Heath Care System: The Challenge for Social policy

Introduction:

Social policy aims to improve human welfare and to meet human needs for education, health, housing and economic security. Important areas of social policy are wellbeing and welfare, social security, justice, unemployment insurance, living conditions, animal rights, pensions, health care, social housing, social care, child protection and labor issues.

 Significance of the study:

This study will be a significant endeavor in promoting the notion about Social Policy as well as Heath Care System in Bangladesh, Especially about the taken step of Heath Care System by Bangladesh Government .This study will also be beneficial to the student in Social Policy.

Moreover this assignment will provide recommendation on how to evaluate the Heath care System in Koyra Upzilla.

Therefore, this assignment will be helpful to the student and learners of social policy and heath care system that will evaluate higher research in the field of Heath Care System in Bangladesh.

This have shown in this assignment, how an upzilla faces the problem of heath care consciousness which is in side of Sundarbns at the near of Bay of Bay of Bengal.

Data collection procedure:

A questionnaire was chosen as data collection instrument. A questionnaire is a printed self-report form designed to elicit information that can be obtained through the written responses of the subjects.

I have talked with the different NGOs organization who were working in koyra Upzilla based on their project of heath caring and education and the development of infrastructure of society.

I also taken the help from the government website and other web site.

My Facebook friends who worked on this koyra also given answers different questionnaire. Koyra Upzilla Chairman & medical heath officer also given the answer after questionnaire.

 

Study Area

Time and economy are the most influential factor to derive any successful study. These are the main preconditions to get an effective and reliable result of any research. Because of time and financial shortage, I have limited my research within a small area. My study area is a prominent hospital named ‘Shaheed Suhrawardy Medical College & Hospital’ in the capital city Dhaka of Bangladesh.

 

Understanding Social Policy:

What is social Policy?

Social Policy is the study of social services and the welfare state. In general terms, it looks at the idea of social welfare, and its relationship to politics and society. More specifically, it also considers detailed issues in

1.    policy and administration of social services, including policies for health, housing, income maintenance, education and social work;

2.    needs and issues affecting the users of services, including poverty, old age, health, disability, and family policy; and

3.    The delivery of welfare.

 

Issues on Social Policy:

There are some issues on social policy .the following issues are in the main issues of social policy.

Heath Policy:

 Debates about "health services" are not just about health care. The term stands for a range of measures concerned with social protection. These measures typically include social insurance and solidarity provision. Payment for medical goods, such as pharmaceuticals, is much more uneven.

When people pay for social protection, their expectations are likely to be different from consumers paying for specific courses of treatment, like elective surgery. Typical issues in social protection are accessibility, coverage and the responsiveness of services, especially in emergency. These issues are different, and potentially more important for service users, than the kinds of issue which influence decisions in direct consumption, such as quality or the availability of alternative treatments.

 Housing policy:

Housing policy is usually analysed in economic terms, as a form of market. In theory, markets lead to efficient allocation through a complex process of matching supply and demand. This depends on competition (to bring prices down); good information; the existence of multiple suppliers; and the existence of multiple purchasers. In housing, this theory has limited application. Barlow and Duncan point to

1.    Market closure. Housing production and finance are dominated by a few major players.

2.    The impact of space. Location is acutely important in the housing market; there cannot, because of it, be perfect information and full and free competition.

3.    Externalities. Housing both affects the environment and is affected by it.

4.    Credit allocation. The housing market is paid for mainly by borrowing, which has to be based on predictions of future value. It is very unlike the market for food.

5.    Uncertainty. Because the future is uncertain, so is the housing market. Regulation and intervention are important to reduce uncertainty.

6.    Market volatility. Prices are dominated by a limited part of the market - those who are buying and selling property at any time.

7.    The problem of meeting need. If profitability is the only consideration, people will be left with needs unmet - most obviously, through homelessness.

 

Social Security:

 Social security is sometimes used to refer specifically to social insurance, but more generally it is a term used for personal financial assistance, in whatever form it may take. It is also referred to as "income maintenance".

The reasons why financial assistance are given include:

1.    The relief of poverty.

2.    Social protection. The idea of 'social security' implies that people ought to be able to feel secure. This involves, not only being protected against poverty, but being protected against the hardships that may arise through a change in circumstances. If people become sick, or unemployed, they should not, the argument goes, have to lose their possessions or deprive themselves as a result. This is why people on benefit should be expected to have cars and television sets.

3.    Redistribution. Benefits which go to people who have inadequate incomes, at the expense of people who are more, are progressive. Support for children, by contrast, is mainly a form of horizontal redistribution, going from people without children to people with children.

4.    Solidarity. Social security is seen not simply as charity, but as a form of mutual co-operation. It is a principle which can be extended to the rest of the welfare state.

 

Education Policy:

 Education is principally identified with schooling, though in theory it extends far beyond this, being concerned with intellectual and social development. The main emphasis within this is on children, though there is clearly scope for education for all and 'lifelong learning'.

Education has been particularly significant as an instrument of social policy, in the sense not only of policies for welfare but also as policies intended to deal with the structure of society. The aims of education include:

1.    Liberal education: the development of each individual intellectually and socially to that person's fullest potential

2.    Socialization: education is a method of transmission of social norms and values. This is also sometimes seen as a form of social control.

3.    Education as 'handmaiden': the education system serves the industrial process and the economy by producing a trained workforce, and by providing child-minding services.

4.      Social change (or 'social engineering'). The education system has been seen as a means of bringing about social change.

Finch refers to the use of education as a vehicle for other types of social policy. Education provides a convenient basis for policy for children because of its universal coverage, the acceptance of responsibility for children's welfare, and because it has been easy to justify welfare measures in educational terms.

 Personal Social Service:

 There is no clear or coherent category of 'personal social services', which cover both social work and 'social care', services to people which fall outside the remit of health services. In Britain, these departments have developed as a residual category of services not provided by other services.

  Understanding Heath Care System As an issue of Social policy:

What is Health?

There are many definitions of 'health'. They include:

1.    Cultural definitions: health is a standard of physical and mental well-being appropriate to a particular society.

2.    Normative definitions: health as an fixed level, or an ideal physical and mental state

3.    Functional definitions: health is a state of being necessary to perform certain physical and mental activities

Health depends on a number of factors, including biological factors, environmental factors, nutrition, and the standard of living. In other words, health can be seen as a function of welfare. Few of the issues which cause ill health are dealt with directly by 'health services'; they are, rather, issues in the 'welfare state' as a whole. When, in the 19th century, Chadwick identified poor health as a major cause of pauperism, his response was to improve sanitation, not to introduce more extensive medical care. Most of the world's diseases are attributable to poor water supply or nutrition. 'Health services' are better described as medical services.

 Health care System:

Health care can be divided into a number of different branches. Conventionally these include.

1.    Hospital care. Hospitals can be distinguished between acute and long-stay care. Acute care covers the full range of medical specialties: long stay care has principally been used for psychiatric care and continuing nursing care. The current trend is for long stay to be minimized and for acute hospitals to offer a full range of care.

2.    Primary care. Primary care refers to basic medical treatment and non-hospital care, including general or family practitioners, professions ancillary to medicine (including dentistry, optics and pharmacy) and domiciliary health care (home nursing, occupational therapy, etc.). In some countries, the preferred distinction falls between hospital and "ambulatory" care. Ambulatory care includes primary care and most day care in hospital.

3.    Public health. This field includes not only preventive medicine (e.g. screening, inoculation or health education) but also several areas not necessarily linked with conventional health services, including housing, water supplies, and sewerage and food hygiene.

 Public health is probably the most important issue for the health of a population; primary care is the main focus of medical care in practice. Medicine in hospitals is probably the least important in terms of its impact on health or illness, but it costs the most, has the highest status and is the focus of most political attention.

 Strategies taken By Government:

 

In keeping with the goals, objectives and principles, the following strategies were adopted:

 1.    Obtain mass-scale consensus and commitment to socio-economic, social and political development to facilitate appropriate implementation of the Health Policy.

2.    Prevent diseases and promote health to achieve the basic objective of “Health for All”. The Health Policy focuses on provision of the best possible health facilities to as many people as possible using cost-effective methods, and will thus ensure effective application of the available curative and rehabilitative services.

3.    Adopt PHC as the major component of the National Health Policy to ensure delivery of cost-effective health services. PHC is the universally recognized methodology to provide health services.

4.    Liberalize and improve the Drug Policy in keeping with the Health Policy to fulfill the overall needs for health services. There is need to ensure smooth availability of essential medicines focusing on the current needs for such medicines and their efficacy, including their affordability by all people.

5.    Maintain quality standards of the marketed medicines and raw materials and rationalize the use of medicines. In this line, the required number of skilled manpower will be acquired in drug administration.

6.    Ensure distribution of birth control supplies and improve the management of the domestic sources, including encouragement of domestic entrepreneurs.

7.    Integrate Epidemiological surveillance system with disease control programs. A specific institution will be entrusted with the responsibility of such surveillance.

8.    Adhere to quality standards in health care at health centres. Provide standard quality assurance guidelines including monitoring and evaluation mechanism to every health Centre.

9.    Form a Health Services Reforms Body based on the HPSS aiming at meeting the current demand. The role of this body includes reforms in infrastructure, acquisition of HR, inspection of supplies and logistics, and improve management.

10.                       Design an appropriate and need-based approach to develop HRD to maximise utilization of the knowledge and skills of health-related personnel. Create positions with an appropriate career planning system, which will be formulated and implemented. Provide appropriate training.

11.                       Integrate the community and the local government with the health service system at all levels.

12.                       Install an integrated Management Information System (MIS) and a computerized communication system countrywide, to facilitate implementation, action planning and monitoring. The existing MIS will be further strengthened with skilled and efficient people. Extensive, but appropriate, training will be arranged for them to maintain the system. The number of people working in this system will be increased and their skill enhanced.

13.                       Restructure and strengthen the BMDC and the BNC to ensure strict supervision of professional registration and their quality of skills and related ethical issues.

14.                       Restructure and organize education and training of the pharmacists, medical technologists and other paramedics, the Pharmacy Council and the State Medical Faculty to maintain required performance standards.

15.                       Integrate professional organizations such as BMA, BPMPA, BNA, unani etc. with the country's health service system.

16.                       Provide need-based, people-oriented, updated medical education and training.

17.                       Institutionalize management and administrative training for improving doctor’s management capabilities.

18.                       Establish a National Training Institute to provide regular training such as reorientation, continuing medical education, and administrative and management courses etc. to all staffs in the public and private sector.

19.                       Improve the management of medical colleges/ institutions and related hospitals with increased levels of financial and administrative delegation to ensure efficient hospital services.

20.                       Emphasize nutrition and health education since they are the major forces of health and FP activities. Establish one nutrition and one health education unit in each Upzilla, to reach every village.

21.                       Disseminate information on health education through incorporating the community leaders and other departments/ organizations of the government in the health system.

22.                       Charge minimum user fees at public hospitals and clinics and provide free care for the poor and disabled.

23.                       Encourage NGOs and Private Sectors to perform a complementary role to the public sector.

24.                       Develop infrastructure and transport systems to minimize the disparity in access to health services between rural and urban areas.

25.                       Pay non-practicing allowances to those doctors/trainee doctors who act as full-time and resident doctors thus refrain from private medical practices.

26.                       Provide clear policies governing those want to practice within public facilities.

27.                       Ensure accountability of all concerned in the health system. Design a procedure to strengthen accountability and ensure quick and strict legal disposal of         negligence cases.

28.                       Form a National Health and Population Council under the Head of Government to provide support and advice on the implementation of the Health Policy and ensure effectiveness and accountability of health system. Empower local and regional councils to monitor health activities in their respective areas.

29.                       Intersect oral co-ordination and utilizing resources of the concerned sectors to strengthen linkages.

30.                       Encourage research on management styles and their effectiveness, clinical services, approach to diagnoses, social and behavioral aspects, epidemiology, etc. Strengthen information dissemination systems, especially involving private organizations with an aim to reach grass-root level. Design, implement and supervise an effective referral system.

31.                       Avoid duplication of activities from different projects, programs and activities. Establish a policy-planning cell in the MOHFW to ensure effective and sustainable co-ordination.

32.                       The goal of the Policy will be to provide client-center health and reproductive health services, so that an individual have the opportunity to select services as per need and choice. This approach of service delivery will be an important strategy of the National Health Policy and will contribute to reduce unwanted pregnancies.

33.                       Distribute budget from district to community level within reasonable flexibility to provide increased benefits to the poor and destitute communities, optimize expenses and ease accessibility to services.

34.                       Incorporate alternative health care services such as ayurvedic, unani and homoeopathic practices into the National Policy. Encourage an increased scientific basis for these three disciplines.

35.                       Deliver ESP from one-stop centers throughout the country. Train the UHCs.

36.                       Adopt a sector-wide management system.

37.                       Deploy an MBBS doctor in each UHFWC and equip them with residence facilities for doctors

   

NGO activities operationally important NGOs are brac, proshika, Prodipan

 

Koyra Upazila (khulna district) area 1775.41 sq km, located in between 22°12′ and 22°31′ north latitudes and in between 89°15′ and 89°26′ east longitudes. It is bounded by paikgachha upazila on the north, the bay of bengal and sundarbans on the south, dacope upazila on the east, assasuni and shyamnagar upazila on the west.

Population Total 192534; male 95993, female 96541; Muslim 149321, Hindu 42462, Buddhist 454 and others 297.

 In Bangladesh health policy was published in 2011 and adheres to the following principles:

Health is defined as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

1.    Every citizen has the basic right to adequate health care. The State and the government are constitutionally obliged to ensure health care for its citizens.

2.    To ensure an effective health care system that responds to the need of a healthy nation, health policy provides the vision and mission for development.

3.    Pursuit of such policy will fulfill the demands of the people of the country, while health service providers will be encouraged and inspired. People's physical well-being and free thought process have proved to be a precondition for the growth and intellectual enrichment in today's human society

4.    Bangladesh expressed agreement on the following declarations:

a.    The Alma Ata Declaration (1978)

b.    The World Summit for Children (1990)

c.     International Conference on Population and Development (1994)

d.    Beijing Women's Conference (1995)

In the absence of a written and approved Health Policy, the national Annual Development Programme and Five Year Plans substituted for policy principles. The problems in the health services multiplied in the absence of a clear policy. Bangladesh is a developing country with the world's highest population density.

 

 Objectives taken By Government:

 1.    To make necessary basic medical utilities reach people of all strata as per Section 15(A) of the Bangladesh Constitution, and develop the health and nutrition status of the people as per Section 18(A) of the Bangladesh Constitution.

 

2.    To develop a system to ensure easy and sustained availability of health services for the people, especially communities in both rural and urban areas

3.    Third to ensure optimum quality, acceptance and availability of primary health care, and governmental medical services at the Upzilla and Union levels.

4.    To reduce the intensity of malnutrition, especially among children and mothers; and implement effective and integrated programs for improving nutrition status of all segments of the population.

5.    To undertake programs for reducing the rates of child and maternal mortality within the next 5 years and reduce these rates to acceptable levels;

6.    To adopt satisfactory measures for ensuring improved maternal and child health at the union level and install facilities for safe and clean child delivery in each village:

7.    To improve overall reproductive health resources and services;

8.    To ensure the presence of full-time doctors, nurses and other officers/staff, provide and maintain necessary equipment and supplies at each of the Upazila Health Complexes and Union Health and Family Welfare Centres:

9.    To devise ways for the people to make optimum usage of the opportunities in government hospitals and health service system, and to ensure quality management and cleanliness of service delivery at the hospitals;

10.                       To formulate specific policies for medical colleges and private clinics, and to introduce appropriate laws and regulations for the control and management of such institutions including maintenance of service quality;

11.                       To strengthen and expedite the family planning Programme with the objective of attaining the target of Replacement Level of Fertility;

12.                       To explore ways to make the family planning Programme more acceptable, easily available and effective among the extremely poor and low-income communities.

13.                       To arrange special health services for mentally retarded, the physically disabled and for elderly populations;

14.                       To determine ways to make family planning and health management more accountable and cost-effective by equipping it with more skilled manpower.

 15.                       To create awareness among and enable every citizen of Bangladesh irrespective of cast, creed, religion, income and gender, and especially children and women, in any geographical region of the country, through media publicity, to obtain health, nutrition and reproductive health services on the basis of social justice and equality through ensuring everyone’s constitutional rights.

16.                       To make essential primary health care services reach every citizen in all geographical regions within Bangladesh.

17.                       To ensure equal distribution and optimum usage of available resources to solve urgent health-related problems with focus on the disadvantaged, the poor and unemployed persons;

18.                       To involve the people in planning, management, local fund raising, spending, monitoring and review of the procedure of health services delivery etc. with the aim of decentralizing the health management and establishing people’s rights and responsibilities in the system;

19.                       To facilitate and assist in collaborative efforts between the government and the non-government agencies to ensure effective provision of health services to all;

20.                       To ensure the availability of birth control supplies through integration, expansion and strengthening of family planning activities;

21.                       To carry out appropriate administrative restructuring and decentralization of service delivery procedure and the supply system, and to adopt strategies for priority-based HRD aimed at overall improvement and quality-enhancement of health service, and to create access of all citizens to such services;

22.                       To encourage adoption and application of effective and efficient technology, operational development and research activities to ensure further strengthening and usage of health, nutrition and reproductive health services;

23.                       To provide legal support with regard to the rights, opportunities, responsibilities, obligations and restrictions of the service providers, service receivers and other citizens, in connection with matters related to health service; and

24.                       To establish self-reliance and self-sufficiency in the health sector by implementing the primary health care and the essential services package, to fulfill the aspirations of the people for their overall sound health and access to reproductive health care.

 

Health Care System

The health care are designated to meet the health needs of the community through the use of available knowledge and resources. The services provided should be comprehensive and community based. The resources must be distributed according to the needs of the community. The final outcome of good health care system is the changed health status or improve health status of the community which is expressed in terms of lives saved, death averted, disease prevented, disease treated, prolongation of life etc.

Health care delivery system in Bangladesh based on PHC concept has got various Level of service delivery:

• Home and community level.
• Union level,
• Union sub centre (USC) or Health and family welfare centre; This is the first health facility level.
• Thana level, Thana Health Complex (THC): This is the first referral level.
• District Hospital: This is the secondary referral level.
• National Level: This is the tertiary referral level.

A) Primary level health care is delivered though USC or HFWC with one in each union domiciliary level, integrated health and family planning services through field workers for every 3000–4000 population and 31 bed capacities in hospitals.

B) The secondary level health care is provided through 100 bed capacities in district hospital. Facilities provide specialist services in internal medicine, general surgery, gynecology, paediatrics and obstetrics, eye clinical, pathology, blood transfusion and public health laboratories.

C) Tertiary Level health care is available at the medical college hospital, public health and medical institutes and other specialist hospitals at the national level where a mass wide range of specialised as well as better laboratory facilities are available.

The referral system will be developed keeping in view the following.

1. A clearly spent-out linkage between the specialised national institutes, medical college and district hospitals to ensure proper care and treatment of patients from the rural areas served by lower level facilities.

2. Patients from the rural areas referred by lower level facilities to district and Medical College hospitals and specialised institutions should get preferential treatment after admission.

Health Problems in Koyra

The health problems of Bangladesh can be conveniently grouped under the following headlines:

1. Population problems
2. Communicable disease problems
3. Nutritional problems
4. Environmental sanitation problems
5. Health problems.

Communicable Disease Problems

Communicable diseases are still the major diseases in Bangladesh. Mortality & morbidity due to these disease are very high. Infectious diseases like cholera, typhoid, tuberculosis, leprosy, tetanus, measles, rabies, venereal diseases and parasitic diseases like malaria, filariasis, and worm infestations are responsible for major morbidity. An expanded immunisation programme against nine major disease (TB, Tetanus, Diphtheria, Whooping cough, Polio, Hepatitis B, Haemophilus influenza type B, Measles, Rubella) was undertaken for implementation).

Nutritional Problems

Bangladesh suffers from some of the most severe malnutrition problems. The present per capita intake is only 1850 kilo calorie which is by any standard, much below required need. Malnutrition results from the convergence of poverty, inequitable food distribution, disease, illiteracy, rapid population growth and environmental risks, compounded by cultural and social inequities. Severe undernutrition exists mainly among families of landless agricultural labourers and farmers with small holding.

Specific nutritional problems in the country are—

1. Protein–energy malnutrition (PEM): The chief cause of it is insufficient food intake.
2. Nutritional anaemia: The most frequent cause is iron deficiency and less frequently follate and vitamin B12 deficiency.
3. Xerophthalmia: The chief cause is nutritional

deficiency of Vit-A.

1. Iodine Deficiency Disorders: Goiter and other iodine deficiency disorders.
2. Others: Lethyrism, endemic fluorosis etc.

Environmental Sanitation Problems

The most difficult problem to tackle in this country is perhaps the environmental sanitation problem which is multi-faceted and multi-factorial. The twin problems of environmental sanitation are—

• Lack of safe drinking water in many areas of the country.
• Preventive methods of excreta disposal.

Health Problems

• Indiscriminate defecation resulting in filth and water pond disease like diarrahoea, dysentery, enteric fever, hepatitis, hook worm infestations.
• Poor rural housing with no arrangement for proper ventilation, lighting etc.
• Poor sanitation of public eating and market places.
• Inadequate drainage, disposal of refuse and animal waste.
• Absence of adequate MCH care services.
• Absence and/ or adequate health education to the rural areas.
• Absence and/or inadequate communications and transport facilities for workers of the public health.
• Absence of control of communicable diseases.

Service Provided by the Health Care Centre in the Study Area:

The hospitals of this area deal with comparatively more complicated diseases, which is beyond the scope and capacity of the primary level. Most of the hospitals in the study area are curative in nature. These hospitals are assigned to provide some specialist services particularly in internal medicine, general surgery, obstetrics and gynecology and pediatrics.

 

 

General Health Knowledge and Awareness of the Respondents:

To know the knowledge about the awareness of preliminary health care some questions had been asked to the respondents. The survey report shows that the respondents are well alert about their health and they know the primary care needed for them.

  Table-4: General health knowledge and awareness of the respondents.

 

Conclusions:

There seems to be a distinct spatial variation in the patterns of attendance between low and high income people, between low and high education level. The low income peoples mostly avail of public health care facilities and they are experiencing much longer travel to primary care services than other respondents. The high income people mostly use the private doctor’s facilities. The poorer households have no choice  to undertake frequently lengthy journey often too crowded hospitals or public clinics. In the study area most of the  respondents use Rikshaw as mode of transportation. There are some high income respondents with private vehicles at their disposal. Long waiting at the health centers discourages the people who consider it as potential loss of wages or work hours. Many of the respondents did not be use the nearest facility due to reason not explained. This is understandable in the context of Bangladesh, in mixed health care system, spatial proximity does not necessarily equate with social or economic access. The reasons given by respondents for not using the nearest facility are varied. If the poor class of patients do not use public health facility nearby , they need to travel a long distance to get treatment which is many case become impossible. The high income respondents traveled to doctors with whom a good relationship is already established and who are situated either in the study area or outside the study area.

 

 

References

BBS. (2011), Statistical pocket book of Bangladesh, 2011, Statistics Division, Ministry of Planning, Government of the People’s Republic of Bangladesh.

CUMPER, G.E. (1984), Determinations of Health Levels in Developing Countries, England: Research Studies Press Ltd. England.

FELDMAN, S (1987), Overpopulation as Crisis: Redirecting Health Care Services in Rural Bangladesh, International Journal of Health Services, Vol. 17, pp. 113-131.

MITRA, S.N. AND S. ISLAM. (1996), Diarrheal Morbidity and Treatment Survey 1994/95. Dhaka Mitra Associates and Social Marketing Company.

MITRA, S.N, A. AL-SABIR, A. R. CROSS, AND JAMIL. K (1997), Bangladesh Demographic and Health Survey 1996-97. Calverton, Maryland: National Institute for Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc.