How inclusive is our healthcare system?

In Bangladesh, an emergency healthcare service will perhaps not cost you as much as it would cost in higher-income countries like the US. We have hospitals and community clinics spread out all across the country. 

Besides, new buildings and infrastructure have been established with much vigour and we will potentially see more of them in the future. Hospital complexes have increased in numbers at the district and upazila levels, while more doctors are joining the services. 

And yet, Bangladesh has scored the lowest in the latest healthcare index by The Economist Group. One of its branches, Economist Impact, ranked Bangladesh 40^th on the Health Inclusivity Index among 40 countries consisting of higher, middle-income, lower-middle income and lower-income countries. Bangladesh scored 26.6 out of 100. 

Among the three domains of the index, Bangladesh ranked 40^th in all three, scoring 22.6 in inclusive health, 36.3 in health in society, and 22.3 in people and community empowerment. Among the top three countries in the index are Australia (81.1), Sweden (79.3) and the United Kingdom (78.8). 

And among the last three besides Bangladesh are Algeria (42.2) and Egypt (43.5). Among our neighbours, only India was included in the 40 countries. India ranked 35^th and scored 53. 

The Economist's index defined health inclusivity as the process of removing the personal, social, cultural and political barriers that prevent individuals and communities from experiencing good physical, mental and social health. And over 60% of people, in their global survey, found that they experienced barriers to healthcare. 

What are those barriers? Mostly appointment hours and availability, distance or cost of travel and lack of trust in healthcare services. 

A Bangladeshi, perhaps, would immediately relate to most of these.  

However, the summary from the Impact Report also mentions that low and middle-income countries are more likely to inform people about health risks, with fewer resources, they tend to encourage people to manage their own health. 

One of the few remarkable achievements in Bangladesh's healthcare system is perhaps how field-level health workers reach out to people in villages and how they accelerated the drive to vaccination and health services in remote areas. 

And yet in a previous TBS report, Dr Syed Abdul Hamid, a professor at the Institute of Health Economics, University of Dhaka, said that Bangladesh would still come out last even if more [than 40 countries] were added to the list. 

So, where is the gap? 

Public health expert Dr Abu Jamil Faisel said that a big gap lies in our overall approach and perspective of healthcare. There is an issue with our approach being through the "management perspective" rather than the "demand perspective". 

"It has always been about providing healthcare from a management perspective. It means we need hospital and equipment, but here the manpower comes at a lower priority, etc," Dr Faisel said. "Besides, our service delivery is not community or people-oriented. Also, it is on the supply side where our expenditure too is centred around."  

Regarding the three domains the Economist Index is referring to, he said all are based on the demand side. 

"All we do on the demand side is making people aware, and if you think of the third domain, which is people and community empowerment, it never happens here. Because for that to happen, you need a different structure, communication and changing of our behaviour." 

The public healthcare expert also added that although we need to have more buildings and equipment, the significance of manpower has to be taken with seriousness. 

"If you visit an Upazila-level hospital where 10-12 doctors should be available, you will hardly get three to four doctors," he added.  

Dr M Mushtaq Hussain, another public health expert, said that our healthcare is not well-equipped, we don't have the required number of doctors in proportion to our population, and our emergency healthcare is poor — except in medical colleges and larger cities. 

He also said that we don't have strong primary healthcare. Our community clinics are there, though. In the UK, for example, they have area-based general practitioners. But another pressing issue here is not having adequate primary healthcare facilities in cities as well. 

"We don't have a robust public health-centred healthcare system focusing on prevention of disease and healthcare development. Vaccines and other services are provided door-to-door in village areas, but it is not so in the townships. Those who have money here are taking services from private hospitals. A lot is wasted here," Dr Mushtaq said. 

The public health experts also decried that nothing new is happening at our policy level — especially since we don't get to see "pro-people laws and regulations". 

"This should be an eye-opener for us," Dr Faisel said. "It has become our habit to raise our salaries sitting in Dhaka despite being stationed somewhere in Jhenaidah, for example. Until and unless that attitude is changed, we won't get far."  

Bangladesh, meanwhile, has pledged to ensure healthcare for all by 2030. 

"There is definitely a lack of inclusivity," Dr Mushtaq said. "So, we should be looking at our gaps and faults based on this report. If we want to ensure healthcare for all by 2030, our healthcare should be developed based on the 'public healthcare system', which now remains as a 'clinical-treatment' based healthcare system."