Health System Need To Revisit The Flaws
The standard of health-care in Bangladesh, compared with many other countries in the world, is unequivocally poor. This is because Bangladesh is a country that has for centuries been politically, and consequentially economically, a colony of foreign countries. To emerge from servility after such a long period is not easy. This fact still affects the people who are running the country, as well as the population at large. However state and non-state forces -NGOs and private sectors-have complemented each other and contributed to the progress of health-care, education, and life expectancy in Bangladesh. Poverty forces our people to find ways and means merely to survive. This situation allows and encourages the rich and powerful politicians and policy makers to abuse their power by exploiting the vast multitude of poverty-stricken ordinary people, even against the best interest of the country itself. Bangladesh, like most other third world countries in Asia, Africa, Central and South America, is also tradition orientated. The lack of education has distanced the people from scientific innovations and an awareness of the alternatives to their traditional ways of life. They therefore value most their religious beliefs and traditions, and use these as support in their lives of economic hardship.
It is widely recognised that the healthcare seeking in Bangladesh is rapidly changing for the better, triggered by improvement in economic status, education and communication network and transport. The country has made significant gain in improving access to maternal, newborn and child health services, as indicated by the consistent improvement in the coverage rates for many of the health service indicators. While a vast majority of the population depends on private health providers and hospitals, the government facilities continue to play a very important role in meeting the healthcare need of a large segment of the population. It is high time that the country made deliberate efforts to meet the minimum acceptable standard of care provided by the government and private health facilities across the country. For, the mere expansion of services without the explicit strategies for ensuring quality may prove to be a wastage of scarce resources. Bangladesh's commitment to join the movement towards universal health coverage also demands that the country should take definitive steps for guaranteeing minimum level of quality in health-care.
Health-care services need to be focused not only on the outcome of treatment but also on the positive experiences of the user - effective and respectful. For maternal, newborn and child health, this would mean a continuum of care approach linking home and community-based services with the primary, secondary and tertiary level facilities. In addition, the healthcare providers need to be competent and well-equipped to deliver the care as per the expected standard and ensuring a positive experience for the users. Such care can also help to rebuild the trust and confidence of people in the health system and further enhance the utilisation of health services. It is imperative that the foundations of the health system be strengthened to focus on improved quality of healthcare in the public and private domains. This requires strong leadership at all levels, an appropriate organisation of healthcare delivery platforms, skilled and motivated health workforce, health supplies and technologies, reliable and user-friendly data on quality of care. The recent assessments on the readiness of health facilities, both public and private, raise many concerns about their preparedness to ensure the minimum level of quality. The education of healthcare professionals in the country, in addition to the technical competencies, need to pay special attention to ethical, patient-centered and compassionate care.
A developed health care system is impossible without a smoothly functioning nursing sector. Plus, the profession requires qualified leadership able to empower nurses and improve their professional competence. Bangladesh's public health challenges require a skilled health care work force to provide or improve access to quality care. Gaps in quantity and quality of nurse and midwife services and education will have an impact on attaining the health related SDGs. Health-care issues, such as the increased need to deal with current and future health effects of climate change, have merged to create the sense of urgency that now catalyzes work to improve nursing and midwifery. The WHO nursing and midwifery program provides support to the Government of Bangladesh (GoB) via the Directorate of Nursing Services (DNS) and the Bangladesh Nursing Council (BNC) in order to alleviate the severe nursing and midwifery shortage, and to improve quality of education and services provided by them which may address the multiple urgent needs for a strong health-care work force.
The nursing profession is undoubtedly a very important part of the health-care infrastructure. I will therefore highlight a few of the issues that are responsible for the low quality of inadequate nursing care of the population. The course outline for the Senior Registered Nurse developed by the Bangladesh Nursing Council in Dhaka encompasses anatomy, physiology, microbiology, social science, nutrition, nursing art, first aid, pharmacology, community nursing, family health nursing, health education, adult and child medicated and surgical nursing, psychiatric nursing, and management and supervision. Nursing ethics is not included in the syllabus. The whole period of training emphasizes for practical application of theoretical learning. The training period for senior nurses is four years. Instruction is given by sister tutors, guest lecturers, hospital nursing personnel and, occasionally, some local authority employees. Bangladesh must ensure health-care to protect its human resources and fulfill a basic human need. Hence, nursing is a crucial factor in health care system. As a profession, existing condition of nursing in Bangladesh remains poor with below-average standards. They spent remaining time in unnecessary socialization. The leaders in the nursing profession should change the scenario and play a proactive role in Bangladesh's health-care system.
Apart from the lack of infrastructure and equipment, healthcare facilities in Bangladesh are also not staffed with adequate numbers of healthcare service providers. As of 2018, there was one registered physician for every 1,581 individuals in the country (BBS, 2019). The level of healthcare awareness among the general population was also found to be very low in Bangladesh. For example, the WHO recommends washing hands frequently and thoroughly with soap and water in order to kill viruses such as the coronavirus that may be on people's hands. According to Bangladesh's National Hygiene Survey 2018, only 15 percent people were aware of the need for washing hands using soap and water before feeding a baby, 36 percent people were aware of the need for washing hands before preparing or serving food, 40 percent people were aware of the need for washing hands before eating, and 55 percent people were aware of the need for washing hands after defecation.
Global initiatives are urging countries to prioritize quality as a way of reinforcing human rights-based approaches to health. Yet evidence from both high- and low-income countries shows that services for adolescents are highly fragmented, poorly coordinated and uneven in quality. Pockets of excellent practice exist, but, overall, services need significant improvement and should be brought into conformity with existing guidelines. WHO/UNAIDS Global Standards for quality health care services for adolescents aim to assist policy-makers and health service planners in improving the quality of health-care services so that adolescents find it easier to obtain the health services that they need to promote, protect and improve their health and well-being.
The development of a culture of caring which encompasses the set of norms including altruism, excellence, caring, ethics, respect, communication, and accountability begins within the confines of nursing education. Undergraduate nursing curricula emphasize caring as a basic tenant of nursing education. The art and science of nursing involves all dimensions of patient care; a focus on the patient's needs is paramount for the nursing student as the student develops a connection with the patient. A connection to the patient is part of the initiation of compassionate appropriate care. The establishment of core values in the education of a student nurse is part of the advancement of a strong caring culture in the nursing profession. In conclusion, we can say that nurses play a very significant role for better health care in our society. Their profession can no way be ignored or neglected. Rather it has a bright and prestigious position with pride, honour and dignity. So the status of nurses must be upgraded and virtually this sector needs to be reformed and taken care of nurses' skill development.
The regulatory system in the country falls short of the expectations in terms of enforcing accountability for quality. Lastly, people everywhere need to be capacitated to ask for effective and respectful care, irrespective of their ability to pay. There has to be a sense of urgency across all spheres of the health system in Bangladesh to take decisive steps to fill the glaring gaps in the quality of health-care delivered in the country. Hence to ensure a balanced health system, a regulatory body needs to be mobilized in every department and ministry of our country. Again health control wings in different levels need to be launched in all govt. and non govt. organization.
(Dr. Forqan Uddin Ahmed is former Deputy Director General, Bangladesh Ansar VDP)