Technical assistance to restructure the health services directorate

The objective of this study was to define and project the mandates and scopes of the Directorate General of Health Services (DGHS) in terms of health related SDGs, Seventh Five Year Plan, Perspective Plan, Project Implementation Plans of the 4th Health Nutrition and Population Sector Program (HNPSP), and various national and global Health, Nutrition and Population related  commitments of the Government of Bangladesh. The mandate of DGHS was to be inferred from listed documents and this study attempted to identify a range of themes that emerge from the policy documents. These themes can be described against an indication of the overall policy direction of the Government of Bangladesh (GoB) for health.

As part of the study, our team:

1. defined and projected the mandate of the DGHS;

2. assessed the organisational capacity of the DGHS to deliver the mandate and identify gaps; and

3. proposed a scheme to restructure the DGHS

Our approach

Study methodology included reviewing key policy documents, undertaking key informant interviews, making field visits to contrasting areas of Bangladesh, production of summary reports, small group meetings with DGHS leads, and holding workshop sessions with DGHS, MOHFW officials and development partners.

It was possible to access on-line accounts of health ministry restructurings in different countries and organograms of a number of national ministries of health were also available as inputs to the study. 

The key informants included DGHS, Secretary Health Services Division, Joint Chief Planning Wing and PMMU as well as the heads of MOHFW agencies such as National Institute of Population Research and Training (NIPORT), National Institute of Preventive and Social Medicine (NIPSOM), and Institute of Epidemiology, Disease Control and Research (IEDCR) along with divisional directors, civil surgeons and medical college principals.

Field visits were undertaken to four districts outside Dhaka and to facilities at all levels of health system including medical college hospitals, district hospitals, upazila health complexes, union sub-centres and community clinics. Visits were also made to Dhaka Medical College and Hospital (DMCH)  and to a not-for-profit hospital in Dhaka.

Outcomes

Based on the study, our report sets out a vision for a new structure for DGHS that responds to its mandate. In light of that, the proposed structure includes:

The potential for establishing new units within DGHS: proposal to establish new units or significantly enhanced units in the organogram supported with justifications. In this nomenclature a unit can refer to an ADG’s Wing, a Director’s responsibility or a cell under the control of a Deputy Director.

The potential for enhanced delegation to divisions, districts, and upazilas: significant strengthening of the role and capacity of the eight existing divisions is possible. Delegation of authority and responsibility aims to enhance decentralisation of decision making within DGHS and would:

• Permit each layer in the government health system to focus on its essential role: policy formulation by MOHFW, strategy development by DGHS centrally, strategy implementation by Divisional Directors, Hospital Managers and Civil Surgeons locally,
• Enable decision-making to be more sensitive to local needs and circumstances,
• Increase flexibility in the use of available resources,
• Permit greater influence on the development and operation of services by those who use them and local leaders,
• Lead to more timely decisions,
• Take pressure off the central DGHS staff, permitting more time for reflection and strategic thinking,
• Give purpose and direction to the Divisional Directors whose role currently is limited in scope.

Organograms, roles and functions

The existing structure is flat, with 12 Directors whose work is coordinated by two ADGs. It does not facilitate focussed delivery of the Directorates’ mandate and does not include some important functions. The new proposed structure is aimed at:

• Organising the Directorate’s functions into six distinct work streams under six ADGs designed to facilitate delivery of its mandate each with a manageable span of control;
• Making ADGs accountable to the DG for the performance of the Directors and opening the possibility of creating a top management team comprising the DG and the ADGs;
• Incorporating important functions that are currently lacking;
• Bringing all branches of DGHS (including IEDCR and Divisional Directors) into a cohesive management structure under the ADGs; and
• Creating a unified managerial structure from DG to Upazila with clear lines of delegation and accountability.

Legal and regulatory issues: existing policy and regulatory framework of the country pertaining to the health sector, including in particular the Health Policy 2011, needs to be reviewed and aligned in line with the TA recommendations.