The main aim of this assignment is to uncover the dynamics of politics in the agenda setting of the health governance of Bangladesh through investigation of the role of deferent actors. In every policy process politics play an important role in idea generation, formulation and implementation. Policy reform in health sector is not different from other policy reforms. In the process of health policy making of any country, different actors try to bring the governance in their favor through playing significant role.
This interaction of deferent actors in governance is known as politics of public policy. In the complex political process of health sector reform viability of special agenda, type of changes in policy reform, vision of national politics play an important role. In Bangladesh, health is one of the most important sectors since good health ensure more social and economic production and good quality of life. Beyond debate, priority of the health sector is forefront in the development discourse, even though, ‘health sector’ it is associated with multi sectoral factors and actors.
Thus, making implementation of health sector policy requires interplay of actors and factors from different sectors and levels: local, national, regional and international. Health situation in Bangladesh Till today, health situation in Bangladesh is not quite satisfactory. Lack of broad national health policy or policy vacuum, lack of policy priority setting, discontinuity of policy, lack of policy ownership, lack of resource allocation and lack of proper uses of resources due to lack institutional arrangement and elite dominated health sector are the main characteristics of health sector in Bangladesh.
These characteristics create hindrance in the process of achievement of national and international goals and ultimately health situation of common people remains vulnerable. Bangladesh, being a country with small land size of 144,000 sq. km, has the burden of a huge population of 140 million. Still, with low per capita income and low literacy. Though Bangladesh has one of the strongest networks for delivering countrywide health services among developing countries, still the quality of services are not up to the mark and the services are neither client focused nor need based.
In the following tables we demonstrated the trends of basic health indicators of Bangladesh Indicators1970s (1978-80)1980s (1990)1990s (1996-972000s (2003)2007 Population growth rate2. 72. 101. 741. 54NA Infant mortality rate(per 1000)150116776652 Maternal mortality rate105. 74. 13NA Delivery care by trained2581218 Under 5 mortality rate(per 1000)2991101169465 Table 3. 1: Trends of Basic Health Indicators of Bangladesh Heath governance system
The government driven healthcare service has a network in all over the country from the centre to the extreme periphery, having two wings, one concerned with Population and Family Planning and the other concerned with Health in total. The service network has three approaches with primary care at upazilla level; secondary care at district level; and tertiary care at divisional level. To administer administrative activities the country has six administrative divisions and 64 districts and furthermore the districts are divided into upazilas (476 in number) and upazilas into unions (4,770).
It is estimated that each of the union consist of 25,000 people in most cases each of the unions are again divided into nine villages. The upazila health complexes (463) acts as the first referral centers for primary health care along with one district levels hospitals at all districts (64) and most of the specialized hospitals resides at tertiary levels, mostly in Dhaka – the capital of Bangladesh. There is a standard setup for health services in an upazilla consisting of one upazilla health complex, one union health & family welfare center (UHFWC) at union level (4062) and community clinics at village levels for every 6000 populations.
It is mentionable that the community clinics were established under the Health and Population Sector Program (HPSP) – a donor driven mega program – were not functioning till now and being revitalized in recent periods (from the regime of interim caretaker government to present AL government) Apart from general health services other services i. e. minimal reproductive, maternal, and child health care services get provided by these centers for the local people free of cost.
The ratio of physicians and registered nurses to population is 241 and 136 respectively per million people and the number of hospitals available for a million people is 10, while the availability of hospital beds is one for about 4000 people. Non government organizations (NGO) and private sectors also play an important role to provide health services for the country. Numbers of NGOs have targeted projects, program and facilities to provide antenatal care (ANC) and safe delivery care. Besides in urban areas the number of private service delivery centers and private physicians are also on the rise.
Thought the private clinics get operated privately, most of the doctors working in public hospitals work there on part time basis. These clinics have high charges and operate on commercial basis and people living in highest quintiles prefers such clinics for good quality service, which sometimes is not available in public sectors, as per the wealthiest quintiles perception. Recent politics in policy making Like many other developing country the lifetime of a public policy in Bangladesh depends on the change of political power and health policy is no exception.
Visions and directions of all health policies got changed with the change of ruling government. Likewise the NHP 2000 was also interrupted as the government changed. After that two attempts were made to revise the policy till 2008. This instigated disruption in policy implementation rather than bringing any positive change. Many arguments took place in favor of policy reversal by the policyactors but the decision remained absolutely political. The following subsection illustrates the policy vulnerability of NHP 2000 as reflected in its reversal and formulation of NHP 2006 and 2008 and the political dynamics behind it (BHW, 2010).
The first and fully operational national health policy was initiated in 1988 during the autocratic regime. In 2000 the democratic government promulgated a national health policy with five goals and objectives, in October 2001 after the Bangladesh Nationalist Party-led coalition government came to power. This new government deviated from NHP 2000 and got engaged in redrafting a new health policy, without rejecting the existing one in its entirety. This NHP 2000 was to some extent rejected when two of its essential components related to structural transformation were made dysfunctional.
The issues were i) unification of health and FP wings ii) the issue of community clinic. Key policy actors (both politicians and bureaucrats) had staid uncertainties about the outcome of these two major reforms and believed that these two issues introduction had been politically motivated by Awami League (AL), which finally resulted in non-implementation. The following segments give an outline of how two major reforms proposed by the policy faced rejection. Integration or unification of health and FP wings – the ornerstone of the NHP 2000 – was formally approved earlier through the HPSS and HPSP (1998-2003), did not experience smooth implementation even during the AL arena.
This unification was intended to provide health and FP services in a package for improved service efficiency by minimizing duplication and overlapping of service delivery, which did not take place due to bureaucracy. During the era of 2001-2006, reversal of NHP 2000 became the interior of a whirlpool of conflicts, delays, and difference among policy players, including the bureaucrats, politicians, medical professionals and donors.
At the early stage of BNP regime, the system of government held substantial power over the execution of NHP 2000. And the final decision on reversing unification was taken by the Health Secretary and the Prime Minister. The new senior level bureaucrats during this period contrasted the amalgamation and community clinics. The bureaucrats believed that incorporation would marginalize the FP section of the health sector, when it was decisive to uphold the responsibilities and sovereignty of the FP workers.
The ruling BNP leaders were rigid to renounce the NHP 2000 since it was formulated by the previous AL government. And political leaders played a fundamental part in the policy implications during 2001-2006. It has been observed that the harmonization between the medical professionals and political leaders led to dealings with the bureaucrats and other forces and exercise more power (BHW 2010). The partial refusal of NHP 2000 can be accredited to the customs of confrontational politics and prejudice that permeates every level of the polity, rather than ideological dissimilarity often political parties.
There was little ideological difference between the BNP and AL governments, as demonstrated in similar policy proposals of the two respective health policy documents. Interest group & policy issues According to the views presented by the study respondents, numerous problems were highlighted by different levels of organizations and individuals. More than 160 organizations and individuals have submitted written demand to the Program Support Office (PSO), HNPSP, MoHFW more prior to the preparation of the final draft. All of these demands reflected personal or professional interests.
The written comments covered about 70 issues and a significant number of NGO participation was seen. All the policy issues were not dominant. Weight of the problems and proper evidence and strategy to highlight the problems play important role to catch attention of the policy makers. Among the policy issues, following were more dominant compared to others. State policy in health governance State actors and non-state actors play their role in the policy process. During the time of agenda setting interest groups try to influence the policy makers to consider their preferable issues.
Like other policy process, different actors and factors impacted the generation of ideas in health policy. Till today, health situation of Bangladesh is not satisfactory in term of ‘equity and justice’. In the literature of policy ownership, source of ideas/visions is treated as one of the major indicator to measure the ownership of policy (Osman, 2006). In public policy process ‘agenda setting’ is a stage where owner of ideas/vision and promoter of the ideas adopt different strategy to draw the attention of the policy makers.
In public policy making ‘ownership’ can be measured with participation of different actors in policy process. In this connection role of the different actors were investigated in this study. According to Jhon Kingdon’s Garbage Can Model, an issue becomes agenda with three confluence “streams”. Different actors play their role from their own perspective in these steams. In this study it was found that three steams emerged at the same time and opened a window. In problem stream evidence production and dissemination were highly supportive for highlighting the problems of community health issues as policy agenda.
In proposal stream national and international policy coherences, international and national good practices and positive attitude of donors were among other factors that supported the community clinic issues as policy proposal. Also, political support of the ruling party (AL) was also positive to highlight the community clinic and community health issues. These problems were highlighted in different documents of governments, NGOs and donors. Moreover, these problems were recognized by bureaucrats, politicians, media people, donors and NGOs.
Apart from evidences, ordinary people through experiences and observations also recognized these problems. Thus, all stakeholders had good faith about these evidences. It can be said that three confluence streams emerged and opened a policy window to take a decision for establishing community clinic for solving the community health problems in Bangladesh. In every stream, different actors and factors played vital role to highlight the issue. Evidence is crucial to guide improvements in health systems and develop new initiatives.
In this connection state actors and non-sate actors create evidence for highlighting the importance of a policy problem or issues. In this study effort has been made to analyze the system of evidence creation and evidence dissemination. From the systems perspective, it is important to understand how research and knowledge from various sources are produced and synthesized. In addition, effort has also been made to investigate how the research findings were highlighted to strengthen the demand of good health services for community people.
These evidences revealed that maternal health situation and services have not reached to the satisfaction level. Situation of child health is still in an alarming condition for attaining national and international goals. Till now population problem is a big challenge for development of Bangladesh but evidence showed that there are human resource gaps in community level to offer proper services to the community people.
Cost of health services, absenteeism and distribution of health service providers in the community level were dominant factors which played vital role to highlight the community health situation as a problem. It was found that about 160 organizations and individuals took part in the agenda setting process of the health policy. Among the participants, NGOs presence was significant considering their number. A one may wonder why a significant number of NGOs took part in the agenda setting process.
The answer is a large number of NGOs are working in health sectors of Bangladesh whose mission is to highlight the common peoples’ rights and external support for doing policy advocacy. Majority of the participants’ expressed their personal, organizational or professional interest.. Health professionals from government side played significant role while creating evidences. In the absence of wide ranging government sponsored research these professional remained engaged in writing articles in journals and news papers. Due to contracting system of evidence creation, bureaucrats were guided or assisted y a number of consultants and their influences are decreasing nowadays.
Apart from the findings of the present study many previous studies showed that during unification of two wings of MoHFW (family planning and health) IMED created evidence to analyze the context. Research findings showed that bureaucrats who were influential during the period of 1996-2001 did not able to exert influence after 2000. It is mentioned that successive health secretaries were either explicitly against or remained passive over the unification process and community clinic program, resulting weak bureaucratic leadership within the ministry.
Among the professionals who are involved with party politics, DAB (Doctors Association Bangladesh, aligned with the BNP) and SCP (Shawdhinata Chikitshak Parishad, aligned with the Awami League) played influential roles in agenda setting health issues. In this study it is found that these members who are affiliated with SCP remained vocal from the very beginning of the policy process when Health Advisor of immediate past caretaker government (2008-09) initiated the process of health policy formulation.
Historical evidences showed that DAB had great influence in the agenda setting during the draft preparation in 2006. In case of NHP 2010, SCP played an important role in community related agenda setting since they are well connected with the Prime Minister and Health Minister. Medical professionals, particularly physicians, were in favor of the implementation of major reforms under the NHP 2000. Previous researchers found that support of the professionals for the two major elements of the NHP 2000 was reflected in the policy document prepared by the Bangladesh Medical Association (BMA) (BHW, 2010).
Donors provide financial supports during evidence creation. While offering financial support, donors imposed some conditions including methodology finalization and indicators setting which ultimately, influenced the process of making evidence based policy. In addition, donors suggested government to include NGOs in this process on the ground of GO-NGO collaboration or public-private partnerships. In the community health related evidence creation USAID, UNICEF and WHO played leading role since 2000.
Thus, it can be said that donors had great influence in evidence creations about community health issues. Of course, this is not new in the health sector of Bangladesh. In case of evidence creation for Sector Wide Approach introduction donor community provide guidance and financial supports for evidence creation. When compared to equivalent government operations, NGO services generally run more efficiently and cheaply keeping closer ties with communities. For this reason, donors often favor them as entry points to accessing communities in Bangladesh, especially since the 1980s.
In other words, NGOs become powerful and influential, especially because of their external sources of financial support, cooperation, and advocacy. In this regards, NGOs are considered as spokesman of donors. Civil society/NGOs are potential actors to highlight health rights and social welfare goals through mobilization of citizen demand. Through different activities NGOs emphasized on the decentralization as a means of localizing policy-making, bringing decision- making closer to disadvantaged groups, and encouraging local participation.
Also NGOs are playing roles of academics and professionals by monitoring and analyzing contextual factors. In this study we found that NGOs remained more or less equivalent in the creation of evidences. Bangladesh health watch was in the leading position to provide evidence for policy making Present Government and Health Strategy: According to the majority portion of respondent, the present government consists with a number of health professionals and they were very much enthusiastic to promote the health facilities issues for ensuring the health rights of community people of Bangladesh.
Also as a political party AL has commitment to the people to provide health services for the betterment of common people. Election Manifesto of AL in Election 2008 highlighted the health issues in the following way – “In order to ensure health facilities to every citizen of the country, the health policy of the erstwhile Awami League government will be reevaluated and adjusted according to the demands of the time. In the light of this policy, 18000 community clinics, established during Awami League rule, will be commissioned. ” [Source: Election Manifesto of AL in Election 2008]
Conclusion It can be said that proper evidence for highlighting the problem, stakeholders support in the solutions and strong political support highlighted the community health issues as issues to be considered in government actions. In evidence creation and conducting advocacy, NGOs who backed by the donors remained vocal. Top level bureaucrats also played their role with the help of consultants who were generally recommended by the donors. Finally, recognition of ruling political party played an important role in this regard.