The world has been grappling with the deadliest pandemic of the century, and Bangladesh is badly affected. As of December 05, 2020, some 475,879 cases (#24 in the world) have been identified with a death toll of 6,807 (#33 in the world) and one of the lowest rate of tests per million (15,863) in the world and the second-lowest among its South Asian neighbours (only above Afghanistan). The Health System of Bangladesh has been suffering from a shortage of budget, high out-of-pocket expenditure, an absolute and relative deficiency of human resources, skill-mix imbalance among health service providers, lack of quality services, unregulated private sector, and a highly centralised secondary and tertiary care, only waiting to be blatantly exposed by the COVID-19 pandemic situation. In addition to the existing health systems weaknesses, few others became evident throughout the progression of the pandemic, namely, lack of preparation, coordination, leadership invoking a generalised negative perception, lack of trust and suspicions about the health system at large.
Bangladesh has been caught off-guard by the Covid-19 pandemic, mainly due to its historical negligence towards a public health system and related public health education. While both the curative and the preventive health experts concur on the importance of public health measures to address the pandemic and other disease outbreaks, the health system, and the collective public psyche are oriented only towards a curative approach to health. The common people, journalists, policymakers, and even many health professionals consider the clinicians to be the sole representative and the torchbearers of the health sector. The government's health cadre, recruited through the Bangladesh Civil Service (BCS), does not recognise the promotive and preventive health services in its recruitment rules, deployment, and promotion norms. The BCS does not prioritise anyone with an advanced degree in public health even in the primarily public health positions, such as the Upazila Health and Family Planning Officer (UH&FPO), Civil Surgeon (CS), Directors, and other high administrative positions in the Directorate General of Health Services (DGHS), let alone the Ministry of Health and Family Welfare (MoHFW).
While the pandemic cried need for a central as well as a local level public health response by trained public health professionals through a well-developed public health track, such a response could not be ensured due to the non-existence of a public health track in the health sector of Bangladesh. Negligence towards a much-needed science-based public health response was also evident in the composition of the National Technical Advisory Committee (NTAC). Bangladesh formed the 17-member NTAC on April 19 2020, more than a month after the first Covid-19 case detection and death in the country. Until then, most of the pandemic control actions were taken by the bureaucrats or administrators, many of whom lacked expertise or experience in health, let alone pandemic management. Even the NTAC was devoid of adequate public health representation; among the 17-member committee, only three has a public health career track. On April 21, the government announced assigning 64 top bureaucrats to supervise and coordinate relief distribution activities in 64 districts of Bangladesh, ignoring the public health professionals in providing technical leadership for pandemic control.
Why, then, the public health professionals, including epidemiologists, whose, as the name of the discipline clearly suggests, prime professional activity is managing epidemics or pandemics, are ignored in managing the deadliest pandemic of the century? The answer may lie in a policy analysis that I conducted for BRAC James P Grant School of Public Health in 2013. The policy analysis focused on three health policy areas, including the career development pathways of the health workers within the government health sector of Bangladesh. Examining the relevant policy documents, it was realised that the Bangladesh Civil Service or BCS (health) Recruitment Rule of 1981 does not explicitly mention anything about the different tracks under BCS (health) cadre; however, by practice, the jobs under this cadre can be classified roughly into three amorphous and often indistinct tracks: 1) General Health Service, 2) Medical Teaching, and 3) Health Administration. Another relevant policy document is the Gazette Notification on Transfer and Posting Policy for Officers in Health Service 2008, which has a provision of providing training and access to higher education. Still, this document also does not clearly explain the definitive pathway for the health workforce's career development. It was further surprising to find that according to the Public Service Commission (PSC) job circular, only the doctors with a Bachelor of Medicine and Bachelor of Surgery (MBBS) degree (or equivalent) are recruited as officers in BCS (health) cadre. There is little provision for recruiting or leveraging applicants with additional training in allied health disciplines (e.g., public health, health systems management, health administration, etc.), especially under the DGHS.
A fundamental principle of career development is that anybody entering a cadre service must have the scope to climb up to the highest level. But this principle is not adhered to in the health service cadre of Bangladesh. After being recruited through the BCS examination of PSC, doctors undergo foundation training with other civil servants. Only after serving the government at the entry-level post (known as Medical Officers or Assistant Surgeons) for five years and obtaining a higher degree, doctors can choose one of the three tracks. The career tracks being intensely porous, the migration from one track to another at various career stages is also common. Track changes are most common between Medical Education and General Health Services tracks. Doctors traditionally fill up the highest posts of DGHS through lateral migration from either Medical Education or General Health Service tracks, usually not by vertical promotion within the Health Administration track itself.
On top of it, the MoHFW posts are rarely filled-up by the employees from any of the health cadre tracks. Running the ministry requires solid administrative skills, management knowledge, leadership capabilities, which arguably cannot be managed on a makeshift basis by untrained professionals. Due to the existing recruitment policy, MoHFW allegedly never finds adequate staff with the required qualifications to run the ministry. The Secretary of Health, the supreme administrator of MoHFW, is almost always borrowed from other BCS cadre services than the Health. This person, who comes to this vital position, usually never has experience working in the health sector, nor does he have any formal training in public health or health systems management or leadership.
Contrary to Bangladesh, another South Asian Country, Sri Lanka, with a similar colonial history of health service development process, incorporated public health or a preventive service as one of their health service delivery backbones. Any new recruit in the Sri Lankan health service has to choose either of the two tracks, namely: A. Curative Healthcare Institutions, which include National Hospital, Teaching Hospitals, Provincial General Hospitals, District General Hospitals, Base Hospitals, Divisional Hospitals (unlike Bangladesh, Divisions in Sri Lanka are much smaller administrative units, comparable to Unions or Wards of Bangladesh) and Primary Medical Care Units; and B. Preventive Healthcare Institutions, which include 338 centres overseen by a Medical Officer of Health, who is responsible for all the preventive healthcare activities of the allocated area. Besides, field health staff, such as public health midwives, public health inspectors, and their supervising officers, are attached to the Preventive Healthcare Institution under the Medical Officer of Health. These Preventive Healthcare Institutions are responsible for providing antenatal and postnatal care services, immunisation services, family planning services, nutrition care for children through field clinics, and domiciliary services by the field staff. Control of communicable diseases, an inspection of occupational settings, environmental health and food safety, surveillance and notification of notifiable diseases are also responsibilities of the Medical Officers of Health and their staff, belonging to the public health track, i.e., Preventive Healthcare Institutions.
Bangladesh experienced several local disease outbreaks over the past several years and a dengue epidemic in 2019. Still, due to their lower magnitude compared to the Covid-19 pandemic, the need for a comprehensive overhauling of the health systems has not been felt so deeply before. Low- and middle-income countries like Bangladesh are particularly vulnerable to pandemics due to weak governance and limited health system preparedness. When managing any health crisis, a science-based professional response by engaging the relevant experts is essential. Experts may include, but are not limited to public health professionals, including infectious disease epidemiologists, health policy and systems experts, medical anthropologists, health economists, and health communication experts; laboratory scientists, including virologists, microbiologists, biochemists, and lab technicians; and relevant clinicians, including physicians, nurses, and paramedics. The usefulness of such a science-based public health approach has been established in countries like Switzerland, Georgia, and New Zealand. A recent article in the British Medical Journal outlined two distinct benefits of engaging experts from diverse disciplinary backgrounds. Firstly, it can improve the quality of collective judgments and help avoid epistemic pitfalls, especially when no single expert or a discipline has the right answer to the pandemic's enigmas. Secondly, the inclusion of diverse disciplinary perspectives can help legitimise political decisions and encourage public compliance with rules and regulations, critical for a country like Bangladesh with a sizeable non-conforming populace.
In the long run, however, a separate public health track, which is currently absent in the Bangladesh health sector, must be implemented. Our proposition for introducing such a reform for Bangladesh's health service structure, similar to Sri Lanka, is to formalise public health within the mainstream health service architecture. As much as we do not want to prescribe a specific or concrete structure, we demand a transparent and inclusive stakeholder consultation on behalf of the MoHFW with a vision of a radical reform of the Bangladeshi health system, involving all relevant public health experts, clinicians, and other stakeholders. On principle, newly recruited doctors or employees in the BCS (Health) cadre, with expertise and experience in public health, health systems, health administration, and similar backgrounds, should be given leverage, or at least recognition. Secondly, the health service tracks (General Health Service, Medical Teaching, and Health Administration) must be clearly defined, distinct, and respected. New recruits should be assigned from the very beginning to one of these tracks, with the possibility of track changes only on exceptional circumstances. Lateral entry from other tracks, especially in high ranks, should be discouraged. This principle should apply to MoHFW positions as well, up to the highest level. Finally, instead of just reorganising or reorienting the existing posts or positions, the health systems stewards should resort to a scientific and evidence-informed approach, a scheme of which could be: A. Identify the public health posts within the existing structure; B. Create additional public health posts aligned with the essential public health functions; C. Create a distinct, yet interlinked public health career ladder, starting from the recruitment to the retirement, the choice for which should be made by the employees at the early stage of the recruitment; D. Carry out necessary educational reforms in both the undergraduate medical curriculum and beyond to reflect the centrality of public health in the national health system of Bangladesh; and E. Bring about necessary infrastructural and institutional changes to accommodate the public health career ladder or track.
Dr. Taufique Joarder is the Executive Director of Public Health Foundation, Bangladesh.
