Health reform cannot wait, fix the system, not just the symptoms

Bangladesh's health sector has reached a point where short-term actions, isolated inspections, and reactions to individual incidents are no longer enough. A missing laboratory test, a broken machine, an unavailable reagent, a shortage of staff, or a weak referral pathway may look like separate problems. In reality, they often reflect deeper weaknesses in how the system is organised, managed, monitored, and held accountable.

The discussion must therefore move beyond individuals and focus on the system.

One of the most worrying developments would be the creation of a "public versus doctors" mindset. Patients and doctors are not on opposite sides. They are partners in the same health system. Their relationship depends on trust, communication, and mutual respect. If that trust is damaged, the whole system suffers.

Doctors must, of course, be accountable for attendance, professional conduct, clinical competence, communication with patients, and the quality of care they provide. No profession should be above accountability. But no doctor works alone.

A hospital depends on administration, nursing, laboratories, pharmacy, stores, procurement, supply chains, equipment maintenance, human resources, finance, information systems, and effective leadership. If one part of this chain fails, the effect eventually reaches the patient.

For example, if a critically ill patient urgently needs a serum electrolyte test and the hospital cannot provide it, the main question should not simply be, "Why did the doctor send the patient outside?"

We should also ask: Why was the test unavailable? Was the reagent out of stock? Was the machine not working? Was maintenance delayed? Was there a shortage of trained staff? Was procurement started on time? Where did the supply chain fail? Was the problem reported to the administration, and what action was taken?

That is the difference between blaming an individual and identifying the real cause of a problem.

Health reform requires root-cause analysis, not public blame; institutional accountability, not selective accountability.

Accountability Must Follow Responsibility

Every part of the health system should have a clear responsibility.

Doctors should be accountable for clinical decisions and patient care. Hospital administrators should be accountable for the overall functioning of the institution. Procurement and supply teams should ensure that medicines, reagents, and essential supplies are available when needed. Engineering and maintenance teams should keep equipment operational. Human-resource authorities should ensure appropriate staffing. Policymakers should provide the financing, rules, workforce planning, and administrative structure necessary for the system to work.

The principle should be simple: if someone is responsible for a function, that person or institution must also be accountable for its performance.

When responsibility is unclear, blame moves from one person to another and the real problem remains unresolved.

The Right Person in the Right Position

Health reform is not only about money, buildings, or equipment. It is also about leadership.

One of the most important questions is whether the right people are being appointed to lead hospitals, medical colleges, medical universities, directorates, and other major health institutions.

These are not ceremonial positions. The quality of leadership affects patient care, staff morale, discipline, education, research, procurement, financial management, and the overall performance of the institution.

Appointments should therefore be based on competence, experience, integrity, professional credibility, administrative ability, and leadership capacity.

Personal preference, political loyalty, patronage, or gratitude should never replace merit.

This principle should apply under every government.

A weak appointment can damage an entire institution. Decisions may be delayed, capable professionals may become frustrated, discipline may decline, resources may be poorly used, and patient care may suffer.

In the end, the public does not usually separate the failure of one official from the failure of the health system. They see it as a failure of the state.

That is why putting the right person in the right position is itself an important health reform.

The Better Question Is: Why Did the System Fail?

Public debate often asks: Who is responsible?

A more useful question is: Why was the system allowed to fail?

Where is there responsibility without authority? Where is there authority without accountability? Where are there hospitals without enough staff? Where are there machines without maintenance? Where are there budgets without timely procurement? Where are there specialists without proper referral pathways?

These are the questions that lead to real reform.

Health reform is not simply about building more hospitals, buying more equipment, or creating more posts. It is about improving how the whole system works—how patients enter the system, how they are referred, who makes decisions, how services are monitored, and who is responsible when something goes wrong.

Patients and Doctors Must Be Partners

The public has every right to expect good service from doctors. Doctors, in turn, must uphold professional standards and treat patients with dignity, competence, and respect.

But doctors also need a working system around them.

If essential tests are unavailable, medicines are missing, ICU beds are limited, trained staff are insufficient, or referral links are weak, no individual doctor can correct every system failure.

The solution is not confrontation. The solution is cooperation and trust.

Patients and doctors should be seen as partners, not opponents.

Accountability should apply at every level—clinical, administrative, institutional, and policy.

Accountability must be fair, practical, and linked to responsibility.

A Permanent National Health Commission

Bangladesh also needs a structure that can keep health reform moving beyond the tenure of one government, one minister, one secretary, or one administration.

A Permanent National Health Commission could provide that continuity.

The Commission should not have executive power.

It should not run hospitals, appoint or transfer officials, control procurement, or replace the Ministry of Health.

Its role should be to oversee, supervise, evaluate, and recommend.

The Commission should monitor whether agreed reforms are being implemented, identify delays and gaps, review institutional performance, assess outcomes, and provide practical, evidence-based recommendations to the government.

It should function as a high-level independent oversight and advisory body.

The Ministry and other relevant authorities would continue to make and implement executive decisions. The Commission would help ensure that reform stays on track.

It could regularly review areas such as primary healthcare, referral systems, workforce planning, hospital performance, procurement, supply chains, health financing, quality assurance, digital health, and patient experience.

It could also publish a periodic National Health Reform Progress Report, showing what has improved, what has not, and what needs to be done next.

Ministerial Status, Without Executive Power

For such a Commission to work effectively, its Chair should have sufficient institutional standing.

The Chair could be given ministerial status, allowing effective coordination with ministries, directorates, universities, hospitals, and other national institutions.

But that status should not mean executive authority.

The strength of the Commission should come from its credibility, independence, professional quality, and evidence-based recommendations.

In practical terms:

It should not run the system; it should review the system.
It should not issue orders; it should make recommendations.
It should not replace the Ministry; it should help the Ministry and the government keep reform on course.

Why Dr Zubaida Rahman Could Be Considered

In recent months, Dr Zubaida Rahman has become increasingly visible in health-related programmes and public discussions, and this growing engagement suggests that the time may be right for a more structured role in national health reform. She could be considered to lead a Permanent National Health Commission not simply because she is the spouse of the Honourable Prime Minister, but because of her medical background, public-sector experience, postgraduate academic exposure, and broader interest in health and social-sector issues. In a non-executive, convening, and oversight role, she could help bring together government, clinicians, public health experts, universities, civil society, development partners, and patient representatives around a common reform agenda, while her access to the highest level of government could help ensure that evidence-based recommendations receive timely attention. In such a role, she would not run the health system; she would help keep reform focused, coordinated, and on course, within a merit-based, non-partisan, professionally credible, and institutionally independent Commission.

No Patronage, No Factionalism

The quality of the Commission will depend heavily on who is appointed to it.

If it becomes another platform for political loyalty, personal influence, or professional group interests, it will lose credibility.

The Commission should therefore be built around people who have proven knowledge, experience, integrity, and the ability to deliver.

It should include experienced clinicians, public health professionals, nurses, health economists, hospital managers, researchers, digital health experts, health-financing specialists, legal experts, administrators, and representatives of patients and civil society.

The principle should be clear:

No partisan patronage.
No factionalism.
No personal favouritism.
No monopoly by any one professional group.

The country needs people who understand the problems and can contribute practical solutions.

What Reform Should Deliver

Real health reform should focus on a few clear priorities.

Primary healthcare must be strengthened. A functional first-contact and referral system must be established. District and regional services must be made capable enough to reduce unnecessary pressure on tertiary hospitals. Leadership appointments should be merit-based. Hospitals should have greater management flexibility, but with clear accountability. Procurement and supply systems must become reliable. Workforce planning should be based on need. Health financing should become more sustainable. Digital health systems should support continuity of care and monitoring. Institutional performance should be reviewed regularly.

Decentralisation is also important.

Not every decision should be made centrally. Where responsibility is given, adequate authority and resources should also be provided.

The goal is straightforward:

The right patient should receive the right care, at the right place, at the right time.

The Questions That Matter Most

The biggest challenge facing Bangladesh's health sector is not only money, infrastructure, or the number of doctors.

The more important questions are:

Who will lead reform?
What structure will keep reform going?
And who will be trusted to lead our major health institutions?

Without credible answers, occasional inspections, sudden directives, public criticism, and short-term administrative action may attract attention, but they will not produce lasting change.

Bangladesh needs to move from person-centred management to institution-centred governance.

Governments change. Ministers change. Secretaries, directors, vice-chancellors, and doctors eventually leave office.

Institutions remain.

That is why the goal should be to build institutions that work regardless of who is in office.

Not blame, but problem-solving.
Not patronage, but merit.
Not confrontation, but trust.
Not temporary reactions, but lasting reform.

The future of Bangladesh's health system may ultimately depend on one simple principle:

The right people, in the right roles, working within strong institutions, with fair accountability for all.

And to maintain reform beyond political and administrative change, a non-partisan, professionally constituted, non-executive Permanent National Health Commission is now not merely desirable—it is a practical national necessity.

Prof Dr Syed Akram Hussain, PhD, MPH, FCPS, is a cancer and public health expert, former member of the Health Sector Reform Commission, and advisor to the Doctors' Association of Bangladesh. He is the founding chairman of the Department of Clinical Oncology at Bangladesh Medical University.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the views and opinions of The Business Standard.