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Bishwajit Mazumder

Nursing Instructor
Dhaka Nursing College, Dhaka
E. mail: mbishwa@rocketmail.com


The constitutional commitment of the Government of Bangladesh is to provide
basic healthand medical requirements to all people in the society. The Constitution of
the PeoplesRepublic of Bangladesh ensured that Health is the basic right of every
citizen of theRepublic, as health is fundamental to human development. Bangladesh
is committed to achieving the millennium development goals (MDGs) by 2015 and
has been pursuing various programs to translate the MDGs into reality.
Bangladesh has a health system which is dominated by the public sector and
the private sector is run by local entrepreneurs, different NGOs and international
organizations. In public sector, The Ministry of Health and Family Welfare is the
leading organization for policy formulating, planning and decision making at macro
and micro level. Under the ministry four Directorates e.g. Directorate General of
Health Services, Directorate General of Family Planning, Directorate of Nursing
Services and Directorate General of Drug Administration are providing health
services to the citizens.
Non Government Organizations (NGOs) are significant and growing sources
of HNP services in both rural and urban Bangladesh . Their services have mainly been
in the areas of family planning and MCH. More recently, NGOs have extended their
range of services and are now the major providers of urban primary care.


According to the World Health Organization, the goal of health care systems
are good health, responsiveness to the expectations of the population, and fair
financial contribution. The vital function of the system depends on progress towards
the system such asprovision of health care services, resource generation, financing,
and stewardship. Other dimensions for the evaluation of health systems include
quality, efficiency, acceptability, and equity. They have also been described in the
United States as "the five C's": Cost, Coverage, Consistency, Complexity, and
Chronic Illness. Also, continuity of health care is a major goal.

Health care system:

A health system consists of all organizations, people and actions whose
primary intent is to promote, restore or maintain health. In short, it is the
infrastructure through which the desired services to the intended population are
delivered. Home care of a sick baby, health care in private sectors, behavior change
programs, vector-control campaigns, health insurance and financing are all integral
part of the system. It includes inter-sectorial actions through comprehensive approach
to ensure family, community and country health. Health service delivery, workforce,
information, products, financing and stewardship are the six building blocks for
strengthening of the health system in a country. The health care system of Bangladesh
depends on current status and future challenges can be conceptualized within the
gamut of the six building blocks.

Health Service Delivery

The significant progress in health outcomes has made in Bangladesh. The
country has made important gains in providing primary health care and most of the
health indicators show steady gains and the health status of the population has
improved. Health services are provided both through public and private sectors. The
public sector is largely used for out-patient, in-patient and preventive care, while the
private sector is used largely for outpatient and in-patient curative care. In
Bangladesh, the Ministry of Health and Family Welfare (MoHFW) is responsible for
planning and management of curative preventive as well as promotes health services
to the population. But in urban areas, delivery of health services including Primary

PHC services is mandated to the Ministry of Local Government, Rural Development

and Cooperatives (MoLGRD&C).
There are many steps has taken by the present government to revitalize PHC
services by making the community clinics operational. These are the community
clinics, one for every 6000 rural populations, were constructed in 2000-2001; but the
previous governments were not used for service delivery.There are some unique
characteristics of these service point. The local public leader and representatives are
managed by a Community Clinic. The policy in this regard is to place the
responsibility for the health of the people in the hands of the people themselves. A
quick assessment of the community clinics, supported by WHO in 2009, showed that
with the expansion of the health-care facilities to the peripheral level the distribution
of health-care inputs and their utilization became more equitable and the utilization
rate of these facilities was almost universal.
The running community clinics with adequate staff, supplies and logistics
along with strengthened union and upazila level services is to improve the delivery of
preventive and curative services at the PHC level, particularly for vulnerable women,
children and particularly old men.In the public sector, the primary and secondary
levels of treatment are providing curative care in Upazila health complexes, and
district hospital. National and divisional level hospitals are provided tertiary- level of
curative care. While curative, preventive, primitive and rehabilitative services are
rendered by public sector facilities and institutions, the private sector facilities, now
gradually taking a big share of services at all levels, are mostly providing for-profit
curative services.
In spite of availability of all those services at different levels, utilization of the
services by the population is comparatively low. Improvement of the access of the
population, the government maintain quality services and increase responsiveness of
the service delivery system to the needs and demands of the population.

Health Workforce
There are 59 Medical colleges (41 of them are private), 13 nursing colleges (7
of them are private), 69 nursing institute (22 of them are private), 17 medical assistant
training schools (10 of them are private), and 16 institute of health technology (13 of
them are private).The nation of Bangladesh has managed to develop wide network of
medical college, nursing college, nursing institute and paramedical institutes. In spite
of this growth to health workforce production, the country is still having health
workforce shortage and geographical imbalances.

Health Information
Significant initiatives of present government has taken for improvement of the
MIS at all levels for enabling the system to deliver timely reliable information to the
planners, managers and professionals of the health sector for evidence-based decision
making. Health bulletin is published in regularly and timely, collected and storage
system of modernize data, publication of health information system (MIS),
assessment report using Health Metric Network HMN) assessment tools are few
examples of recent initiatives of the government to improve Health Information
System (HIS) in the country.

Health Financing
There are about 3% of GDP is spent on health, out of which the government of
Bangladesh contribution is about 1.1%. In term of dollar, the total health expenditure
in the country is about US$ 12 per capita per annum, of which the public health
expenditure is only around US$ 4 only.

Health Stewardship
The government has taken many steps to improve its leadership and regulatory
role to improve equity and quality of services, especially to reach the poor and the
disadvantaged. Initiatives for development of new health policy, revitalization of

primary health care by making all community clinics functional with required human
resource, supplies and logistics, recruitment and appropriate deployment of human
resource for health and gradual extension of e-health services to the rural area.

The public sector: upazila health Complex and District Hospitals

The public health sector of Bangladesh is based on a number of tiers of health
care delivery. The lowest administrative tier in Bangladesh is the union, which
consists of around approximately 20 villages. The only health care available at the
union level in Bangladesh consists of a number of Health and Family Welfare Centers
for the provision of outpatient services. In 2000, out of 4,484 unions in Bangladesh,
4,062 were covered by centers. Of these 4,062 centers, 2,700 were primarily
concerned with the delivery of family planning services, and 1,362 were primarily
rural dispensaries.
The government focuses on health care delivery plan has been on the next
administrative tier above the union. This is the upazila, which consists on average of
20 unions. The governments policy has been to implement a nationwide health
program based on the provision of primary health care (PHC) services at the upazila
level. Successive governments have committed themselves to establishing health
complexes in every upazila.
The aim of the Upazila Health Complex is to ensure that primary health care
services are accessible for the entire rural population. But out of the 507 upazilas in
Bangladesh, by 2000 only 374 had a completed health complex. Each of these
complexes is intended to provide specialized facilities for medicine, surgery,
genecology, anesthesia, and dentistry. In addition, they are supposed to have an
adequate supply of essential drugs and vaccines.
For the vast majority of Bangladeshs population an Upazila Health Complex
is their first point of contact with formal public sector primary health care. But with a
very low level of public spending on health, the quality of services available in the
Upazila Health Complexes is not very high.

The next tier of public sector health care is located at the district level where
each of Bangladeshs 64 districts can now provide modern hospitals with a bed
capacity ranging from 50 to 200 patients. There is a government program to increase
the bed capacity in many of these hospitals to 250 beds. It is estimated that by 2000,
there were 34,786 hospital beds in district hospitals, giving a bedpopulation ratio of
approximately 1:3,450. The zila or distric hospitals are better equipped than the
upazila health complexes, and cases that are more serious are referred to this level.
In contrast to the primary health care system available in rural areas, there is
very limited availability of public sector primary health care in the urban areas to
service the urban poor. But urban areas also have big public hospitals where serious
cases from rural areas are referred in addition to serious cases from urban areas.


provision of primary health care in the urban areas is a gap that needs to be addressed,
and the solution lies either in a partnership-based approach with NGOs and the
private sector or in the development of an urban network of public sector primary
health care provision.
The big public hospitals in the cities, and particularly in the capital Dhaka, are
the apex of the public health system and serve as teaching hospitals where the next
generation of doctors are trained. Although the quality of equipment is often very
poor, as is the supply of medicines, many of the best doctors in Bangladesh are still to
be found in the big public teaching hospitals.

Involvement of NGOs in health service delivery

The role of NGO in the private sector in Bangladesh includes both the private
health clinics and hospitals but provides different types of health services, mostly to
the poor. The NGOs are financed by charities, usually international charities, and this
sometimes means they can pay their staff more than the public sector, and have access
to medicines and other requirements for delivering health services. The NGO sector
has grown in Bangladesh because of the limitations that the government has in raising
taxes and making money available to the public sector. The lack of resources in the

public sector has meant that the access to health services for poor people has not been
satisfactory in the past, and this has justified the entry of NGOs into the health sector.
Unless Bangladesh can develop its own public sector health system based on
taxes it can collect within Bangladesh, the provision of health care across the country
will remain patchy and vulnerable to the changing funding decisions of international
donors and charities.
The work of the Bangladesh Rural Advancement Committee (BRAC)
highlights the nature of the interventions made by the NGOs. They started their
interventions in health care in 1979, in collaboration with the International Centre for
Diarrhea Disease Research Bangladesh (ICDDR,B), to provide oral rehydration
solutions (ORS) to prevent deaths from diarrhea. The idea was to teach households to
treat diarrhea with oral rehydration solutions that could easily be made up at home.
These programs were very successful in reducing mortality and became
internationally recognized as successful innovations in health care in developing

Health Systems Strengthening

According to the World Health Organization, health systems strengthening can be
defined as

the process of identifying and implementing the changes in policy and

practice in a countrys health system such that the country can respond


better to its health and health system challenges and

(ii) any array of initiatives and strategies that improves one or more of the
functions of the health system and that leads to better health through
improvements in access, coverage, quality, or efficiency.

URC uses a health systems approach, emphasizing a systematic, evidence-based

approach designed to bring about significant improvement in:

Patient and population health outcomes, particularly among the poor;

Efficiency and effectiveness of systems and processes of care; and

Social responsiveness and accountability.
In 2002, the total spending on health in Bangladesh was 3.1% of Bangladeshs

total GDP (gross domestic product). But public health spending was only 0.8% of
GDP, the remaining 2.3% of GDP being accounted for by private health care
provision. Thus, public sector health spending was only about 25% of total spending
on health. In addition, the total spent on health is small because Bangladeshs per
capita GDP is not very high. In per capita terms, in 2002, Bangladesh spent only
US$11 per head on health, which means that each individual in Bangladesh on
average only had $11 to cover all their health needs.
The low level of health spending and the growing share of the private sector
raise important questions about whether the emerging health sector in a country like
Bangladesh can address the constitutional right of all its citizens to access health care.
We can also ask whether these developments are appropriate for ensuring a healthy
workforce that can contribute to the rapid development of the economy. On the other
hand, there is no doubt that the public sector was not well funded, that the quality of
health care delivery was often poor. Therefore, the growth of private hospitals and
clinics has at least improved health care for those who can pay for these services.
Parallel to the development of the private sector clinics, there has also been a
growth of NGOs (non-governmental organizations) providing health care to the poor.
NGOs are classified as part of the private sector, but they are funded by international
donors and local charities, and therefore have characteristics of the public sector. But
their coverage is still limited and their future depends on the continued availability of
funding from these sources, primarily international donors.
Finally, we have to note that the public sector health care system in
Bangladesh has had some notable successes, particularly in expanding immunization
and fighting diarrhoeal diseases and epidemic control, and in family planning. These
areas are not suited for private sector development at all, and here Bangladesh can be

proud of a relatively good public sector performance on which it has to build on in the

Disease control and ways of improving quality of life:

An important aspect of health care in developing countries is control of easily
preventable diseases that would not be widely seen in advanced countries. This is
because in poor countries the health of the population is adversely affected by other
factors such as poor nutrition, poor sanitation, poor hygiene, as well as health care
failings such as poor immunization and treatment. Thus, while improvements in
immunization and treatment are critical, in other areas health care has to deal with
problems that are not directly due to the health care systems but are due to other
factors such as poor quality water and sanitation.
In these cases, the health care system has to respond by tackling with problems
such as diarrhea and malaria, which will remain recurrent because of these other
factors. The quality of life improvements in developing countries thus depends on the
health care system contributing to both disease control and related factors such as
nutrition, water quality, and hygiene.

Future vision:
The government has formulated a perspective plan keeping in view the needs
of the health sector for the future. The formulation of a national health policy would
provide strategy directives on major health issues. The future vision for the health
sector would include universal access to basic healthcare and services of acceptable
quality; improvement in medical education; improvement of nursing education;
improvement in nutritional status, particularly of mothers and children; prevention
and control of major communicable and non-communicable diseases; strengthening
planning and management capabilities; improvement in logistics of
production/procurement, supply and distribution of essential drugs, vaccines and other
diagnostics and therapeutic equipment; increase in overall life expectancy of the
population; survival and healthy development of children; the health and well being of

women; protection and preservation of the environment; disability reduction; and the
adoption and maintenance of healthy lifestyles.

Nursing resources management Bangladesh:

Bangladesh offers public and private health care . Common to both sectors are
the nurses who act as a front line work force in delivery health care services. Nurses
are the main professional component of the front line staff in most health systems,
and their contribution is recognized as essential to meeting development goals and
delivering safe and effective care. Both act of focal points where sickness or disease
are fought. On the front line stands nurses who serves as the backbone of health care
sector . Nurses in Bangladesh face unique challenges, both professional and societal ,
that impact their workand how health care service are delivered to the patients.
Abetter understanding of the nursing profession in Bangladesh will allow for
improvement to their position that will ultimately have beneficial impacts on the
delivery of health care to the public.
Nurses in health care system: In Bangladesh , the national nursing g
curriculais the responsibility of Bangladesh nursing council(BNC). Acting in
conjunction the University of Dhaka, the BNC Determines the knowledge nurses
need, how they should be trained , what values nurses should uphold. The curricula
was last updated in 2006 citing concern that the 1991 curricula did not properly
develop client and community oriented nurses, and that discrepancies existed between
what was taught in nursing institutions and what was practiced in hospital ( BNC
2007). The first step becoming a nurse in Bangladesh is to passsecondary high
school certificate and higher secondary certificate examwith a focus on science and
biology. After passing these exam, a student can apply to any of the 51 public nursing
instituteor 19 private nursing institutionsin the country(Khan et al.2008).
Once accepted four years nursing education followed by comprehensive BNC
licenseexam .Cost of education vary between institutions to institutions. Completing
four years nursing education IUBAT comesat a cost of tk 2.56 lakh( IUBAT
2005).The ministry of education subsidesmuch of cost to individual seeking training
of the public sector. The Bangladesh nursing council, which is associated the

University of Dhaka, offers subsides to students but applies much higher admission
requirements. Cost of individual seeking nurse training at private institutionsbear cost
privately , but they can offset these cost through scholarships or rebates based on their
HSC performance . A nurse practice legally in Bangladesh only after passing the
listening examand registering with BNC.

Currently, the number of licensed nurse

in the country in 23,8093(Khan et al2008).

The curricula emphasizes professionalism and competencies , adaptability,
awareness of human behavior and attempts to improve nursing quality. The BNC has
also directed that entire curricula to be taught in English, using Bangla as a
supplementary language, since no modern nursing text book are available in Bangla
and English is now the international languagefor professional
development(Berland2007,2). Using English as the primary language of nursing
instruction has provided difficult. Regardless of the barrier English creates for some
nurse, the BNC confident thatthis new curricula will improve nursing servicein
Bangladesh and that any students who complete bachelor degree program me will be
a complete professional nurse who can demonstrate the competency of using
knowledge based practice for provision of holistic, client centered quality nursing and
midwifery care to meet needs and expectations and to promote , maintainand restore
health individuals, families, and communities in common , simple and complex
healthproblemssituations( BNC 2007, 3).
The BNCcurricula is intended to produce nurses who can practice
competently. Education and training does not end with completion of a nursing degree
. The nurses job requires practicumsand refresher training at regular intervals
following graduation. Pearsonand Peels(2001) examined major challenge s nurses
face around the globe. The increase number of nurses is subject to uncertainly.
Currently, as estimated 2280 students are admitted into nursing programs each year
with an average annual graduation rate of 1200(Khan et al.,2008). The expansion of
nursing demand of private sector health service may help to increase the professions
prestigeand indirectly increase nursing supply, nurse in both public and private sectors
over the next 20 yearsrange from high of 68125, a medium estimate of 44625 and low
of 27600(Khan at et al 200

Minister of

Secretary of
Minister of

Director of Nursing

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Autonomous from Government

Structure of Nursing in Bangladesh

The constitution of Bangladesh clearly stipulates securing for its citizens
.the provision of the basic necessities of life, including food, clothing,
shelter, education and medical care. All governments have recognized the
importance of improving health care provision in Bangladesh and have
pledged to ensure that there is universal access to essential health of an
adequate quality for all its citizens. Health care in a developing country raises
a number of important issues and debates. Access to health care is a
fundamental right in itself, as the constitution of Bangladesh recognizes.
Therefore, as an end in itself, the government has to ensure that the quality of
health care improves over time. The health of a societys citizens is critical for
the performance of the economy and the capacity of the economy to compete
internationally. Therefore, health care is also a means for achieving the
broader development goals of the country.




5. WHO country co-operation strategy 2008-2013, Bangladesh

6. Zaph P.D, Curing what alls you: Improving health care delivery in
Bangladesh through nursing policy 2009( p- 3,6,11,14)

3.Health Care System

Health service delivery

Health work force
Health information
Health financing
Health stewardship

4.The public sector: Upazila Health Complex and Districts Hospital

5.Involvement of NGO (Non-Governmental Organization) in health
service delivery
6.Health Strengthening system
7.Disease control and ways of improving quality life
8. Future vision
9. Nursing resource management in Bangladesh
10. Conclusion


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External links

World Health Organization: Health Systems

HRC/Eldis Health Systems Resource Guide research and other resources on

health systems in developing countries

OECD: Health policies, a list of latest publications by OECD

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