1. Does the Quality of Governance Contribute to the Quality of Health Care in Bangladesh? Presented by: Mohammad Shafiqul Islam Ph.D Candidate School of the Environment Flinders University, Adelaide Australia

2. Background Bangladesh has made significant improvements in its quantitative health indicators (BFHS, 2012): –Maternal Mortality Ratio (MMR) declined from 322 per 100,000 live births in 2001 to 170 in 2013 –Life expectancy at birth increased from 45 years in 1970 to 70 in 2013, and –Infant Mortality Rate declined from 94 per 1,000 live births in 1990 to 33 in 2013. [sources: World Bank, 2013]

3. Background But the quality of health service delivery is unsatisfactory One of the reasons for this rests on governance issues in health care organisations of rural and urban areas. These governance issues include :  Poor management,  Resource constraints,  Lack of professionalism, and  Inadequate policy initiatives [ source: BDHS,2012;WHO,2010, World Bank,2010] There are no studies dealing with these governance issues.

4. The present study To help fill this gap in knowledge, the author has conducted a study in selected areas of Bangladesh with the following objectives:  To examine the role of administrative and political actors in delivering health services  To examine how the management, politics, and socio- demographic factors contribute to accountability and quality of health services  To examine how the actors and factors contribute to inequality of health services in rural and urban health service organisations and why accountability works differently in the two areas This presentation deals with a part of the larger study mentioned above

5. Methodology  This is a qualitative study comparing one rural and one urban health service organisation in two different districts of Bangladesh, namely 1)Rural : Chhatak Upazila (sub-district) health complex in Sunamgonj district, and 2)Urban : Savar Upazila (sub-district) health complex in Dhaka district (urban)  These two areas were selected to provide a contrast in socio-economic conditions

6. Selected socio-economic indicators of study areas s Socio-economic indicators Savar sub- district Chhatak sub- district Education (Adult literacy %) 68.038.8 Employment (% employed population 7+, not attending school) 56.335.0 Economic conditions of households (%): a.Good housing condition * b.Electricity connection c.Good sanitary facility 19.1 96.6 54.0 16.1 49.7 11.8 Women development: a.Female literacy rate (%) b.Female employment (% employed population 7+, not attending school) 63.9 32.7 36.3 7.0 * % houses built with brick and cement Source: Bangladesh Bureau of Statistics 2012

7. Respondents in the study

8. Results: Supervision and Accountability  Leadership in health in urban areas is more efficient than in rural areas because the urban UHFPOs visit the lower level health centres more frequently [Source: prepared by author based on field data]

9. Supervision and Accountability Availability of manpower  Inadequate manpower in rural organisation Lack of motivation Poor supervision  High absenteeism in rural organisation Bureaucratic management Politics Lack of planning “I work in a ward (the lowest administrative unit) and provide health services for 296 children and 1,672 women as part of my responsibility. I also participate in meetings, training and field visits every month. I try to work with my best effort; however it is difficult for me to manage such a large number of patients and provide quality service” [Source: Interview with a Health Assistant]

10.  Quality of public health care has deteriorated in both Savar and Chhatak In Savar:  Large population,  Lack of coverage by public hospitals  Lack of people’s trust on public health providers  People’s ability to pay for private health services has significantly improved private health care, but reduced not only the role of public providers but also their quality In Chhatak:  Resource constraints in UHC  Lack of people’s trust on public health providers  Poor behaviour of service providers Factors responsible for poor quality of public health services

11.  Allocation of budget  Budget planning for different public hospitals is done by the central government based purely on bed capacity of each hospital  But the allocated funds are not sufficient to provide good quality health care. According the Sub-district Health and Family Planning Officer of Chhatak: “Every year we send our budget to cover our needs for medicine, instruments, other necessary items for tests. We also send our anticipated field visit costs. But the central government does not take into account our needs”  Thus the budget planning is bureaucratic and not flexible to address current and emerging needs  Physical communication system  Poor communication between various levels of government in Chhatak limits supervision and leads to inadequate accessibility to health care Factors responsible for poor quality of public health services

12. Impact of manpower, budget and population on supervision and quality of health care Source: Prepared by the author based on field data

13. Coordination and Accountability Two aspects of coordination : Positive aspects of coordination  Adequate information  Teamwork  Enhanced efficiency of resources  Example: EPI program [Source: Prepared by author based on Field data ]

14. Coordination and Accountability Challenges of coordination  Organisational conflict between Health and Family Planning Departments for lack of chain of command  Inadequate organisational policy for strengthening management  Lack of teamwork among the health professionals  Lack of role clarification whether field workers are responsible to be accountable to local elected representative  Lack of understanding and trust

15. Political responsibility and Accountability Local MP (elected representative) concentrates on new development projects instead of improvement of health care for people Health service committee is politicised and non-functional and the committee organises meetings 2/3 times in a year instead of once in a month Elected representatives have no supervisory authority due to bureaucratic resistance Opposition political parties have limited participation in health service activities because the existing political culture does not allow them to participate. Politics contributes to inadequate decentralised health system

16. Policy Recommendations  Better coordination between various sectors of the government  Improvement of motivation required for promoting accountability and quality of health care  Decentralisation of health care provision and increased participation of elected representatives  Mobilisation of local resources to reduce political/central dependency to promote good governance

17. Thank you Any questions?