:
Pilot testing:
We will conduct a pilot study to collect proper information. With this statement (Sullivan and Gilbert 2004) suggested that pilot testing be required to create a high quality of questions because the test helps to identify and eliminate potential problems. Piloting can involve a pre-test of the conducted questionnaire on a small of respondents to certify the validity and reliability of the questions (Gill and Johnson, 1997).
Validity:
By the depth interview questions was done to ensure that the questionnaire consisted of an appropriate subject based on the research's topic. It was concluded that the questions were suitable to the study and that the final answers version could be released. Validity is significant in doing such research as it allows the research to be both meaningful and interpretable (Symon and Khan1997). According to (Campbell-2005), validity is the ability to measure what is supposed to be measured. The most common way is to measure the face validity of the questionnaire (Karon-2000).
Reliability:
According to (Pallant-2005), internal consistency is commonly measured by using a statistical tool called the Cronbach's coefficient alpha, which judges a score greater than 0.7 as indicating a reliable logic. Reliability refers to the consistency of a measuring instrument, i.e., the internal consistency Nachmias (1992). This is "the degree to which the items that make up the scale are all measuring the same underlying attribute" (Micheal 2000).
Data processing and analysis:
Data Analysis:
The purpose (Gilbert & Dawan-1998) of analysis comes from the collected data. All previous steps in research have been undertaken to support the search of meaning. The specific analytical process to be produced is closely related to the preceding steps, & the careful analyst will remember this when designing the other steps. The search of meaning may take many forms. However the preliminary analytical steps of editing, coding, tabulation are common to most studies. Given their actual values a review of what editing, coding, tabulation entail & how their uses are desirable.
Qualitative data analysis is a term of analysis (Tonny Proctor-2003) data that are not numeric. The concept however means different of researches depending on the type of approach they take. Not only the nature if data varies questions narrative field notes, interview transcript, personal diaries, public documents bit even if two researchers were to analyse the same text their strategies & outcomes are likely to be quite different. Each justified in the light of their actual research framework. It is necessary therefore to take into the account to the variations into the process that researchers employ when they set about analyzing the qualitative research tends to lay considerable emphasis situational & often structural contexts. In contrast to quantitative research which often multivariable but weak in context, qualitative research tends to weak in cross comparisons.
Limitation of the study:
Time is one of the limitations to do broad research like this and another one is money. We are not getting any money from the authority though the research needs enough money to do survey and some other complementary staffs.
