Policies designed to assure health for all must be backed by strategies and a promise to deliver

Bangladesh outperformed some of the best countries in the world in handling the pandemic. It was not because a miracle happened, and that overnight, the health care system became super-efficient.

The fact is the government and people were aware of the cracks in the system and the gravity of the situation. A collaborative effort across the local administration, public and private health sector, ICT sector, pharmaceuticals industry, and citizens’ participation supported by the financial protection to the industries and vulnerable helped fight the pandemic.

The government’s commitment to achieve universal health coverage (UHC) by 2032 will need a similar coordinated effort. Higher health spending, policy reform, optimum health human resource, and innovation in service delivery will be mandatory.

The Western welfare states spend 9-12% of their gross domestic product (GDP) on health when the world average is 5.99%. Bangladesh spends only 3.5% of its GDP on health care where government spending out of the total is 23%, followed by development partners’ 7% and NGOs’ 3%. Although the government’s financing in health care has increased over the years correlating to inflation, the relative share of allocation of funds as a percentage of total spending has steadily declined.

Despite this chronic underspending, the country surpassed its neighbours in increasing life expectancy, reducing fertility, and the mortality rate of mothers and infants.

Bangladesh health service delivery  

Government, private, NGOs, and development sector together participate in delivering health to the people of Bangladesh. The development partners contribute to financing and planning health programs, most of which are channeled through the government and NGOs. The actual services are combinedly delivered by the public and private sector.

Regulatory bodies

The Ministry of Health and Family Welfare (MOHFW) is the regulatory body for both public and private sector health delivery. This institution sets the policies and regulations on medical profession and standards, supply of drugs, medical institutions, and health workforce management.

Primary health care (PHC) at national and rural level are under MOHFW but PHC at urban areas are under the urban local bodies like the city corporations and the municipalities which are regulated by the Ministry of Local Government, Rural Development and Cooperatives. NGOs, regulated by the Ministry of Social Welfare are mostly not-for-profit and provide preventive and basic care to the low-income population.

The private sector, mostly for-profit organizations, consist of medical colleges, hospitals, clinics, and pharmacies. They employ more health care providers than the public sector.

Health financing in Bangladesh

Revenues from tax, non-tax, foreign loans, development funds, and grants are all channeled by the Ministry of Finance to all ministries including the Ministry of Health and Family Welfare.

Public spending on health is entirely borne by the central government. The Ministry of Health’s share of total health spending by the government is about 93.0%. The government budget on health is divided between revenue and development budget.

The revenue budget is the expected outflow of the recurrent costs, for example — institutional running costs, salaries and allowances, drugs and medical supplies, operating costs and maintenance of beds, vehicles, etc. This routine outflow is based on a fixed number of beds and not on the disease burden, population size, and needs.

The local administrations — starting from the union health centre/ community clinics up to the district hospital submit their medical supply needs to the central level, but it is the discretion of the Health Ministry on what they will allocate.

The development budget consists of the health promotion programs. There is chronic underspending of the development budget. The financial allocations are constrained by bureaucratic rules where local officials have no authority to switch money between budgetary subheads without the consent of the Ministry of Health.

Urban health care, under the city corporations and municipalities have their separate budget. 90% to 100% of this is from the Ministry of Local Government, Rural Development and Cooperatives. Only about 8% comes from user fees and drug sales. The resources are used to deliver PHC, recruit health staff, establish facilities, provide mosquito control, ensure child immunization programs, and provide inpatient and outpatient care of city corporation hospitals.

Currently 33% of the population reside in urban locations, which is expected to rise to 50% by 2039. Urban pharmacies and general hospitals are the largest cost centres. 31% of the total population suffering from chronic diseases live in the urban cities. Diabetes and hypertension are closely followed by a rise in lung diseases due to poor air quality and infrastructural development work. In 2015, urban per capita expenditure was estimated at Tk4,869, compared with Tk2,341 for rural individuals.

Services covered

Government provides primary, secondary, and tertiary medical care which, depending on where people live, can be availed from community clinics up to tertiary level medical colleges and specialized hospitals.

The Bangladesh Essential Health Package policy and the 13,000 community clinics were set by the government as the first step towards UHC by making primary care accessible to all citizens. The basic primary care services covered at all levels are — normal delivery, non-communicable disease screening, social and behaviour change communication, immunization programs, antenatal and post-natal care, family planning services, growth monitoring, and nutrition with free supply of listed essential drugs. For every 6,000 people there is one community clinic.

Health care at public facilities is mostly free with a minimal user fee. The outpatient consultation user fee is only 10 taka per visit, drugs on the essential drug list are free of cost, hospital beds in the wards are free, shared rooms and cabins are charged a minimum 150 to 600 taka per day. In public facilities, the out-of-pocket (OOP) expense is incurred while buying medicines, surgical supplies, investigations, and informal payment to staff to receive better care.

In the last two decades the government doubled the supply of free medicines for people. This, along with increased awareness in seeking care from qualified providers have shifted the OOP spending on inpatient care.

Compared to the public health sector, the private sector thrived and offered better-quality services. The private sector market is competitive, and services are charged higher. High OOP expense is attributed to purchase of pharmaceuticals and medical goods. The void in the quality of care and coverage in public facilities is compensated by private facilities but at a much higher cost. However, accountability of the services remains unaddressed in both the sectors.

Health human resources of Bangladesh

Health human resource planning in Bangladesh lacks a structured policy. Every year, 10,500 medical students enroll in the 37 public and 72 private medical colleges. Every year, 3,500 students graduate from the government and 5,000 from private medical colleges. On top of this, there are 39 postgraduate medical teaching institutes, one armed forces and five army medical colleges, nine public and 200 private medical assistant training schools, 13 public and 97 private institutes of health technology.

The number of government-sanctioned positions in the health sector is inadequate compared to the global standard, and 20% of these posts remain vacant, mostly for remote placements.

Currently, there are 5.26 doctors to 3.06 nurses for every 10,000 people. World Health Organization recommends a ratio of 1:3:5 of doctors to nurses to technologists and Bangladesh’s ratio is 1: 0.4: 0.24. The shortage of skilled health workers in addition to the distribution of them disproportionately skewed to the urban areas leaves the rural facilities overburdened, understaffed, and insufficiently equipped.

Most doctors prefer to become specialists and work in private facilities. To retain doctors in public facilities, the government needs to create positions and benefits for family medicine and other disciplines depending on the need. A clear strategy may incentivize more doctors to choose the profession smartly.

UHC can only be achieved when an adequate number of skilled health care providers are working in the system. Service delivery reform must keep human resources at the centre of any policy initiative.

Health-seeking behaviour

Mostly, the educated people have a health-seeking attitude. Health education campaigns on immunization, family planning, hand washing and sanitary practices, etc are frequently conducted by both public and private sectors. A culture of regular health screening is absent which could have produced more informed citizens.

A lot of time, the unavailability of doctors or nurses, their attitudes, waiting time, and travel time in the public facilities trigger a tendency of self-medication. Except for a few, most drugs available in the local pharmacies can be bought over the counter and are not strictly regulated as prescription-only drugs.

Since pharmacies are conveniently located and some offer services like injectable medicine administering and blood pressure and blood sugar monitoring, many people avoid going to doctors to save time and money and instead go to these pharmacies. By law, the government can impose regulation to formalize such entities as primary care givers to expand PHC.

Drug policy

Bangladesh has a robust pharmaceutical industry and most of the drugs are manufactured from buying patents from foreign pharmaceuticals. The industry fulfills 98% of the total domestic consumption. The National Drug Policy of 1982 emphasized on making quality essential drugs available at an affordable price. Currently, the government fixes the maximum retail prices of 117 listed essential drugs. For other “non-essential” drugs, an “indicative price” is fixed by the pharmaceutical companies themselves, to which the government adds 15% VAT, resulting in a steady increase in prices.

Health insurance

Health insurance to finance health care is not established in Bangladesh. There are fragmented policies mainly targeting employed people. Some of the schemes in practice are — the public and private employer operated schemes, Bangladesh Employee Welfare Board, health care of prisoners by the Ministry of Home Affairs, and government schemes for all civil servants, teachers, and students at public universities, employees of railways, docks, estates, and factories.

icddr, b, BRAC, and Grameenphone give part health insurance to their employees. The private insurance companies sell Mediclaim policies for travelling abroad, group health plans to employers, and policies for individuals. NGOs like Gonoshatho Kendro, Grameen Kalyan, BRAC, Sajida Foundation, Shakti, and few others offer health insurance services to their clients.

Commercial banks, pharmaceutical companies, telecommunications companies, and consortiums segregate a fund as corporate social responsibility (CSR) which is used for social welfare programs.

Tools to build an accessible healthcare system

Primary health care (PHC): UHC development’s core competency lies in providing social protection schemes to reduce OOP by expanding public expenditure. The best utilization of this expenditure would be spending on PHC. When PHC is made the first point of contact as the gatekeeper, it will ensure equitable distribution of services, reduce unnecessary over-utilization of hospital or specialist care, and keep the population healthy.

Countries like Thailand, Singapore, Vietnam, and the European nations spent decades consolidating PHC. A robust PHC will justify the tax money spent on health schemes, bring credibility, and gather support from the people. The perceptions of better care will generate public proponents for an enduring policy. Inter-sectoral participation to ensure access to safe water, sanitation, adequate food, pollution-free environments, and health education and awareness are also extensions of PHC.

Health information system: An integrated, secure, agile, and scalable health information system is the backbone of any modern health system. It is an enabler of access to health and a conduit of surveillance system. The information gathered and stored will guide the strategic direction. It is expensive but progressive in nature in identifying disease incidence, gaps in the system, resource planning, ensuring accountability of facilities and providers, and analyzing trends to build capacity of institutions.

Bangladesh has the perfect base to leapfrog through digital innovation in the health care sector.

Accreditation of hospitals: Health care accreditation defines standard and innovation of health care facilities. It is not mandatory by law in developing countries but in countries where health care is paid by a third party, accreditation from authorized bodies is required for accountability of the providers.

Joint Commission International (JCI) is a renowned accreditation organization in Asia and India has 36 JCI accredited hospitals. Bangladesh has only one. Accreditation is a commitment by an organization to continuously improve their quality.

What are the two elements to achieve UHC?

UHC development in Bangladesh will require a variation of a social safety scheme that will promote PHC. It will be difficult to design since most of the population work in the informal sector. A good place to start might be formalizing the schemes already available, pool funds from CSR, zakat, and excise duties already taken from the citizens’ savings.

Policies designed to assure health for all must be backed by strategies and a promise to deliver. Any social protection system reinforced by essential PHC will have social enrollment from the public as it has shown to improve the patient’s journey through the health system at a lower cost.

Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Master’s in Health Care Leadership.

Source of Dhaka Tribune