Most of the problems known refer to either the lack of transparency in management, pilferage in procurement, shortcomings in resources, lack of honourable attitude of the service providers towards the service seekers or poor understanding by the former of the woes of the poor and the female service seekers.

The one problem, to reckon with in the public health sector, is that of the attitude of the service providers. This is reflected in the form of their ignorance about the rights of the poor to seek public service. Keeping the poor waiting for longer than the rich, in not so an attractive environment for example, has several social, biological, environmental and economic drawbacks to the poor, which these service providers have not been taught to understand during their studentship. They have not been told to be socially responsive and responsible towards the community needs and demands.

Health care providers' greatest weakness in this country is that, they have not been taught to inculcate an analysing faculty and strengthen their management capability. Medical and paramedical education should therefore be the first to undergo reorganisation, so that it can address and manage changes in the environment around them, including establishment of an independent office of directorate general of medical, nursing and paramedical education. This would need only an SRO from the establishment ministry without any cost implication.

In addition, among the medical fraternity in Bangladesh there is a strange sense of apathy towards research, which is believed to be the first step towards improving quality of services and management. Public health sector has to sponsor operational research. Strengthening of the relevant structure and process should therefore be a priority.

For the enormity of the responsibility of ensuring satisfactory level of services in the public hospitals and diagnostic centers and providing stewardship towards the private sector health facilities, an office of director general of hospital services is an utmost necessity. In near future management of contracts will be an added responsibility that this office will have to bear, as more and more privatisation of the curative services is bound to occur. This will also need just an SRO, without any cost involvement on the part of the government. It may be noted at this point that health sector is the only public sector that has not seen any change in its structure since independence.

Paucity of resources is only half of the problem in the sector. The real problem is the lack of transparency in logistics and resource management. Whatever resources are available, including the human resources, have greater scope of improvement in efficiency. Duplication of human resources that exist in the bifurcation of the two directorates of the health and family welfare ministry and then addition of appendages of projects, e.g., National Nutrition Project, is a drain on the scarce resources. Procurement of unnecessary goods and ineffective human resource development and management are also source of formidable amount of inefficiency. Health sector expends about 45 percent of its budget on human resources and the rest 55 percent is also handled by them.

Unless the human resource management and development system is need and competency based with appropriate and adequate skill mix and their proper deployment, health sector will keep on failing to satisfy the people. This would require total de-politicisation of the system right from the recruitment to the deployment and awarding/promotion of the health sector personnel. This would need passing of a health policy in the national parliament, with appropriate clauses in adequate terms, on human resources development and management and with unambiguous clauses on need and equity based quality services to the people. Since the national parliamentary election is close by, now is the time to demand for a legally valid health policy.

Management of priority programmes will have to be given in the hands of appropriate personnel who should have adequate expertise to manage these costlier programmes. Inefficiency, that accrues from suspected handling of programmes monetarily and technically, by inept but politically favoured managers, leaves a trail that damages and spoils everything in the milieu. If programme directors and managers are not deft then programmes should be taken to train them up. But the fundamental condition of deploying a manager for managing a programme should be his/her past background of transparency. Unless this is ensured any allocation will be meaningless.

Decentralised management has been found, through numerous studies, to improve efficiency and need based financial management. The present financial rule that bars the public sector organisations from collecting and expending fund locally for local problems, has to be lifted, under some local fiduciary system, where public representatives would play effective roles. There should be public bodies in fact, for each programme and health facility for reviewing and monitoring quality, equity, efficiency and need based services to the poor. For poor areas government should have extra allocation.

Health care financing system itself also needs reorganisation. There are alternatives to the present day public sector financing. For the poor the most tried and successful financing packages are demand side financing in the form of vouchers and health insurance that would give liberty to the poor to choose their service providers, with all its positive consequences, that would follow such a strategy and would also save the poor from catastrophic illnesses.

Curative service may be privatised with safety nets for the poor, as most others would be able to pay for the services, albeit at staggered rates.

While tertiary hospitals are privatised to begin with, government would pay for the services that are given to the poor from these hospitals under some arrangement, e.g., voucher scheme. Free services in fact end up as a paid service, although in some other 'not so transparent' form, where poor are the ones who are marginalised. Free services are also not known for their quality and available range of services.

Because of the ease of ensuring accountability and hence more effective service provision, public-private partnership strategy will have to be resorted to. Public sector's cardinal role should be to ensure services to the people, how this is done should be of secondary importance, as long as it is cost effective and need based. Public sector's role should in fact be stewardship and financing of health provision. To this end the most fundamental function that it needs to do is managing contract rather than try to provide services itself any longer, as it has proved itself to be a failure in that. If government is the service provider and is also the monitor and evaluator of the provided services then the problems in the sector will never be admitted by the government and hence will never be improved. Who likes to confess one's weaknesses anyway?

The last and the most important is the fact that behind all the ills that we hear about the sector, there is some politics entangled. Health in fact is politics. Political support and understanding is the basic condition, if we really want any improvement in the present health care system. The responsibility of ensuring people's health should be in people's hands, which should begin with selecting positive parliament members who would ask the public sector service providers for accountability and transparency. As a vanguard force people should also form forums of health service seekers at every level to voice their feelings towards the sector and the service providers, as a matter of right and also participate in planning, reviewing, monitoring and evaluating the programmes that are taken for their good.

A. M. Zakir Hussain MBBS, MPH, Ph.D. (USA) is a health management specialist