quality of primary health care services in rural ...

QUALITY OF PRIMARY HEALTH CARE SERVICES IN RURAL BANGLADESH: PATIENTS’ PERSPECTIVES Md. Kamrul Hasan a a

Centre for Development Studies, The University of Auckland, Auckland, New Zealand. a Corresponding author: [email protected] ©Ontario International Development Agency ISSN: 1923-6654 (print) ISSN 1923-6662 (online). Available at http://www.ssrn.com/link/OIDA-Intl-Journal-Sustainable-Dev.html

Abstract: A key aim of the health policy of the Government of Bangladesh (GoB) has been to provide quality health services to all its citizens. In line with the policy objective, the GoB has adopted the primary health care (PHC) approach as a health development strategy. Inspired by the Alma Ata Declaration on PHC, the GoB health policy and programmes aim at ensuring “health for all” (Perry, 2000), with special focus on rural population and the poor. There is now a common mistrust of the public health services in the country and the perceived poor quality of health services push the higher socioeconomic groups to seek health services abroad (Mahdy, 2009). I used a narrative interview method to better understand the user perspectives on the quality of PHC to register patients’ voices missed in previous predominantly quantitative studies (e.g., Sohail, 2005). Data for the research came from 10 expatients who sought primary health services in a health centre in a sub-district in Bangladesh. This paper demonstrates that lack of adequate health professionals, misuse of resources, provider absenteeism, provider-centric consultations result in patient dissatisfaction and ineffectiveness of services. I argue that there is a need for proper maintenance of resources, better monitoring and supervision and address process-related quality issues to ensure better quality health services for the rural people. Keywords: Quality of Health Care, Primary Health Care, Rural Health, Bangladesh, Narrative Method. INTRODUCTION

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he quality of health service is now an emerging area of research and policy concern in both the developing and developed

countries. In the 1990s, more than 70 peer-reviewed publications documented serious quality shortcomings in the American health care system (Institute of Medicine, 2001, p. 3). Though little research is available on the quality of health services in Bangladesh, some studies since the 1990s have touched upon the quality of health services (Chowdhury, 1990; Paul, 1999; Andaleeb, 2000; Chaudhury & Hammer, 2004; Sohail, 2005; Andaleeb, Siddiqui, & Khandakar, 2007; Mahdy, 2009; Anwar, Kalim, & Koblinsky, 2009). Sen and Acharya (1997) notes the poor quality of health services is a persistent concern in Bangladesh (as cited in Andaleeb, 2000). Paul (1999) and Andaleeb (2000) have touched on the issues of the quality of health care, but they conducted survey method in the context of the urban wealthy population. In Bangladesh there is common mistrust of the public health services (Mahdy, 2009) and wealthy patients tend to bypass the national health care system and seek treatment abroad (Andaleeb, 2000). Research suggests that the quality of health services is more likely to be compromised in the public health care institutions than in the private ones in the country (Paul, 1999). The Government of Bangladesh (GoB) has established an extensive health care infrastructure in line with its policy goal of “health for all” (Chowdhury, 1990; Perry, 2000). A key objective of the health policy has been to ensure high quality health services for rural people, women and the poor. GoB has established rural health centres, called Upazila Health Complexes (UHCs) in almost every sub-district, sub-centres and community clinics at the village level throughout the country. These UHCs

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and sub-centres provide ante-natal and post-natal care, family planning, child health care and curative care, referral service, safe delivery care, diagnosis, health education and medicines (Kabir, 2006). The latest Report of the Bangladesh Health Watch (BHW) raised serious quality issues (BWH, 2009). Consistent with Andaleeb (2000), the BHW report shows that the quality of health care services is more likely compromised at the government health facilities than at non-government health facilities (BHW, 2009,p. xxii). The perceptions of poor quality and unreliable health services in public hospitals partly explain why many wealthy people seek health care abroad (Andaleeb, 2000). Andaleeb’s (2000) quantitative study assumes certain predetermined elements of the quality of health services such as confidence of patients in services, clarity of communication between staff and patients, and discipline, and thus missed the perspectives of service users and providers. Sohail (2005)’s macro-level quantitative study looked at the process and structure aspects of quality of PHC and suggests that the majority of the users of government PHC services were dissatisfied with the existing level of quality of care. In particular, people were most dissatisfied with waiting time, cleanliness, and privacy of treatment and the standard of inpatient food (Sohail, 2005). Mahdy (2009) claims that the health care system has not been reformed since the independence of Bangladesh in 1971, and dissatisfied patients seek health services in foreign countries such as India, Thailand, Singapore and in cases, the UK and the USA. This phenomenon is known as “health tourism” (Mahdy, 2009). Chowdhury (1990), in a study of the rural health care system, paints a dismal picture of health care service delivery. This research shows that health education was delivered in a non-participatory and callous way, many providers were absent and there was a lack of supervision and motivation of health workers (Chowdhury, 1990). Against this backdrop, understanding the patient perspectives of rural health service quality is critical to address the quality shortcomings. This is because quality improvement must begin with listening to patients or users of services (Lloyd, 2004). This article is based on a larger study aimed at understanding the influences of professional power on the quality of primary health services in rural Bangladesh (Hasan, 2011). One of the objectives of the study was to understand the quality concerns of rural health service users. This article focuses on the key emerging themes related to the quality of the rural health services from the perspectives of service users.

CONCEPTUAL FRAMEWORK Quality of health services is a subjective and relative concept and may mean different things to different groups such as providers and patients (Moullin, 2002, p.7). The concept of health service quality may vary among patients as well, depending on their expectations or perceptions of quality. Though there is no agreed definition of the quality of health services (Moullin, 2002), several frameworks such as Maxwell Six and Donabedain Three allow to assess health service quality (as cited in Whittaker, 1999). These frameworks are well-known and have been widely used in the researches on the quality of health care. The Donabedian Three focuses on structure (the design and organisation of service), process (what is done in terms of procedures and protocols) and outcome (what happens as a result) (Whittaker, 1999; Greenhalgh, 2008, p.276). Maxwell Six uses six criteria to measure quality in health care. They are effectives, efficiency, acceptability, access, equity and relevance (Greenhalgh, 2008, p.276). The Institute of Medicine (2001) lists safety, effectiveness, patient-centredness, timeliness, efficiency, equity as the criteria to consider for quality improvement in the American health care system (pp.5-6). Applying the Donabedian model of assessing health service quality, this article investigates the concerns of rural PHC service users. I applied the Donabedian model because it allows flexibility to understand the patient perspectives of health service quality. METHODS AND MATERIALS Participants I collected data from 10 ex-patients of health services at one of the Upazila Health Complexes (UHC) in a sub-district in Bangladesh. The UHCs are sub-district level rural health centers and lie at the health of rural health service infrasctures. Of the 10 participants, six were men and four were women. They belong to different occupational categories such as farmer, housewives, small businessman, unemployed youth, government employee, single woman, returned international migrant worker and student. All the participants are older than 18 years of age. I selected them because they used primary health services at an UHC in the sub-district selected for the study. All the names used in this paper are fictitious to ensure anonymity of the participants. Procedures To answer the research questions, I applied a narrative interview method to collect data. I purposively selected a sub-district in Bangladesh. I then selected 10 ex-patients who used the services of the UHC in the sub-district. Before the interviews, I

Hasan / OIDA International Journal of Sustainable Development 03: 08 (2012)

gained informed consent and provided adequate information about the objectives and the procedures of their participation in the project. I asked openended questions regarding the quality of services they received. I asked the participants to narrate their experiences of visiting the UHC and what they thought about the quality of the services received. The participants’ narrated their thoughts, ideas and experiences regarding quality of the services received at the UHC and its sub-centres. I recorded the interviews with a digital voice recorder. The duration of the interviews ranged from about 40 minutes to one hour. I also took some notes during the time of interviewing. I did full verbatim transcriptions of all the interviews. Analysis of Data The analysis of data began in the field while I was listening to the participants’ narratives. I had to carefully listen to their narratives and experiences as the questions were open-ended. After returning from the field, I listened to the recorded interviews and transcribed them. In the whole process, I often wrote analytical notes to myself. I read through the transcripts several times and coded important phrases and points regarding the quality of the PHC services. I then compared the emerging themes by applying the Donabedian model of evaluating health service quality. Based on the model, I identified key concerns of quality regarding the structure, processes and outcomes of the rural health services (Whittaker, 1999). RESULTS Certain key quality themes around the structure, process and outcomes of the rural health services emerged from the data analysis. Figure 1 indicates the key quality shortcomings from the perspectives of the users. The diagram indicates that the structurerelated quality themes are absenteeism and unavailability of health professionals, shortage of health staff, lack of resources and cleaniless of the UHC. The process-specific concerns are consultation time, timeliness of health services, access to health services, provider behavior, emergency and referral services. Lastly, patient satisfaction and effectiveness of the UHC services emerge as key outcome-related themes This section is further sub-divided into three subsections, each presenting the key findings related to the concerns of the participants regarding the structure, processes and outcomes of the Upazila health services. The findings are organised in the light of the Donabedian model.

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Structure of the Upazila Health Services Absenteeism and unavailability of providers, lack of adequate drugs and diagnostic facilities, lack of cleanliness and pollution of the surrounding environment emerged as key quality shortcomings related to the structure of the rural health system. The participants suggest that the rural health centres are not well-equipped to provide required services. Rashid said: Rural health system is still not fully welldeveloped. There’re still lacking. There’re many problems. People get some health service from the private providers. ...Otherwise people are going towards the town, because there is better health service in there. The above quote points of lack of adequate infrastructures at the UHC compared to town hospitals or even private clinics and hospitals. The participants pointed out that the number of doctors employed in the UHC is far lower than the demand because there is a large population in the UHC. Salim explained: This is a big Upazila. This is bigger than [the name of a small district]. But there’s only one health centre like this. People are coming from far away. But all of them don’t get health services, because services are inadequate compared to the population. A participant thinks that the number of doctors is disproportionate to the number of patients they are supposed to serve. Rashid pointed out: The quality of health service in this country isn’t that bad. Even though this isn’t of extraordinarily high quality, it can’t be said that this is of very low standard. Some people compare the services with other countries and tend to undermine the health system here. The problem is ... there’re too many people. For this reason, doctors aren’t often able to provide good service at the right time. In his opinion, the health system in Bangladesh is not well-equipped to provide required services. According to the World Health Organisation (WHO), the number of population per physician is 2860 (WHO, 2011). The data suggests that while there is scarcity of heath service providers on the one hand, on the other the currently employed providers do not regularly go to their posts or often do not attend to patients even if they are available. Doctors and support staff often see patients at their home-cum-private chambers, private clinics and occasionally see patients at the latters’ homes far away from the UHC. These practices affect the availability of the existing health professionals to provide services to the poorer patients who tend to go for subsidised health services at the UHCs.

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Figure 1: The key quality shortcomings from the perspectives of the users

The sub-centres of the UHC are staffed with one MBBS doctor and several support staff. The doctors in these sub-centres frequently remain absent. Mizan said: It’s also not clear whether he’s coming regularly. If he comes on Sunday, he doesn’t come on Monday... like that, but he gets full salary from the Government. The above quote further suggests that doctors neglect their duties and the poorer people are deprived of health services as a result. Apart from the absenteeism and shortage of health care personnel, some participants pointed to a lack of adequate diagnostic facilities, power supply and drugs. According to a health worker, some essential health services such as treatment for minor eye problems are not available at the UHC, and patient with minor eye-related sicknesses need to be referred to town hospitals (Personal Communication, January 4, 2011). Health services are often interrupted due to frequent power outages. Shefali, a woman who was admitted to the UHC for delivery services, said: When electricity is out, mosquitoes bite a lot. When electricity was gone, I had to purchase mosquito coil

from outside. As there’s no electricity, I had to buy candles and lit them. The data also indicate that there is a scarcity of diagnostic tools. Doctors tend not to use the tools, even if they are available. This is perhaps because they need to attend to many patients within a short time. A participant said that there are no diagnostic facilities other than the one for blood tests. Otoscopes to check ears are also not available or not used. The participants do not know whether the devices are available or just not used. Moreover, the participants are also concerned with the unavailability of drugs. Though the most essential drugs are supposed to be available at the UHC, very few patients were given medicines from the UHC. They had to buy most of the drugs from private pharmacies. Some participants seem to lack enough information about the availability of the UHC drugs. A participant indicated that the unavailability of medicine is linked to the theft of medicines. The results indicate that some UHC staff sell drugs to the private pharmacies in the area. Some participants expressed dissatisfaction with the lack of cleanliness in the UHC and pollution around


the hospital areas. The patients think that proper hygienic standards are not maintained. An ex-patient saw the toilets rooms were kept untidy. Mizan said: Neither inside nor outside is clean. Toilets were untidy. If people go there, they’ll vomit. Pillows or bed sheets given to patients are also dirty. That’s why, those who’re admitted there, they take bed covers and pillows from home. Salim informed that the hospital kitchen was not kept clean and funds are not used properly: The kitchen is unhygienic. If you see the food, you’ll vomit. They’re not buying food according to the governmental allocation for food. They don’t clean up the kitchen properly. The findings related to poor hygiene, lack of cleanliness and substandard food are consistent with Sohail’s (2005) macro-level study of rural health services. In addition, this study suggests that environmental degradation, sub-standard food and a lack of hygiene at the UHC are not merely due to a lack of resources but misuse of resources. Process of Health Service Delivery The second broad area of the quality of health service relates to the process of service delivery. The duration of consultation time, timeliness of service, poor provider behaviour, coercive referral and poor emergency services emerge as key process-related quality concerns of the patients. Inadequate consultation time appears to be the most crucial quality concerns of the participants. During consultations, patients believe, doctors give very little time to patients. As several participants narrated, doctors just ask name, age and at little bit about the pertinent health problems. Before patients can finish describing their problems, doctors start writing prescriptions. The data indicates that doctors cannot provide adequate time because of the high number of patients. Rashid suggested that people who seek health services privately tend to get more time than those who see doctors at the UHC. It must be noted here that the UHC doctors often provide private services on pay-for services basis. Rashid said: ...and those, who see doctors privately,... they’re getting slightly more time. They ‘re also getting less time, but definitely more than those who go to see the doctors in the government hospitals. It is notable that the poorer people are not being able to seek private health services. The private services are used by those who can afford the pay-for-service available at the locality or in towns. Mizan said: The poor are not going there. The cost is 300 taka per consultation, up from 200 taka. The fee is very high now. It was 20 to 50 taka earlier ...like 10 years ago.

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The data further indicates that patients often do not receive services including emergency services at the right time. This is often because of unavailability or negligence of the health service providers. Rohit narrated the following story: During the last summer, I took a patient to the UHC. Some other people of their family accompanied. There’s none but one person at the Emergency Department. He was an electrician doing electrical repairing works. There’s no health staff at all. We asked him if there’s anyone. He said they’re around. Later, I got a health staff. That person called a doctor over phone. Then the doctor came. It took 15 minutes for calling and the doctor to come. Doctors live in the government houses inside the hospital area. The quote also points to the negligence of the staff tasked with providing emergency health services. The Institute of Medicine (2001) lists the timeliness of services as an important criterion of quality. This study indicates that in most cases services including emergency services are not provided at the right time. This is because of the negligence of on-duty health staff, absenteeism of staff, overcrowding of patients. There are, however, a few rare incidences when patients seemed to receive services at the right time and be satisfied. The data suggest that patients are sometimes denied access to required health services. This is because of their inability to pay, overcrowding of patients and reluctance of the staff to provide health services or absenteeism. A poor woman was, for instance, denied access to maternal health services for not being able to pay bribe. Apart from this, geographic isolation, poor communication system and absenteeism and unavailability of the providers tend to affect the rural patients access to health services. A participant contended that people are deprived of their right to have access to health services. The emergency services appear to be inadequate and are often disrupted due to untimely delivery and the unavailability of health care providers. Hussen narrated a story: Once I went to the UHC. I saw four people suddenly met an accident in a CNG vehicle [auto-rickshaw run on compressed natural gas]. They‘re injured. They’re crying loudly. One was taken inside the emergency room and a doctor was doing an operation on him. Others were kept outside. They’re crying out of pain. There’s only one doctor. He’s doing operations one after another. In the meantime, others needed to wait for their turn. This is because there’s only one emergency room. There’s a need for more emergency rooms. I saw that. That’s a big incidence! Sometimes, normal out-patient health services are disrupted because the doctors have to move to emergency rooms, when suddenly patients requiring

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emergency services go to the UHC. Rashid said: When there’re emergency patients, doctors go to help. They leave us and go to attend to the emergency patients. We have to wait. They go to help patients in the emergency room quickly. The above quote further suggests that the shortage of staff at the emergency room disrupts the daily outpatient services. Some participants expressed dissatisfaction with the UHC’s referral services. The patients thought that the doctors often refer patients to the higher tiers (district hospitals and/or medical college hospitals in the town) to avoid their responsibilities. An old woman was asked to go to a town hospital when she went to the UHC to seek health services for stomach pain. Some participants expressed dissatisfaction with providers’ behaviour. A participant was rebuked for being late to go to the UHC. Services are often delivered in a careless manner causing patient dissatisfaction. The UHC staff tends to express disappointment, reluctance and sometimes even misbehave or harass patients. Rohit said that the staff are often not available at the emergency room and so they need to be looked for. When patients requiring emergency services find staff, the latter tend to express their annoyance, disappointment and unnecessarily delay the delivery of required services. Rohit observed: Sometimes they wake up, but at other times, they express their disappointment. They sleep setting mosquito net at the room beside the emergency room. That’s one of the doctors’ rooms. If they slept in the emergency room, it would’ve been the lesser of two evils. The data analysis suggests that people often avoid the lower tiers of the rural health system. For instance, most people go to the UHCs directly without going to the sub-centres of the UHCs located at the village level. Similarly, relatively wealthy patients directly go to the private providers at the Upazila centres or in towns/ cities. In addition, this study found one patient who went to India for better treatment. Rashid, referring the sub-centres, said: Some people go there, but most people directly go to the UHC. The people of this area aren’t aware about the sub-centres. The lack of information about the sub-centres is perhaps one of reasons why people do not go there. Some people avoid the UHC services due to perceived low quality, specially overcrowding and less consultation time. A young woman had once been sick. She, accompanied by her brother, went to see a private doctor at the Upazila centre. The doctor was taking rest. The young woman was trembling in pain. Then the woman’s brother, who accompanied her to the doctor’s chamber, took her to the UHC. They had to wait for a long time before they could

see a doctor. After this incidence, they often try to see doctors in private in the town. Outcomes of Health Services The data analyses suggest that the structure of the UHC organisation and the processes of health service delivery influence the outcome of the health services. The data indicate that the lower proportion of doctors, unavailability of providers, lack of adequate drugs and diagnostic tools affect both the processes and outcomes of health services. They result in short consultation time and untimely services on the one hand, on the other the unavailability of doctors or their involvement in private services and inadequate consultation time cause patient dissatisfaction. As a consequence the effectiveness of health services and patient satisfaction is greatly reduced. Considering patient satisfaction as an indicator of outcomes, the data reveals that while some patients are satisfied, most are dissatisfied with the UHC services. Similarly, with regard to the effectiveness of services, treatments were sometimes proved to be effective and useful, at times they were ineffective, causing even deaths. Ehsan told me a story of a sick old man who died without any treatment because he was too poor to pay bribe to gain access to the UHC health services. This case indicates the links between the processes and outcomes or the impacts of the rural health services. Another reason for the ineffectiveness of services is that the UHC doctors prescribe patients to buy substandard drugs produced and marketed by unscrupulous pharmaceutical companies. They allegedly do so to earn some extra incomes from those companies. Salim explained: Now there’re so many companies like [the name of a pharmaceutical company]… this and that. Their medicines are not effective at all…. Their effectiveness is very limited, but still the doctors are writing those [substandard] medicines. For a minor problem, they’re prescribing four to five medicines. The participant also pointed to the lack of monitoring and regulation of the drug standard by the relevant government agencies. A participant pointed out the doctors lack credentials to provide quality services in the rural areas. He thinks that doctors, who are the fresh graduates of medical colleges, are posted in rural areas. In his opinion, the experienced doctors live in towns and cities and are reluctant to live and work in rural areas. For this reason, the rural people are not receiving good quality health services. A likely and sometimes inevitable consequence, of dissatisfaction with the UHC service is discontinuation of the services. The dissatisfied


patients move to the private providers in the Upazila centres or towns. However, very few people can afford to go abroad. I found one case where a wealthy patient went to India for treatment. The quality of health services is perceived to be of higher quality in neighbouring India, which is the primary destination of Bangladeshi patients seeking health services abroad. By contrast, a few participants pointed out that though the process of the health services was not user-friendly and patient-centric, the UHC doctors are competent. They suggested that the treatment they received for minor illnesses were effective and they seem to be satisfied with the effectiveness of the treatment. A farmer who went for his wife’s delivery thought the doctors had enough experience and competence, because their treatment was proved to be effective. He thought this because delivery took place on the day doctors had suggested. Rashid, a migrant participant, seems to be satisfied with the UHC services. He had sought health services there several times for minor illnesses. He said he got solutions to his problem all the times. I’d faced several health problems the other time and took medicine from outside. It didn’t really work....but when I got medicine from the medical [UHC], it did. By “outside” he meant private pharmacies in the locality from where rural patients usually buy medicines sometimes without consulting a doctor. DISCUSSION This study indicates that unavailability and absenteeism of providers, lack of diagnostic facilities, essential drugs, and poor hygiene are important structure-related quality issues. In addition, duration of consultations, timeliness of services, provider behaviour, referral and emergency health services were the process-related concerns of the patients. Lastly, the study indicates that both the structures and processes of services influence the outcomes of the services in terms of patient satisfaction and effectiveness of care. Consistent with Andaleeb’s (2000) research in urban Bangladesh, this study suggests that the private health services are perceived to be of better quality in the rural counterpart. This is because of the longer duration of consultation, less crowding, less harassment, provider responsiveness and the use of diagnostic tools. The findings of this research and Andaleeb (2000) are different from the Vietnamese case where public health services are of better quality than that of the private services (Tuan, Dung, Neu & Dibley, 2005). However, the poorer rural people and low-income groups, who form the majority of the rural population, are not being able to take the advantage of the better quality private health services

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in the study areas. This is consistent with Alubo’s (1987) research in Nigeria that showed that the poorer and the less powerful people receive poorer quality health services. This paper demonstrates that the absenteeism and unavailability of providers at the right time plague the rural health services. These findings are consistent with many other studies in different parts of the developing world, including Bangladesh (Justice, 1987; Chowdhury, 1990; Lewis, 1996; Chaudhury & Hammer, 2004). In the case of the Bangladesh health care system, the absenteeism and a lack of motivation was documented in a seminal research on rural health workers (Chowdhury, 1990). This research provides support in favour of Chowdhury’s (1990) research, indicating doctors’ unavailability and absenteeism. The results further indicate that there are fewer numbers of doctors to provide adequate services to the rural masses. The Upazila I conducted this research has a large population which is about four times higher than the average population in a subdistrict in Bangladesh. The shortage of doctors supports the argument that there is a manpower shortage in rural Bangladesh plaguing the obstetric reproductive health care services (Anwar, Kalim & Koblinsky, 2009). This must, however, be emphasised that the shortage or unavailability of doctors or other health staff in the UHC is not merely due to absolute manpower shortages. The doctors remain busy with private practice at their home-cum chambers, private clinics and local pharmacies. These forms of private practice contradicts Mahdy’s (2009) claim that there is no opportunity for private practice in rural areas in Bangladesh. In contrast, this research provides support for Chaudhury and Hammer’s (2004) metaphor of “ghost doctors” who remain frequently absent from their workplace. Apart from weak structure of the rural health institution, this study suggests that the processes of health services at the UHC tend to influence the quality of health services. This means that providercentric consultation, poor provider behaviour, demand for bribe, harassment, lack of motivations among providers, inadequate consultation time, faulty referral procedures cause patient dissatisfaction and result in ineffectiveness of care. Zaman (2005, pp.123-134, 155-176) and Andaleeb (2000) suggested that doctors and support staff such as ward boys, cleaners and gatekeepers misbehave with patients in the context of urban health systems. Chowdhury (1990) suggested a lack of commitment, cordiality and motivation among rural health workers in Bangladesh. This study provides support in favour of these study findings in the UHC context. This research indicates that people avoid the lower tiers of the rural health system. This provides support

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in favour of Paul’s (1999) findings. Paul (1999) had suggested that people tend to by-pass the national health care system due to perceived low quality. This research points to the by-passing within the rural health care system. People bypass the Union or village level health tier and seek health care at the Upazila level. Some relatively wealthy ones bypass the Upazila system and seek health care at the city or town levels. The richest seek health services in India. Thus the bypassing of health services occurs at different levels within the Upazila. However, the research does not show that the majority of the rural people bypass the national boundary for better treatment, perhaps because of lower income. The bypassing appears to be connected with higher income and perceived low quality in the government health facilities. The results further indicate that income, geographic isolation, and poverty translate into health inequalities in terms of access to quality health services. It appears that low income groups and women find it difficult to access quality health services. Consistent with Zaman (2005, p.104), this study shows that the poorer village people seek health services in low-cost government health centres. The low-income groups cannot afford to pay for privately provided health services, whether provided by the Government-appointed doctors or other private providers. Similarly, women face social barriers to access health services. The World Health Organization (WHO) suggests that health systems need to be designed in such a way that they cater to the needs of the periphery (cited in Newell, 1988). The public level Upazila health system does not fully cater to the needs of the periphery. CONCLUDING REMARKS This paper demonstrates some key structure, process and outcome-related quality shortcomings in the rural health system in Bangladesh. The structure-related shortcomings are associated with inadequate resource allocation on the one hand and misuse and even nonuse of the same on the other. In other words, while there is manpower shortages and resource constraints; this paper suggests that the existing resources are not being used properly. Again, the health services at the lower level remain unused as doctors frequently remain absent from their posts. Therefore, the existing manpower and health service resources need to be utilised properly prior to employing more doctors and health professionals to address the structure-related quality shortcomings. To achieve this goal, it is essential to properly monitor and evaluate of the Upazila health service delivery on a continuous basis. Citizens’ voices and participation in ensuring accountability of the UHC may also help achieve this goal. An appropriate needs assessment of

the rural health services need to be done taking due cognizance of the proportion of population and not merely on the basis of administrative unit such as Upazila. This paper also demonstrates the need to pay urgent attention to the process of service delivery for quality improvement in the rural health system. Usually the focus of health development has been on the structure aspects of quality. To improve the confidence and trust of local people in the public health services, the processes of services may be improved by providing adequate consultation time, delivering services at the right time, motivating the providers to provide care more responsibly, curbing corruption, providing more integrated referral services and avoiding unnecessary referrals. These would contribute to quality improvement of the governmental services through greater access, equity and more service utilisation, and thus may help achieve the policy goal of “health for all”. ACKNOWLEDGEMENT This research was partially supported by the Asian Development Bank (ADB) and the Government of Japan. REFERENCES [1] Andaleeb, S. S. (2000). Public and private hospitals in Bangladesh: Service quality and predictors of hospital choice. Health Policy and Planning, 15(1), 95-102. [2] Andaleeb, S. S., Siddiqui, N., & Khandakar, S. (2007). Patient Satisfaction with Health Services in Bangladesh. Health Policy and Planning, 22(4), 263-273. [3] Anwar, I., Kalim, N., & Koblinsky, M. (2009). Quality of obstetric care in public-sector facilities and constraints to implementing emergency obstetric care services: Evidence from high and low performing districts of Bangladesh. Journal of Health, Population and Nutrition, 27(2), 139-155. [4] Bangladesh Health Watch. (2010). How healthy is health sector governance? Bangladesh Health Watch Report 2009. Retrieved August 15, 2010, from http://sph.bracu.ac.bd/publications/reports/bhw/2 009/BHW%20REPORT%202009.pdf [5] Chaudhury, N., & Hammer, J. S. (2004). Ghost doctors: Absenteeism in rural Bangladeshi health facilities. The World Bank Economic Review, 18(3), 423-441. [6] Chowdhury, A. M. R. (1990). A tale of two wings: Health and family planning programmes in an Upazila in Northern Bangladesh. Dhaka: BRAC.


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