Health sector faces ‘policy paralysis’

The ongoing Covid-19 induced health crisis shows the dilapidated state of government hospitals and public healthcare in Bangladesh. At the same time, it shows a lack of accountability in private healthcare.

The health sector in Bangladesh cannot provide the necessary healthcare because of high deficiencies in financing, efficiency, quality and equity. 

In 2017, the share of public health expenditure in the gross domestic product (GDP) was only 0.4 percent in Bangladesh, while the averages for lower-middle countries and South Asian countries were 1.3 percent and 0.9 percent respectively. For this reason, the share of out-of-pocket health expenditure in total health expenditure in Bangladesh is one of the highest in the world.

In 2017, this ratio was 74 percent in Bangladesh in comparison to the lower-middle country average of 55 percent and the South Asian average of 63 percent.

Bangladesh also has a very underdeveloped health infrastructure. For example, the number of physicians per 1,000 people in Bangladesh in 2017 was 0.54, which was 0.76 for the lower-middle countries and 0.83 for the South Asian countries.

If we look at some health indicators, starting from a low base, over the last four decades, Bangladesh has made considerable progress in life expectancy, maternal mortality, and infant mortality. The success of Bangladesh in life expectancy, maternal mortality, and infant mortality lies on three factors – use of low-cost solutions to some vital health-related problems, widespread activities of NGOs creating some necessary awareness, and external remittances raising the capacities of the households for high out-of-pocket health expenditure.

However, under a critical health hazard like Covid-19, and also for pressures originating from the ageing population, rising prevalence of chronic diseases, and the growing need for intensive uses of expensive still critical health-related equipment, scopes of these three factors in addressing new challenges are deemed to be limited. Financing health-related problems through out-of-pocket expenditures increases inequality within society, as this places an unequal cost burden on the poor people, thus keeping the vicious cycle of disease-poverty-disease alive.

The health sector in Bangladesh has a "stable anti-reform coalition" among the dominant actors in this sector and resultant "policy paralysis".

The "policy paralysis" can be described as a situation where critically important and necessary laws and reforms are not undertaken or, even if undertaken, not implemented as a result of lack of commitment from the government or inability of the dominant actors to reach a consensus over the nature of the reform. The "policy paralysis" in the health sector is observed through the continued staggeringly low public spending on health years after years, high prevalence of mismanagement, corruption, and lack of accountability and transparency. 

But why there is the "policy paralysis" and a "stable anti-reform coalition" in the health sector in Bangladesh?

Bangladesh has a pluralistic healthcare system, which is highly unregulated and consists of different actors with different interests and degree of power or influence. However, it is worth noting that the actors are interconnected with various degrees of contest and coalition. The identified actors can be grouped into four categories, namely state, non-state, direct and indirect actors.

The direct state actors in the health sector are the Ministry of Health and Family Welfare, its Directorate Generals, and in particular, the Directorate General of Health Services (DGHS).

The indirect state actor is the Ministry of Finance.

The direct non-state actors are Bangladesh Medical Association, private sector hospitals and diagnostics and their associations, and non-governmental organizations led medical service.

The indirect non-state actors are the pharmaceutical industry, importers of medicine and medical equipment, civil society, and international organizations.

Although the power and influence of the key actors vary depending on the context, a general scenario of the interplay between the interests and influence of the main actors shows that the actors with low-interest and low-influence are pharmaceutical industry and importers of medicine and medical equipment; actors with low-interest and high-influence are Ministry of Health and Family Welfare and its Directorate Generals, in particular, Directorate General of Health Services (DGHS), Ministry of Finance, Bangladesh Medical Association, and private sector hospitals and diagnostics and their associations; and actors with high-interest and low-influence are nongovernmental organizations led medical service, civil society, and international organizations.

However, there are missing actors concerning high-interest and high-influence for health sector reform in Bangladesh, which explains the lack of reform in the health sector. Also, there is a strong incentive to maintain the status quo where the generation of rents from the existing system and distribution of such rents among the influential actors perpetuates the so-called "stable anti-reform coalition".

While the eighth target of the third SDG aims to achieve universal health coverage, Bangladesh is way behind meeting this target. Given the aforementioned political economy dynamics, what can a politically feasible reform agenda be for the health sector in Bangladesh?

A meaningful health sector reform in Bangladesh should include increasing the share of public health spending in GDP from the current poor level to at least 1.5 percent immediately and gradually to 3-4 percent in the next 3-4 years; ensuring full cooperation across government and the Finance Ministry to allocate more resources to healthcare; ensuring transparency and accountability in public health spending; and, reforming and restructuring the institutions through which health policies are implemented.

Looking at the power-interplay matrix of the actors involved in the health sector, it is obvious that the existing highly influential actors have little incentives to break the "stable anti-reform coalition".

There is a need for bringing in a new actor in the power-interplay scenario. For example, a powerful Health Commission with high-interest and high-influence, overseeing the health sector reform, can be set up, which should be supported by the strong political will of the ruling elite.

Selim Raihan is a Professor of Department of Economics of the University of Dhaka and Executive Director of South Asian Network on Economic Modeling (SANEM). Email: selim.raihan@gmail.com