The Influence of Governance on the Quality of Health Service Delivery in Bangladesh: A Comparative Study of Rural and Urban Health Service Organisations

Author: Mohammad Shafiqul Islam

Islam, Mohammad Shafiqul, 2016 The Influence of Governance on the Quality of Health Service Delivery in Bangladesh: A Comparative Study of Rural and Urban Health Service Organisations, Flinders University, School of the Environment

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Bangladesh has made satisfactory progress in maternal and child health as indicated by impressive reductions in quantitative indicators such as the maternal mortality ratio and the infant mortality rate. However, progress is slow in terms of qualitative indicators of affordability, accessibility, and the quality and efficiency of services. The reasons are inadequate responsibilities of health service actors and the various factors, which contribute to weak governance in health service organisations, particularly those issues that deal with accountability, transparency and participation. The main objective of the thesis is to examine the impact of governance on the quality of health service provision of rural and urban health service organisations and to analyse the health professional’s responsibilities and duties for understanding governance, the role of community participation in promoting governance, and the various factors that affect governance and the quality of health service delivery in rural and urban health service organisations of Bangladesh. The thesis uses empirical data to address the following research questions: (a) how do the responsibilities and duties of various health professionals contribute to improving/limiting governance and quality of health service delivery? (b) how does community participation contribute to governance and quality of health care in rural and urban areas? (c) how do various factors affect governance and health care delivery? (d) to what extent does governance work differently in rural and urban health service organisations? and (e) how is the governance of NGOs’ health service delivery conducted - is service delivery of NGOs more efficient than that of public providers? This research investigates the above mentioned aspects of governance with the help of case studies in an urban and a rural sub-district health complex of the government of Bangladesh, namely Chhatak in Sunamganj district (rural) and Savar in Dhaka district (urban).For comparative purposes, two non-governmental health organisations, namely the Bangladesh Rural Advancement Committee (BRAC) and Gonosashtha Kendra (GK) have also been included in the study. In particular, the thesis examines the roles and responsibilities of health service managers and health service professionals in the sub-district health complexes and their associated health centres. Additionally, various factors related to political, managerial, and socio-demographic and women’s empowerment features have been examined to understand the impact of governance on the quality of health service delivery.

The analysis is based on qualitative case studies (mixture of descriptive and hypothesis generating) comprising 68 in-depth interviews of national informants, healthcare managers, health service professionals, elected representatives and local informants, as well as five focus group discussions each consisting of seven to eight health service users. As a mainly qualitative study, the thesis analyses of respondents’ views and experiences in order to gain an understanding of the influence of governance on the quality of health service delivery.

This study illuminates several ways in which governance affects quality of service delivery. Coordination among different units within each health service organisation and that between a government and non-governmental health organisation pose challenges for improving governance (that is, accountability, transparency and participation) and quality of health service delivery, in both rural and urban health service organisations. An important managerial factor–that of supervision- is carried out more efficiently in the urban area (Savar) than it is in the rural area (Chhatak). This may be attributed to better physical communications, proximity to the central administration, and the style of leadership in Savar. With respect to professionalism, the urban health care providers are found to work with greater enthusiasm to provide good quality health services. This may be attributed to their greater motivation to work (with less absenteeism), responsibility and accountability, facilitated by better facilities and greater exposure to national and international healthcare professionals and organisations. On the other hand, inadequate facilities such as children’s schooling or one’s own career betterment mean there is less motivation and greater absenteeism in the rural area (Chhatak). There are better opportunities for the doctors in the urban area (Savar) to do after-hour private practice (allowed by the government), however the lack of such opportunity in the rural area ensures that doctors in Chhatak seek private practice in the nearest urban area, which leads to greater absenteeism. The doctors in the rural health centres are found to be less accountable to their duties. A weaker management in Chhatak also contributes to absenteeism among its doctors.

The findings show that the introduction of modern technology such as the Internet and electronic devices for record keeping contribute significantly to enhancing transparency in health service delivery in the urban health centre (Savar) which, in turn, leads to better quality of health services. For example, information and communication technology (ICT) provides an effective mechanism for sharing information with the public and promotes transparency, potentially reducing corruption. However, resource constraints in the rural health centre (Chhatak) impact adversely on the improvement of technology, which leads to less transparent health service delivery. Moreover, greater community initiatives and frequent oversight by authorities have contributed to better transparency at the urban health complex.

Community participation is an aspect of good governance that might affect quality of service delivery. The findings of the study suggest that health service activities are potentially more participative at the sub-district health centres in rural areas. Compared to their urban counterparts, the local elected representatives and other members of the community in rural areas have greater awareness of local health problems and want to participate in the sub-district healthcare delivery to reduce corruption and absenteeism. However, they are not able to do so due to a lack of decentralisation, limited supervisory authority and poor political commitment. The bureaucrats at the centre are also unwilling to decentralise the health system and dilute their power. In fact, healthcare decision-making is politicised, elite-centred, bureaucratic and centralised. Nonetheless, the story is different when one looks at the lower level community health clinics (below the sub-district health centres). Here, the Savar community clinics are found to be more participative as a result of better supervision and good operating management, which is absent in Chhatak.

Civil society organisations (local informants) have a significant role to play in promoting governance. Evidence shows that the urban sub-district health centre has a greater involvement of civil society organisations, due to which accountability and health service delivery are better than those in the rural sub-district health complex. Women’s empowerment has also been found to promote participation, which leads to better decision-making and improved quality health care delivery. However, women have a poor participation rate in the rural health centre due to their poor socio-economic conditions, lack of education and traditional values. Although women in Savar have improved education and economic conditions, their participation in health care services is not adequate as the majority of the women in Savar are migrants and are busy working in the garment industry. Moreover, local politics limit people’s effective participation in both the rural and urban health service organisations.

Staff members of NGOs ensure their accountability to their higher officials and their funding agencies and perform their job responsibility. They are not as much accountable to the government and local elected representatives because of poor coordination, lack of policy, and an inadequate legal framework. In addition, community participation in the activities of the NGO is also very low, which limits the community’s ability to promote accountability in these organisations. The mechanism of supervision in the NGOs is cooperative and supportive which closely guides the staff to contribute to improved quality of health care. NGOs have limited resources for promoting health care although they use their available resources efficiently, with strong monitoring and supervision to provide satisfactory health service delivery. In addition, the positive behaviour of NGO health care providers, the minimal amount of time needed in getting services, friendly insurance schemes, freedom from politics and greater fairness all contribute to improved accessibility and affordability of health care. This study has however found that women who have a poor decision-making role in family and society have less empowerment that consequently affects their participation in the NGO health programs.

This study recommends the oversight of management and coordination, strengthening of the community and civil society organisations, government-non-government/public-private collaboration, and decentralisation of health care services to improve and enhance the quality of governance and health service delivery.

Keywords: Governance, accountability, transparency,participation, quality health care, Bangladesh

Subject: Environmental Studies thesis

Thesis type: Doctor of Philosophy
Completed: 2016
School: School of the Environment
Supervisor: Associate Professor Dr. Gour Dasvarma