Background: Following series of discussion during the first quarter of 2017, European Union supported SHARE (Strengthening Health, Applying Research Evidence) project of icddr,b has formed ‘Health Policy Dialogue’- a  Think Tank group involving eminent scientists, academicians, development thinkers and civil society members, who have  expertise and knowledge in the area of public health, human rights and development issues. The establishment of the Think Tank was an agreed outcome of the European Union supported SHARE project which aligns with the broader aims of evidence-informed health policy making in Bangladesh.

First event to mark the initiative: To launch this initiative, SHARE project of icddr,b organized a national level discussion event on ‘Achievements in Health Sector and People’s Expectation’ on 23 September 2017 at CIRDAP Auditorium where representatives from government stakeholders, academicians, researchers, community, health managers, mass media, NGOs, development partners, and civil society groups participated and developed recommendations. After formal introduction, Prof. Robaet Ferdaus of Dhaka University took moderator’s role. He started with propagating language in health issues to be easily communicated and understandable for wider audience.

Reflection from SDGs and peoples participation: Dr. Mushtuq Hussain, ex- Principal Scientific Officer of IEDCR and icddr,b consultant gave welcome remarks in the roundtable. He spoke about the constitutional duty of the government in public health and nutritional intervention. Based on the experience from MDGs, policy makers need to settle role in implementing SDGs which underscores the necessity of working with all- improved and developing countries to achieve the goals. No one should be deprived of health services, as Government is committed to ensure health equity and universal health coverage. It is noteworthy that with piloting scheme on universal health coverage in three upazilas of Tangail district, Government has set goals to ensure universal health coverage and quality health services by 2032.  It is important to ensure adequate drug supply for the people.  Private sector is also providing health services. Momentum should be created for marching forward with involving multiple stakeholders –government, private sector, NGOs and civil society. Dr Mushtuq remarked that newly formed think tank ‘Health Policy Dialogue’ would ensure civil society role in improving health services. He reminded of the achievements in health sector and the challenges health sector is facing. Dr Mushtuq ended with an urge to listen to opinions from different stakeholders and professional groups.

Agenda setting for Health Think Tank: In his welcome remarks, Prof. T.A. Chowdhury, Senior Consultant of BIRDEM and lead coordinator of Health Policy Dialogue narrated the background of the think tank initiatives which has started undertaking policy analysis on emerging health issues and organizing a series of dialogues for evidence-informed health policy process for improved health outcomes. Prof TA Choudhury explained the role and objectives of forming Health Policy Dialogue- a new think tank- first of its kind in health sector of Bangladesh. Drawing his experience in health sector for the last four decades, he talked about the success in reducing maternal and child mortality, vaccination programme and providing safe drinking water and hygienic sanitation for a large population in Bangladesh. He noted disappointing scenario of inadequate government expenditure in health sector of Bangladesh which is much lower than other countries. He further highlighted formidable challenges of low nutrition situation, high prevalence of non-communicable diseases and declining trust between physicians and patients. He called for collective efforts of health policy makers, service providers, stakeholders and mass people in improving health services. This health think tank will give a space for raising voices about health sector, sharing expectations and challenges and promoting policy recommendations. Besides ensuring quality health services, strong regulation is needed in private sector health service provider. Public-private partnership is another area emphasized by Prof TA Choudhury. He also gave importance on alternative medical care which exists for a large population in Bangladesh. Developing skill of these alternative health service providers deserves attended, Prof TA Choudhury commented.

Facilitating policy discussion: Ms. Catherine Spencer, icddr,b Communication Lead gave special remarks in the event highlighting icddr,b work with government and NGOs in conducting scientifique research and facilitating evidence-informed health policy making.  She expressed hope that Health Policy Dialogue will facilitate fruitful policy discussion between general people and health service providers. She expects this forum will be a platform for working together with national health experts, policy makers, mass media, researchers, private sector, citizens and other stakeholders.

Key presentation on challenges and expectations: In the keynote presentation, Dr. Iqbal Anwar, icddr,b Scientist and Project Director of the SHARE Project, explained the achievements in Bangladesh’s health sector in reducing maternal and neonatal mortality rate, population control and other maternal health indicators. He gave briefing on informal health sector, urban health services under local government division and private health sector. Dr. Iqbal also pinpointed inadequate budget allocation, shortage of human resources, inequity in health service delivery in hard-to-reach areas, prevalence of non-communicable diseases and high out of pocket expenditure of people as key challenges.

Human resource deserves attention:  Mr. Mashiul Alam, an eminent journalist from the daily Prothom Alo talked about uneven distribution of resources in sub urban and rural areas, unregulated private sector hospital and overdose of antibiotics. He identified lack of adequate human resources as a major problem in health services.  He urged the physicians to behave with empathy and care when any patient goes to them with expectation of getting good services. This should be a culture of health services if we want restore trust among the people, Mr. Mashiul said.

Social medicine and equal approach: Professor Jobaida Nasreen of Dhaka University referred under-served population like sex workers who deserve equal treatment from doctors, though it does not happen in real scenario. While treating a patient, his or her local practices or behavior should be taken in to consideration.  She shared the idea of social medicine integration of social determinants in health policy to develop a comprehensive health care system. Ms. Fauzia Islam, a documentary maker discussed gender friendly approach in health services. She addressed the issue equity and professionalism for ensuring quality health services and promoting female participation in decision making for taking family planning method. Dr. Fariha Haseen, Assistant Professor of BSMMU stressed significance on holistic approach in health services where gender mainstreaming should be adequately addressed in health services and academic curriculum will be modified as per changing context. Increasing number of female doctors is also a good progress, she mentioned. She suggested inviting more public health students, medical students and paramedics practitioners in such health dialogue. Citing success stories in health sector, Dr Fariha gave importance on building more researchers in health sector and including social science elements in curriculum so that challenges in health sector can be addressed appropriately.

Services targeting under-served and hard-to-reach: Dr. Mahmud Rashid, UHFPO of Monpura Health Complex shared his experience how sincerity, dedication and peoples trust can bring positive changes in health services in hard-to-reach areas like Monpura, one of the remoted islands in Bangladesh. He suggested strengthening people participation in improving health services and conducting relevant research on quality health services. Mr. Sanjib Drong, a civil society leader on tribal people’s rights mentioned how constitutions and national health policy have given emphasize on serving under-served and hard-to-reach areas. He suggested involving under-served people like laborers, tribal population, people living in hard-to-reach areas in policy dialogues so that real scenario can be showcased in policy level. ‘We often take pride in reaching MDG goals in reducing maternal and child mortality, but as a matter of regret, our studies or statistics does not include any disaggregated data on health service and health indicators for tribal population or people living in remote areas in Chittagong Hill Tracts or char areas’ he commented. Mentioning current trend of punishment posting in remote areas, he urged for deploying best doctors and special allocation for hard-to-reach areas with a view to improving health services of the under-served population living there.

Reconstructing system needed: Mr Arup Rahi, a civil society representative said that health system is not a separate issue from state system. When top down development model dominates in capitalist system, it will be difficult to develop pro-people health services. A democratic and inclusive system is imperative where more entrepreneurs will be encouraged in health sector in a field of fair competition.  A social and political re-construction is needed for developing good health system. Donor driven agenda or westernized approach can do little change in health system, as he cautioned.

Young voices’ call: Some young voices were represented in the event. Ms Tanzina Hossain, a student of Dhaka University talked about building healthy behavior and health food culture from the childhood. She gave importance on mass media role in this regard. Two MPH students talked about patients satisfaction, inadequate time and care dedicated by physicians and behavioral problem of physicians. Dr. Tarek Mahmud- a young medical officer from Jamalpur Sadar hospital shared inadequate career development opportunities of government doctors in comparison to other administrative cadres. He talked about political pressure on doctors, lack of maintenance of hospital machineries and budget allocation in maintenance.


Focus of strong health system: Drawing comparative advantage of demographic dividend due to big number of working age group of 15-64, Professor Mainul Islam of Population Science Dept from University of Dhaka emphasized on investing more on social capital like health and education, and providing adequate health services to urban poor or slum dwellers and bringing coordination between service providing ministries.  He also talked about establishing consistency between national health policy and national population policy while setting health targets. ‘We need to do research how Cuba has built strong health system despite its limited economic resource’, Professor Islam said during sharing good practices in health service model.

Best practices on community participation: Mr. Saidul Karim Mintu, Jhenaidah Municipality Mayor said that effective health service and hospital management require local support and participation. Public health and hospital services and resources are inadequate to serve the need specially for the poor. This gap can be minimized through local participation. He shared how local administration in  Jhenaidah, teachers, lawyer, businessmen, cultural activists, representatives of local political party and different professional representatives are working closely with community support group for health services in Jhenaidah. He urged to remove evil politicization of doctor’s association and health sector to get better health system. Ill-motive prescription for unnecessary diagnosis is another area which requires corrective step.

Politicization as an obstacle: Mr. Shishir Moral, eminent journalist and Prothom Alo correspondent urged to stop administrative appointment in health sector based on political allegiance. He thinks mass people and health sector managers have lack of understanding on good health services and service indicators. High out of pocket expenditure of people and social requirement of health should be addressed properly while designing health services. In Bangladesh, currently, there is no functional Think Tank in the area of health that is actively engaged to identify gaps in health service provision by both public and private sectors. It is National Parliament where policy discussion on health issues should have taken place. This think tank can fill up the gap and play a good role in health policy analysis, Shishir Moral commented with optimistic tone.

Cancer treatment to be decentralized: Dr Habibullah Talukdar Raskin, Associate Professor of National Cancer Institute and Research Centre discussed about high prevalence of non-communicable diseases with special focus on cancer.  He recommended comprehensive cancer treatment in all divisional cities in a decentralized manner.  Pointing out the existence of Cancer dept in 15 govt medical colleges where teachers recruitment and radio therapy machine installation have long been a pending issues. He also requested to revert preventive part of cancer epidemiology curriculum to impart awareness issues in cancer treatment.

Citizen charter and monitoring on health services: Dr. Md Shah Newaj, Additional Director General of Drug Administration asked for giving attention on health citizen charter which is applicable to service providers and service recipients also. Govt should initiate strict monitoring on private sector hospitals and clinics who are charging illogically high for providing health services. Frequent changes in senior officials of health sector and inadequate number of health workers are two obstacles, Dr Newaj identified in his remarks.

Equitable access to resources and services: Prof. M A Faiz highlighted urgency of developing quality health work force for 21st century. In Bangladesh, policy making process is almost centralized, non-inclusive and lack policy-relevant research.  He desired for solid institutional efforts from organizations like icddr,b for health system strengthening. Md. Masum Talukder, a business Consultant said that with a view to improve peoples health, government need to ensure equitable access to food, nutrition, safe water and sanitation. Govt must give attention to primary health care, preventive care, universal health coverage and increasing GDP allocation in health sector, he remarked.

Several focused areas for think tank:  Dr Abbas Bhuiyan, ex-icddr,b Director appreciated think tank initiative and requested think tank members to promote health evidences and learn evidences from mass people. He suggested more focused discussion which should be organized periodically with fruitful participation from relevant stakeholders. Prof Liakat Ali Vice Chancellor of BUHS said that think tank should discuss economic policy and political principle which determine health sector. Expensive health services of private sector compel people to rethink whether health is services or products. It is important to determine State responsibility in providing health services for people and State regulation in private sector. Increasing out of pocket health expenditure is real concern for Bangladeshi people. To tackle NCDs, more attention is needed in preventive care where private sector does not have visible role, he commented.

Collective responsibility: Prof. Ismail Hossain Khan, Principal of Dhaka Medical College (??)referred to ‘committing all for health’ in the spirit of SDGs and reminded of collective responsibility for developing desired health services. He also emphasized on developing high quality health education and allocating more budget in health sector. Ex-Health Secretary, Mr. Humayun Kabir pointed out the urgency of systemic preparedness to address health challenges like lack of resources, prevalence of NCDs, high out of pocket expenditure etc. He commented that developing health system exhibits necessity of holistic approach where community voices should be taken into consideration and a model of community participation should be developed accordingly.

Inclusive health systems: Mr. Ashadul Islam, DG of Health Economic Unit gracefully summarized key discussion points. He shed lights on people’s empowerment through ensuring community participation in health services and making the health system more inclusive. Be in service providing role or regulatory role, government must give attention in quality health services issues as echoed from different corners of the roundtable. He urged academicians and researchers to dedicate more efforts in strengthening health systems and these efforts should avoid traditional trend of over- reliance on donor fund in any way.

Way forward: In closing remarks, prof TA Choudhury gave thanks to all participants for their lively discussion and recommendations. He informed that think tank would continue this health discussion where physicians, scientists, researchers, medical students, health workers, pharmacists, nurses and support staff will be invited to share their ideas. He further added, ‘We also need work more to develop community based health services. We would like to give thanks to Dr. Iqbal Anwar ad his team for this initiative. We hope this will not be donor dependent initiative. This think tank will initiate more data driven and evidence based discussed on different public health issues in focused manner so that we can get solid recommendations.’ Unavailability of drugs and commodities have been a constant problem as identified in the discussion. Restructuring health system should go through profound changes like up-to-date health education, community participation, evidences etc. Lack of Community involvement and behavior of health professionals have been a much-talked issue in the dialogue. Health think tank should analyze and disseminate evidences to facilitate decision-making. Discussants have addressed health resources which are heavily concentrated in urban areas where rural people are facing inaccessibility to essential health care services. Experts referred to constitutional responsibility of Government of Bangladesh in improving health and nutritional status of the people.

Health dialogue at CIRDAP auditorium demonstrated urgency to improve both the public and private health sectors of Bangladesh. It has fairly addressed different challenges health sector currently facing. Evidences should be analyzed and disseminated systematically to the appropriate authority to facilitate decision-making, as emphasized in the dialogue. Only collecting raw data is not enough; those data must be managed, analyzed and disseminated systematically to the appropriate authority to facilitate decision-making. It was expected from different corners in the health dialogue that newly formed think tank would continue process of reviewing emerging best practices and innovative approaches of health sector to achieve impact, facilitate research-policy communication and attribute to a better understanding of what is needed to bring enabling policy environment in the area of Health in Bangladesh. This was the ultimate notion of urgency felt in the first event under think tank initiative, as expected.