Bangladeshi healthcare system needs a complete revamp. Question is how?

Our country's healthcare system is at a crossroads. Its burgeoning economy has raised the income and purchasing power of the populace. But along with financial prosperity came a plethora of non-communicable or chronic diseases. These two phenomena mean that Bangladeshis are now frequently seeking at least some form of healthcare, driving the price of the service.

Bangladesh has the smallest public sector relative to its economy in South Asia. As a result, even though healthcare is primarily led by the public sector, most people obtain it through the private sector. The country is yet to adopt a deliberate national healthcare financing strategy.

To ensure equitable access to healthcare, Bangladesh is committed to achieving Universal Health Coverage (UHC) by 2032. Directly or indirectly it affects several SDGs like guaranteeing sound health, eradicating poverty and reducing inequalities.

This year, 2021, is supposed to mark a crucial era for the process of obtaining UHC. So critically assessing its progress and identifying the obstacles is of utmost importance.

Healthcare costs pushes people into poverty

Perhaps the most egregious symptom of the failure of our healthcare system is the high out-of-pocket (OOP) payments patients have to bear. Almost 74% of the total health expenditure is paid OOP, the second-highest in South Asia and even higher than the average of other low-income countries.

While the share of OOP payments in other low-income countries is sharply falling, it is steadily growing in Bangladesh. About six million people are being pushed into poverty by their medical payments in our country each year. About 9% of households suffer from catastrophic spending while 5% face impoverishment.

Most families have to spend their savings while many are either forced to take out high-interest loans or sell their assets. This cycle of ailments and poverty hinders economic growth and reduces the standard of living.

Another important issue is the quality of healthcare in our country. There are only 5.46 doctors for every 10,000 citizens, which is the second-lowest in the region. On average, people have to wait 1.5 hours for consultation in public hospitals only to get one minute of consultation time.

Dearth of healthcare professionals 

There are also gross imbalances in doctor-nurse and doctor-technician ratios. Bangladesh is declared by WHO as one of the 58 countries facing an acute HRH (human resources for health) crisis. There is also a gross urban bias in the distribution of healthcare professionals.

Additionally, 70% of rural hospitals do not have basic equipment while 50% of rural doctors are not satisfied with the supply of medication to their hospitals.

Tk600 crore counterfeit medicines are being circulated in the market each year, garnering about Tk18 thousand crore in revenue. Government drug testing labs, despite being fully equipped, only test 5% of the 100,000 batches of medicines being produced every year.

Our medical education sector is also wanting as 65% of teaching positions are vacant in medical colleges. 40% of hospitals, clinics, blood banks and diagnostic centres are not registered. Doctors are often blamed for prescribing unnecessary medicines and diagnostic tests to gain commission from pharmaceutical companies and diagnostic facilities.

This has debased the image of the healthcare industry and the people are starting to lose faith in them, creating a base for medical tourism. About 700,000 people go abroad every year spending $3.5-4 billion which was only $2 billion in 2012, bleeding our foreign reserve.

Those who can not afford this, tend to resort to untrained professionals like village doctors, kabiraj, faith healers and, crucially, apprentices who operate the 200,000 retail drug stores in our country. Despite having no qualifications, they often prescribe unnecessary medicines and people tend to buy them.

In fact, nearly 62% of the total health expenditure goes towards buying medicines or consulting doctors. It is evident that the healthcare sector in Bangladesh is in a grave predicament and large-scale reforms are necessary for achieving universal health coverage. However, there are multiple levels of barriers that we have to overcome.

Three main problems of the healthcare sector 

According to the Health Care Financing Strategy 2012-2032, there are three main problems in the healthcare system. First of which is inadequacies in healthcare financing. The government contributes about 18% of the total healthcare cost of the nation, which accounts for only 3% of the general government expenditure. 5% of the last budget was spent on healthcare making up for less than 1% of the country's GDP, which is the lowest in South Asia, far lower than the 5% recommended by the WHO.

The current healthcare expenditure in Bangladesh is about $42 per capita. While the government spends $18 per person, the rest is paid by OOP payments. A government spending of $54 per capita is necessary for a fully functioning health system and for covering a basic package of services. But Bangladesh falls awfully short of this mark.

The second problem is the inequities present in health financing. The rich pay more OOP and get better services while the poor pay less and therefore get none to minimal services. Budget allocations on the ground level are made based on the number of beds and historical precedence, not based on their needs.

Every Upazila level facility receives an equal amount of payment irrespective of the population of their Upazilas and subsequent needs, which has steadily decreased. Hospital-based subsidies are pro-rich and other subsidies (to NGOs) are pro-poor as poorer populations are likely to seek medical help from informal sources. As a result, The richest 25% of the populace receive 30% of the subsidies.

Another major problem with our healthcare system is a lack of efficiency. Retail drug shops as the primary providers of healthcare promoting 'self-treatment'. Unnecessary, harmful or counterfeit drugs are distributed often in expensive branded form rather than the generic form and to a limit that can create drug resistance.

Lack of transparency in government spending

Every year, a portion of MOHFW's budget remains unspent reflecting weak absorption capacity due to rigid public sector financial efficiency. Budget execution is poor as hospitals are not allowed to buy their own equipment or hire their own staff. Even though multiple suggestions have been made to change the system, there are significant obstacles on the part to reformation.

The government currently practices supply-side budgeting. They ignore the growing need for healthcare services and instead focus on doing whatever they can to make the best of the available resources. But as we have seen, the resource allocation is not sufficient.

Government spendings are structured in a way that makes altering health service financing impossible. The Ministry of Finance has to change its mechanisms and rules for other ministries if they want to do something for one ministry.

The legacy of British colonial bureaucracy makes even small changes extremely complicated and have massive ramifications for other sectors. There are also no regulatory or mediatory bodies for the private sector. By letting them do whatever they please, it creates a lack of transparency and accountability.

There is a severe lack of properly trained healthcare professionals. Many do not receive adequate compensations, resulting in low motivation and poor service. There is also no agreed-upon protocol for treatment, referral, follow-up and general service management; therefore implementing any new change is difficult.

Physicians are recruited through the BCS examination in the public sector. As a result, deploying them quickly is not an option. Even those who are deployed often leave their jobs and go on to private practices as it is more financially viable. Due to severe difficulties in administering disciplinary actions, some doctors simply choose to ignore their duties, hindering the system.

As of 2021, 66.8 million people were supposed to be under the Social Health Protection Scheme. But even the basic structure for this plan has not yet been created. Additionally, 12% of the annual budget was to be allocated for the health sector, which also did not materialise.

It is certain to say that we have failed to achieve the targets set for this year. As the economy continues to grow, people will seek to purchase better and frequent healthcare services. This will drive up the price and make Universal Health Coverage increasingly expensive and unattainable.

The author is an Economics student from University of Dhaka

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