Muddling through: limitations and challenges of the health policy process in Bangladesh

Abstract

This article is an attempt to analyse health-related policies in Bangladesh in the light of the policy cycle. It explores how health policies have been developed and implemented in the specific Bangladeshi context. Formulating a comprehensive health policy has been difficult despite several trials and experiments. Generally, a highly centralized top-down approach has been followed with the policy process conditioned by partisanism, bureaucratization and non-participation. The influence of internal and external forces in agenda setting has been apparent and prioritizing of policy options has happened without adequate research and analyses. The failure to effectively implement policies has been due to absence of sincere political will, resistance of different professional and pressure groups, mal-coordination among implementing agencies and inadequacy of policy evaluation and impact assessment. These factors create obstacles toward adopting an integrated holistic national health policy with proper strategies for implementation.

Keywords:

• health policy
• policy process
• Bangladesh

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. World Health Organisation (WHO), United Nations Population Fund (UNFPA), United Nations International Children Emergency Fund (UNICEF), USAID, AUSAID, the UK Development Fund (DFID), World Bank, Asian Development Bank, Japan Fund (JAICA), etc.

2. Bangladesh Medical Association (BMA), National Anti-Tuberculosis Association, Bangladesh Association of Voluntary Sterilisation, Bangladesh Family Planning Association, Bangladesh Red Cross, Obstetrical and Gynecological Society of Bangladesh (OGSB), Bangladesh Nurse Association.

3. International Centre for Diarrhoea Disease Research of Bangladesh (ICDDRB), Bangladesh Rural Advancement Committee, National Institute of Population Research and Training (NIPORT), National Institute of Preventive and Social Medicine (NIPSOM) and different centres of various universities.

4. Centre for Policy Dialogue, Bangladesh Institute of Development Studies, Transparency International of Bangladesh and different print and electronic media.

5. In collaboration with the World Bank and other international agencies, Bangladesh executed many projects/programs during the Fourth Five Year Plan period (1990/1991–1994/1995).

6. The HPSP is a constellation of different ideas or themes discussed in different forums in different times. For instance, the ICPD, the country-assistance strategy of the World Bank and the donor-led HPSS of 1997 entirely influenced the generating of this idea. The main aims were to bring revolutionary change in health system management and health service provision (Osman 2005).

7. Apparently, several policies were initiated under donor influence. These included: the First Population Project (1975–1982), Second Population and Family Health Project (1979–1985), Third Population and Family Health Project (1986–1992), FHPP (1992–1998), Bangladesh Integrated Nutrition Project (1996–2002), HPSP (1998–2005), National Nutrition Project (2000–2005), HIV/AIDS Prevention Project (2001–2006), HNPSP (2003–2010), HPNSDP (2011–2016) (Daily-Star, 24 August 2011).

8. In general, the policy cycle encompasses the following phases: problem definition; agenda setting; policy formulation; policy adoption; policy implementation and policy evaluation.

9. The government and donors are the primary sources of health care financing (Miller 2001). Bangladesh spends less compared with other developing South Asian countries. For instance, Bangladesh spent less than 3% of its GDP on the health sector, while India, Nepal and Sri Lanka spent 5.0, 5.8 and 4.1% of GDP respectively in 2005 (Islam 2009). The public sector contributed 26% of the Total Health Expenditure (THE), while the contribution of development partners and household in the THE was 8 and 64%, respectively in 2006–2007 (DGHS 2011). Thirty-five per cent expenditure of MOHFW is borne by 31 bilateral and multilateral organizations (Schurmann and Mahmud 2009). The donor’s financial contribution in the newly approved HPNSDP is around more than 35% (Daily-Star, 24 August 2011).

10. Policy instruments are ‘techniques of control’ used to achieve desired policy goals (Anderson 2011, p. 242). Howlett et al. (2009, p. 117–35) distinguish between information-based instruments (public awareness campaigns, suasion, performance indicators, public inquiries), authority-based instruments (command/control regulation, delegated regulation, advisory bodies), treasure-based instruments (subsidies, taxes, advocacy funding) and organization-based instruments (direct provision, public enterprises, partnerships, community organizations, structural reorganization). Key instruments applicable in the implementation of health policy include capacity building (developing skills), system change (transferring authority to the private sector or public–private partnerships) and suasion (influencing preferences of clients).

11. In one instance, consultations with national and international agencies, NGOs, professional medical associations and research institutes took place before formulating the National Anaemia Strategy of 2006 (IPHN 2007).