Health Sector Problems in Bangladesh: Developing a Management Point of View

1. Introduction

This paper originated from a series of research focused on ‘management in government’ in Bangladesh where author argued that government of Bangladesh as an organization need to develop managerial approach both from top down or strategic angle or from bottom up view of citizens (Khaled, 2013; 2018). Using the media reports, field visits, and citizen interview, an earlier paper argued for education sector problems that those are management problems rather than budget shortage problem (Khaled 2023). Similarly, this paper focuses on health sector problems.

According to reports from the World Health Organization and other development partners, quantitative figures show Bangladesh has made notable progress on key public health indicators (WHO, 2015; Ahmed et al., 2015; Chowdhury et al., 2013). Though the exact figures vary across organizations like WHO, USAID, and DFID, there is consensus that Bangladesh has made commendable strides in basic health service coverage—particularly in immunization, child and maternal health, and life expectancy (World Health Organization, 2015; Ahmed et al., 2013). However, substantial challenges persist, such as low doctor-to-population ratios, under nutrition among children, and uneven access to quality care (Chowdhury et al., 2013; Ahmed et al., 2015). Across multiple reports, the quality of service delivery and the effectiveness of management systems have consistently been identified as key areas of concern, overshadowing the progress made in physical infrastructure and coverage (Haque et al., 2021; WHO, 2022).

This paradox suggests that health sector performance is often undermined not by the lack of medical expertise or funding, but by weak planning, poor coordination, and insufficient accountability in service management.

Bangladesh has a health system predominantly governed by the public sector, with the Ministry of Health and Family Welfare (MOHFW) playing the central role in policy formulation, planning, and resource allocation. Under this ministry, key agencies such as the Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP), Directorate of Nursing Services (DNS), and Directorate General of Drug Administration (DGDA) are responsible for service delivery at various levels (Ahmed et al., 2015). However, poor coordination, overlapping roles, and centralized control often delay implementation and reduce responsiveness at the local level (Osman, 2004; World Bank, 2010). Accountability remains weak, especially in upazila and district facilities, where local needs are often unmet due to bureaucratic rigidity (Martinez et al., 2011; Haque & Osman, 2021).

There are many reforms and projects in the health sector by Bangladesh government and international donors. While appreciating the right reforms, we need to continuously check and balance what all these mean at the citizen experience level. As we know, there are so many reforms that failed by design or by implementation, or produced too little result (Andrews, Pritchett, & Woolcock, 2017; Martinez et al., 2011). How can management in the health sector be improved where many health sector problems may not be health-related problems, but rather management-related ones (Haque & Osman, 2021; Lewis, 2006)?

With this central question, we conducted a qualitative inquiry by systematically reviewing national newspaper reports and conducting field visits to medical colleges and health centers across Bangladesh. Rather than focusing on frequently reported incidents, we intentionally selected diverse examples to reflect the broader range of systemic health service failures. The aim was not to statistically map the prevalence of specific problems across administrative regions (e.g., upazilas or districts) or health workforce categories (e.g., physicians, nurses, or equipment technicians), nor to analyze public perception through attitudinal surveys or factor analysis. Instead, our primary objective was to explore the type, scope, and recurring nature of service delivery breakdowns - especially those which we think is a matter of management (or lack of it). That means we looked for those problems that stem from weaknesses in public sector management rather than from medical or financial deficits (Haque & Osman, 2021; Andrews, Pritchett, & Woolcock, 2017; Khaled, 2023).

The remainder of this paper is organized as follows. Section two outlines the qualitative methodology used for this study, including case selection strategies, data collection techniques, and the rationale for combining secondary media analysis with primary field observations. Section three presents findings from the content analysis of newspaper reports collected in two distinct phases (2009–2012 and 2021–2024), highlighting recurring patterns of management failures in the health sector. Section four complements these findings with citizen narratives and field-based observations gathered during site visits to various healthcare facilities. Section five synthesizes these insights to provide a consolidated analysis of systemic dysfunctions from a management perspective. Section six offers policy recommendations to address the identified management gaps, while Section seven concludes by reflecting on the broader implications for public health governance and service delivery reform in Bangladesh.

2. Methods of Observations and Analysis

Since our objective is to understand in-depth, the nature of the problem, the qualitative approach was deemed appropriate (Creswell and Creswell, 2017; Bryman & Bell, 2011; Saunders, Lewis, & Thornhill, 2012). Case development is a particular type of qualitative approach where systemically detailed examination combines various methods of inquiry using multiple sources of evidence (Yin, 2018; Stake, 1995). Case study research is particularly valuable for developing in-depth understanding of complex issues within real-world settings, as it draws upon multiple sources and methods to construct a comprehensive view of the phenomenon under investigation (Yin, 2018; Stake, 1995; Creswell & Creswell, 2017).

In this study, the health sector of Bangladesh is treated as a holistic case, where various sub-instances across time and place were synthesized to analyze the broader pattern of public sector management failures. This method was more suitable than conventional health sector metric studies, which are already abundant from government and donor sources, but often fail to capture the operational realities on the ground (Ahmed et al., 2015; Buse, Mays, & Walt, 2012).

To understand the main problems in the Bangladesh health sector, both primary and secondary information was gathered from the ground.

Secondary: Leading newspapers were randomly selected and articles related to health sector were selected up to the point that all levels of health and problems are represented in the sample. This was done in two phases, 2009-12 and 2021-24 to see the recurrence of the same nature of the health sector problems. This longitudinal approach helped to capture persistent patterns of dysfunction, in line with qualitative content analysis strategies (Bowen, 2009).

Primary: An ethnographical approach was followed to understand the nature of the study problem. Primary data were collected through ‘living is the setting’ field visits, direct observation, and citizen interviews, to study how service failures are experienced at the point of care (Hammersley & Atkinson, 2007). Observations were conducted both on-site and off-site over extended periods (Marshall & Rossman, 2016).

Another important point to repeat here is that in such empirical, naturalistic, in-depth qualitative and field research, analysis is intertwined with observation (Yin, 2003; 2018; Creswell & Creswell, 2017); Charmaz, 2014). Thus, the following sections integrate observation, interpretation, and narrative to develop a management-oriented diagnosis of health sector problems in Bangladesh.

4. Analysis and Discussions: Field visit and citizen observations

In addition to desk research based on recognized national media outlets, we conducted extensive field visits to several health complexes (names are not mentioned due to confidentiality of particular health complexes and KIs- key informants). We also interviewed patient citizens, onsite at health complexes and offsite elsewhere at convenience

Following is a sample of mismanagement of health care sector problems in citizen life:

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Lack of government initiative in monitoring price of medicine.

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Pharmacies selling illegal medicines is a rampant practice; mobile court operations are seen sometimes; welcomed by citizens but it is irregular and not sustainable. (Drug administration issue)

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Doctors prescribe those company medicines which maintain ‘good’ relationship with doctors.

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There is an unhealthy competition among pharmaceutical companies to push their medicines to doctors and ultimately to citizen patients.

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Medicine stores sell the medicines without any effective control and monitoring of drug administration and related authority.

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Mobile court of district administration is run suddenly on some days and some retail drug shop owners are punished on the spot for selling unapproved medicines. But there is no systemic mechanism of coordination among the district administration, police and concerned directorate.

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Shortage of doctors or nurses or medical assistants or technicians in different medical centers (Union level Community Clinics, Upazila Health complex, General Hospital)

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Diagnostic equipment like X-Ray machines, are out of order; repairing takes long time even for years; technologists remain idle.

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When machines are repaired, or new machines arrive, technologist’s posts are vacant due to transfer or long process of recruitment. When machines and machine handling technologists are there, maybe doctors are not there.

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Doctors drawing salary without attending medical centers or work places.

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Doctors on deputation to district hospital; medical centers remain without adequate doctors.

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Post vacant in the hospitals; nurses remain unemployed

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Doctors are posted into union medical sub center but there are no office logistics for their sitting or working.

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Using the title of ‘Dr.’ by untrained and unqualified person citizens going to them unknowingly. It is not clear to citizens how to check the qualification.

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First impression of a health complex is not healthy. Bad impression starts from premises. Patient waiting area, corridors, rooms are not kept tidy. They said, they continually have shortage of cleaning and support staffs.

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Medical officers are busy, consultants are not busy, surgeons are almost idle due to unavailability of medical logistics. Some consultants are deputed to district level hospitals or medical college hospitals to fill the gaps there or for post-graduate training.

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X-ray and other pieces of laboratory equipment are either out of order, or films are in shortage, or technologist post is vacant. So due to lack of any one component of service system, patients have to go to external private lab or clinic for diagnostic tests as prescribed by medical officers and consultant doctors.

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Ambulance is there, driver post is vacant, if driver is there, fuel budget is not allocated. If fuel is there, driver is not there. If everything is there, ambulance is out of order due to maintenance problem. So Ambulance remain idle and driver remain without any work.

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Union health centers are in name only, doctors can hardly go there and sit there because most health centers do not have bare minimum logistics facility for a doctor or even a SACMO (sub-assistant community medical officer) to provide a package medical treatment of patients.

Upazila Health and Family Planning Officer (UH&FPO) is almost helpless because he neither can dictate the consultant doctors who are more qualified by education and post-graduate qualifications, nor he can fill the vacant positions of doctors, medical technologists, or other support staffs according to his need instantly. For filling up the posts to run the health complex as a system, he has to wait for long government recruitment procedures. In the meantime, patient cannot wait and citizens loose the trust on the system. So, the system is there but it does not work at no fault of UH&FPO and or doctors.

5. Consolidated Analysis and Discussion

Medical challenges—such as disease outbreaks or a shortage of trained specialists—are often cited, but deeper examination reveals that even available resources are misaligned or underutilized due to managerial dysfunction. Similarly, while low health budgets are a concern, numerous examples show that existing funds are wasted or fail to translate into service delivery due to poor planning, delayed recruitment, lack of accountability, and mismanagement of logistics. For instance, diagnostic machines remain idle not because of budgetary constraints, but due to the absence of trained technologists or maintenance oversight.

Doctors complain that they do not have sufficient work environment and living condition in Upazila and even some district level hospitals. Also they say that there are not minimum facilities for their children’s education and other social facilities. Citizens complain they do not get service oriented mentality from doctors. Doctors give necessary and unnecessary diagnostic tests and medicines. There are good doctors but negative impression is very dominant.

About medicine, we have a very good drug policy that enabled Bangladeshi pharmaceutical companies excel and even export to international market. But within the country citizens are at the mercy of the pharmaceutical companies combined with weak law enforcement for illegal and outdated medicines. Effective monitoring and controlling mechanism is absent due to poor management control and coordination from Drug directorate and law enforcement mechanism.

Hospitals lie empty while patients flood private clinics, not because there are no buildings or equipment, but because of personnel misallocation and weak service integration. Vacant posts coexist with thousands of unemployed nurses due to weak HR planning and broken recruitment pipelines.

These are problems that reside in how the ‘health system’ is organized, governed, and led — the core concerns of management. Therefore, to truly reform and improve health outcomes, attention must shift from merely increasing funds or medical capacity to redesigning and strengthening the management systems that determine how healthcare resources are planned, deployed, and held accountable.

6. Policy Implications: Addressing the Management Gap in Health Sector

The persistent nature of service failures in the Bangladeshi health sector—reflected in repeated headlines over the past decade—underscores a crucial insight: the primary challenges are more non-medical in nature, nor are they simply about insufficient funding. Rather, they reflect deep-seated management failures that cut across planning, coordination, implementation, and accountability functions. Following is a set of policy recommendations based on the above analysis and discussion. The categories presented (strategic human resource planning, operational systems and service integration, regulatory and institutional governance, performance monitoring and management capacity building) addresses core dimensions of the management failures identified in the study.

• Strategic Human Resource Planning

• Integrated human resource planning (HRP) should be introduced to align the supply of health workers with the actual demand across different locations and levels of care.
• Real-time HR databases can be utilized to monitor the availability, attendance, and deployment of doctors, nurses, and technicians.
• Strategies aimed at rural retention should be developed, encompassing hardship allowances, housing provisions, educational support for families, and career incentives.
• A merit-based and transparent recruitment system needs to be established to eliminate irregular hiring practices and to restore institutional credibility.

2.

Operational Systems and Service Integration

• End-to-end operational protocols should be created to integrate infrastructure, staff, logistics, and service delivery, ensuring the simultaneous availability of machines, technologists, and doctors.
• Key operational decisions ought to be decentralized to functional management units at district and upazila levels, with clearly defined authority and accountability.
• Facility expansion, such as the addition of beds, must be accompanied by proportional increases in staffing and operational budgets.

3.

Regulatory and Institutional Governance

• The Drug Administration should be strengthened through enhanced staffing, targeted training, and the implementation of digital systems to monitor drug quality, pharmacy operations, and illegal sales.
• The mobile court system requires regularization and expansion via coordinated efforts among district administration, police, and the Directorate General of Drug Administration.
• Licensing and monitoring of medical practitioners must be rigorously enforced, including measures to prevent the illegal use of the “Dr.” title.
• The Bangladesh Medical and Dental Council (BMDC) should be empowered to take decisive action against quackery and fraudulent medical practices.

4.

Performance Monitoring and Management Capacity Building

• A transition from routine compliance to performance-based accountability systems is needed, incorporating regular monitoring of absenteeism, service quality, and patient feedback.
• Digital attendance tracking and biometric systems can be introduced to support more effective monitoring of presence and performance.
• A trained cadre of public sector health managers at middle and facility levels should be developed through specialized education in health management.
• Citizen satisfaction and service responsiveness may be included as key indicators in the evaluation of health facilities.

By embedding these reforms within a coherent management-centered approach, health sector governance can shift from reactive firefighting to proactive service delivery. Without such a realignment, medical and financial investments will not be effective in terms of producing desired citizen outcomes.

7. Conclusions

There is a management problem at system level in the health sector. Top level management – ministries, secretariats, and DG health has little understanding of nuances of the system and incentive mechanism of bottom level upazila health complex and union health centers. The persistence of recurring failures in Bangladesh’s health sector—across both time and geography—demands a strategic shift in policy focus: from medical inputs and budgets to management systems and accountability.

There are clearly visible signs of progress in health sector in terms of indicators, physical investments, vaccination programs, and even strategic documents. Said that however, there is a need to be critical about what is missing on the ground at the bottom, where citizens interact with health system on a day to day basis. It is sometimes said in popular media that budget should be increased in health sector. But our core argument from the analysis above is increasing budget will not solve the nature of the problems of Bangladesh health sector. There should be a significant ‘management’ reforms or improvement of the whole system of resource allocation, incentive system and enabling environment.