For a more democratic health policy

Previous "consultations" with "communities and stakeholders" have been, to put it bluntly, desultory; with scant evidence of feedbacks actually impacting on either policy or programming. Equally scant has been the involvement of beneficiaries/clients in programme implementation and rigorous evaluation of end results.

Government of Bangladesh (GoB) is now negotiating credit agreement with Development Partners (DP) for 3-year Health, Nutrition and Population Sector Programme (HNSP) and medium term (2005-2010) Sector Investment Plan (SIP). This is a highly opportune time to establish a permanent mechanism -- an "open forum of prime movers" or equivalent -- on health and population policy and programming. And clearly, it is not sufficient or useful to confine the debate within selected academic and research organisations (with limited experience in operations and restricted independence due to funding); it is essential for "prime movers" to gain direct access to and interface with both the prime actors -- GoB and DP.

The writer is convinced of the need to create an open forum robust and representative enough to fill a significant space; a forum that articulates and advocates consumers' concerns and rights more on evidence than on opinion. As hinted earlier, I would caution against the forum being monopolised by elitist academics and research scholars. Experience suggests that to make a difference, it is not the form or finesse of the debate but how and upon whom the messages impact is more important. That is why the forum needs to be inclusive and not exclusive, not to be yet another "committee" or "think tank" but a loose network of members with demonstrated competence, integrity and representation. Also, not confined to the central level but multiplied to middle and grassroots level over time.

What has been missing (as noted by Rounaq Jahan) in academic debates is that dynamic interface with GoB and World Bank (as the leader of donor consortium). Without specifying exact details, I feel the forum has to be inclusive of policy associates within ministries and departments, social activists, peoples' representatives, and consumers. In the absence of a better name, this would be more or less a coalition of "prime movers"; such coalition groups could spring up over time at central, middle and grassroots level. The members of "prime movers" act in individual capacity in the coalition bringing experience, expertise, and evidence in the debates, discussions, and recommended solutions; incidentally, solutions applicable without depending on external interference matter more than list of problems. Local autonomy and ingenuity begin with local self-reliance.

The writer recalls experience in Thailand, where in the mid eighties, the permanent secretary of ministry of public health established a diverse group of "prime movers"; conceptualised and implemented a novel primary health care programme based upon village self reliance and inter-village collaboration. By its persuasive advocacy and later by real evidence, the group prevailed over the National Economic and Social Development Board to accept and adopt its innovative strategy. The key factor was the intensity and extensiveness of consultations at village and above levels that went into policy and programming. Interestingly and of much relevance to Bangladesh, the programme gave priority coverage to the poverty stricken provinces of Northeast Thailand.

Public consultations can take diverse forms but with same core concept. It can occur in an assembly of stakeholder/beneficiaries. The writer recalls another innovative (and risky?) undertaking when the ministry of health of Maldives (an archipelago of atolls and islands in Indian Ocean) carried out a "country health programming"(CHP) -- a health planning and programming exercise promoted by the World Health Organisation. Besides intensive consultations with officials, an assembly of residents of several atolls brought out raw but robust array of real and felt needs and constraints in health services; indicated how and where the islanders were willing and able to participate as partners and take charge of their own health (health promotion and health protection activities) adopting critical behavioural alternatives. .

The above two anecdotes are illustrative examples; are not necessarily recommended to be grafted. Yet, these might be eminently adaptable to suit Bangladesh conditions.

While on the subject, something that puzzles this writer is the creeping inferiority complex in Bangladesh that undermines the full expression and assertion of existing technical and intellectual capability in policy and programme development. Why else there is preponderance of foreign consultancy in design of policy and programme strategy? A permanent Open Forum (call it by any other name you wish) as an institutional mechanism (minus the inflexibility or elitism) gives the writer optimism that experience will prove such a forum as a good partner to GoB and the DP, hopefully by the objectivity and variety of independent findings. A more discretionary utilisation of external expertise is much better and rational leaving enough space for national expertise to grow in confidence and competence.

Let me turn briefly then to the second issue. It is customary to carry out what is often termed as "mid term" programme evaluation. Again, if my recollection is correct, the beneficiaries are not a part of the evaluation process and product. In health and population programme with huge investment of borrowed funds, one would assume it is extremely important to find out, to put it simply, "who gets what and when"? It should be disturbing to note many reports that GoB capital and recurring expenditures do not give the expected or intended outcomes; often produce unintended result of serving the relatively better off more than the poor whose needs are greater and more urgent. Evaluation should probe not only how much was spent by which allotted time but also for whom and to what effect. When it does, it informs policy and might impact upon all partners.

Again, to do this, you need a permanent mechanism that monitors the process and outcome and gives out situation alerts (chiefly at micro levels) to inform programme managers. Of course, evaluation should benefit from tested design and methods but yet again, in quite a few cases, a rapid (even if a bit dirty) evaluation will often give as reasonably valid and usable findings. Thus, a permanent joint evaluation mechanism (the mechanism is permanent but the team composition is not) that involves the beneficiaries in probing the right issues and measuring intended results will be a huge advance to the current "official" evaluation that normally puts one party (GoB) on the defensive and the other (DP) on offensive, with mutual complements thrown in as sweeteners.

The writer does not wish to be prescriptive; nor does he claim extraordinary expertise. But given the enormity of challenge the population policy and programme poses to the survival of Bangladesh; given also the tremendous opportunities underlying the same challenges, and that the programme is at a "take off" stage, all innovations towards a more refined and robust policy and new strategic direction based upon more responsive consumer orientation are welcome. There is a strong case for moving towards a health policy and programming driven more by the GoB than the DPs; supported by the twin inputs of an inclusive permanent "Open Forum" or equivalent mechanism, and a more probing evaluation of outcomes and impact. Would it be too courageous to call for a more democratic, more representative, and more evidence based health policy and programming where many more voices are raised and heard? Hopefully not.

Dr Zakir Husain is former Director, Programme Management, World Health Organization, South East Asia Region and former Chief, Health and Population, Planning Commission, Bangladesh.