The ails of the Ministry of Health and Family Welfare's structural divide

Health care and family planning services in our country have been managed by two separate administrations (DGHS and DGFP) since 1975. In 1998, these services were unified at the field level (from district to union level), but this was later repealed and reinstated through an unsolicited decision in 2001. 

In 1977, the Nursing Directorate was established with the aim of improving nursing management, and it was later upgraded to the Directorate General of Nursing and Midwifery in 2016 as an attached department of the Ministry of Health and Family Welfare.

Despite the fragmentation of the health sector at different times, the Ministry of Health and Family Welfare (MOHFW) of Bangladesh, like all other countries in the world, had a single head until March 2017.

Previously, all services including health education, health care and family welfare were overseen by a single head – the Secretary of the MOHFW. However, on 16 March 2017, the MOHFW was divided into two divisions: the Medical Education and Family Welfare Division (MEFWD) and the Health Service Division (HSD). 

Each division is now headed by a secretary, resulting in two leaders.

Medical students need to be linked to medical college hospitals for all experiments, including internships and hands-on training Photo: Rajib Dhar.

Under the MEFWD, all institutions of medical education – such as medical universities, medical colleges, nursing colleges and medical technology institutes – were placed. Besides, a part of primary health care including family planning and maternal and child health was also put under this Division. 

The HSD, on the other hand, is responsible for providing primary, tertiary and specialised healthcare services. However, after the division of the MOHFW, there was a need to restructure the body once again.

In 2019, the health sector was once again restructured with the formation of the Directorate General of Medical Education (DGME), which was separated from the Directorate General of Health Services (DGHS). 

As a result, medical education – specifically, the teaching of medical colleges – is now under the purview of the MEFWD, while the medical college hospitals, where medical students gain practical experience, fall under the HSD.

These numerous reconstructions were carried out without any skilled "surgeon" and are an example of thoughtless planning and execution. 

In the midst of increasing urbanisation, primary health care for urban dwellers has been delegated to local government institutions, which are constrained by numerous challenges and therefore unable to provide adequate health care.

In reality, it is impossible to separate medical education from medical college hospitals. Medical education is incomplete without a connection to hospitals. Medical students and teachers need to be linked to medical college hospitals for all experiments, including internships and hands-on training. 

Since the hospital management is connected to one head (HSD) and the medical college administration to another head (MEFWD), it was inevitable to increase the distance between them, which could have severe negative consequences on the quality of medical education, something that would be detrimental to the nation as a whole.

Furthermore, medical college hospitals in Bangladesh are not just learning fields for medical students; they are also primary centres for secondary and tertiary medical care. However, medical college hospitals in Bangladesh do not have their own workforce beyond some resident physicians and surgeons, who generally belong to the rank of medical officers. 

Medical college hospitals are mainly operated by clinical faculty members and medical college trainees. The two-headed administrative structure of the MOHFW is unsuitable for providing quality medical care by medical college hospitals. Therefore, the argument for bifurcating medical education from health services is not acceptable in any way.

It has been six years since the bifurcation of the MOHFW, and it is imperative to reflect on what the nation has achieved from this decision. In theory, having two bodies and two heads would strengthen monitoring and supervision and expedite the Ministry's work. 

However, this would have only been possible with effective coordination between the two Divisions. 

Unfortunately, in a country where government officials mainly seek personal privileges and promotions, it might not have been realised that such separation would only increase the rivalry between the two Divisions. The rivalry has reached its pinnacle during the last six years, and the absence of coordination has slowed down the pace of work. 

The unjustified operation to divide the Ministry has left a serious wound in the health sector, and it is continuously bleeding. Therefore, an urgent reconstruction is needed, but it should be done with an expert surgeon. However, where and how to reconstruct and who will lead the reconstruction procedures require further discussion.

Primary healthcare is the cornerstone of a health system, and its effective provision ensures around 80% of the success of the health sector. However, primary healthcare is currently in poor condition, particularly in rural areas where there is a lack of suitable and adequate manpower despite having a strong network of primary healthcare systems. 

Furthermore, the Directorate General of Health Service and the Directorate General of Family Planning are administered separately, wasting resources and impeding people from receiving desired health services. In urban areas, no primary healthcare structure has been established by the MOHFW.

Therefore, it is essential to establish a solid foundation for primary healthcare in urban areas by emphasising prevention and promotional health to achieve Universal Health Coverage. 

The "Aalo Clinic" model designed by the Institute of Health Economics of Dhaka University in collaboration with UNICEF may be a potential model for primary healthcare solutions in urban areas. Given the size of primary health care, a separate division is needed for the effective provision of primary health care, including family welfare and nutrition services in rural and urban areas.

Rather than establishing an additional head or division within the MOHFW to manage it, one of the two existing divisions can be converted into a 'Primary Health Care Division' (PHCD). In this case, the upazila or thana-level primary healthcare system should be restructured at the field level by integrating health, nutrition, and family welfare service institutions. 

The other division should be converted into a Secondary & Tertiary Services and Medical Education Division (STSMED). In this case, the medical cadre should also be split into two groups: primary health cadre and secondary and tertiary health cadre.

Furthermore, the Directorate General of Health Services (DGHS), Directorate General of Medical Education (DGME), Directorate General of Nursing and Midwifery (DGNM), and Directorate General of Family Planning (DGFP) should be reasonably aligned with the activities of the two reconstructed divisions. The Directorate General of Drug Administration (DGDA) needs to be strengthened and converted into a Drug Administration Authority (DAA) or Drug Administration Commission (DAC). 

Above all, medically trained professionals should be appointed in all higher posts, including the secretary of the reconstructed divisions.

It is important to note that any retired or serving bureaucrat-surgeon is not capable of performing such a large, multifaceted, and complicated operation. Instead, it requires a competent, proficient, and prudent surgeon. The Honourable Prime Minister is perhaps the only competent surgeon who can accomplish this reconstruction. 

Dr Syed Abdul Hamid, Professor, Institute of Health Economics, University of Dhaka.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard.