52 years of independence and the state of public health

With great pride and honour, we have reached 52 years of independence. Throughout the decades, we have attained many of the rights for which we fought. 

We fought for the right to speak in our mother tongue, to live independently, and create a society with equity.

Quality and equality in health services was one of our many expectations from an independent Bangladesh.

And indeed, our healthcare situation has significantly improved over the past 52 years. Average lifespan has increased from less than 50 to above 70 years, indicating increased access to healthcare, and higher number of hospitals and community clinics in our rural and urban areas.

Our child and maternal mortality has also reduced and we have achieved success in fighting tuberculosis, malaria, diarrhoea, smallpox, polio, rubella and many other diseases.

A 2019 report by IEDCR (Institute of Epidemiology Disease Control And Research) found that since liberation, our child mortality rate has dropped from 221 deaths per 1000 live births in 1972 to 38 deaths per 1000 live births in recent years.

However, Bangladesh is still far behind in achieving Sustainable Development Goal (SDG) target 3.2, which states, "By 2030, end preventable deaths of newborns and children under five years of age."

Although we have proven our ability to fight certain infectious diseases, the Centre for Disease Control (CDC) has revealed other diseases like cancer, diabetes, Chronic Obstructive Pulmonary Disease, liver cirrhosis, diabetes, etc. to be the major causes of deaths in the country.

Despite our success stories, we still have persistent health inequalities stemming from socioeconomic inequalities in Bangladesh. In fact, the population experiences discernable differences in health and longevity due to socioeconomic status differences.

These inequalities have affected those who are living in deprived locations in both rural and urban areas, the ethnic minority groups, and other vulnerable groups of the society.

In the past few years, the Covid-19 pandemic has also confirmed the health inequality picture in our country. It has impacted every person, group, and community but not in the same ways and not in equal percentages.

For the vulnerable and marginalised communities, structural barriers such as  economic inequality, gender norms, and several other intertwining factors have aggravated their situation even further after the pandemic.

According to a report by the Leave No One Behind (LNOB) Network, during the peak time of the pandemic, ethnic minority communities and sex workers were stigmatised and many times they did not get access to hospitals.

Our country is critically suffering from both a shortage of health workers and a disproportionate distribution of hospitals and health service providing institutions. We have only six doctors and four nurses per 10,000 patients and the ratio is disappointingly low.

In the early years of independence, the health system in Bangladesh concentrated largely on the health service requirements of rural areas. The First Five Year Plan (1973- 78) emphasised on building a network of health facilities, establishing a hospital in every district, accompanied by a Maternal and Child Welfare Centre (MCWC) and an Upazila Health Complex (UHC) in every upazila.

However, the scenario is different now. 70% of our population reside in rural areas and one-third in cities but the healthcare sector is heavily concentrated in Dhaka city and the rural people are deprived of quality health as stated by the World Health Organization (WHO).

Likewise, the health workers, especially doctors, also tend to be gathered in urban hospitals. The treatment and medicine facilities in government hospitals and community hospitals are quite frustrating.

As a result, patients are rushing to the big cities for treatment and the metropolitan hospitals are struggling to accommodate them. People from the cities are also frequently travelling to neighbouring countries for better treatment.

According to the quality healthcare ranking of WHO in 2023, Bangladesh ranked 88th in the world, which was better than any of the SAARC countries, even better than India, which ranked 112th.

Nevertheless, Bangladeshi patients spend around two billion dollars a year for treatment in India.

The health financing system in Bangladesh is quite underfunded and in terms of healthcare financing policies, the country follows a combination of general revenue taxation, donation from development partner countries, and largely depends on an Out of Pocket-Payment (OOP) System.

The funding for mental health is still far behind; mental health expenses are only 0.44% of the total health budget. The same is for adolescent healthcare, which is yet to be introduced in the national healthcare budget.

Although public health care expenditure in Bangladesh tries to benefit the poorer section of the society, it is not distributed fairly. But the poorer people tend to fall sicker and have a greater need for health care.

Additionally, we see that lower socioeconomic status is associated with higher mortality compared to others of a higher socioeconomic status. The socioeconomic class differences in getting treatment have increased since independence.

There is substantial evidence regarding racial/ethnic and socioeconomic inequalities in health-related behaviours and health status. The economic growth in our country is also not fully inclusive for all classes and income groups, which impacts the health status.

In the absence of socially inclusive support packages and protection, the rapid economic growth has made the marginalised groups even poorer.

Bangladesh has a healthcare system that still lacks availability, equality, and reliability and these were substantially proved during the pandemic.

Many gaps in the healthcare system were revealed during this time, such as poor governance and monitoring system, increased corruption, inadequate healthcare facilities, and weak public health communication.

We all know that health is the root of all happiness and a long and healthy manpower is the resource of any country and our health sector has a huge potential for growth.

Therefore, there is an urgent need to focus on improving the quality of healthcare in Bangladesh for all citizens.

The government of Bangladesh has a plan to introduce a public health card system. With the help of NGOs working across the country, this system would be inclusive for all marginalised groups, giving them an access to community health care services.

If the government succeeds in establishing this service, this could lead to a major improvement in the public health sector.

We could take measures such as including sanctioning enough budget and ensuring its proper use; increasing the number of secondary and tertiary hospitals with sufficient doctors and nurses in proportion with patients; establishing well-equipped intensive care units in all district and Upazila hospitals; decentralising treatment facilities all over the country; and introducing incentives for health workers to work in remote areas.

Further measures could also be introducing a patient referral system through digital communication and connectivity in primary, secondary and tertiary hospitals; ensuring an insurance system for all citizens and finally, monitoring and evaluating the healthcare system centrally to prevent corruption.

Moreover, we also need to encourage people to seek medical treatment in government hospitals. For this, building stronger treatment facilities with skilled doctors, equipment, and diagnostic facilities, as well as healthier and patient-friendly environments should be established in government hospitals.

Initiatives should also be taken to ensure foreign investment to modernise our hospitals should be encouraged. And finally, a thriving Bangladesh must aim for a better score on the Healthcare Index to build a healthy nation for all.

Dr ASM Amanullah is a public health researcher and a professor at the Department of Sociology, University of Dhaka.

Laboni Khatun is a development worker and an MPhil researcher at the Department of Sociology, University of Dhaka.