Towards a pro-poor health system in Bangladesh

In the words of Nobel laureate Amartya Sen, health, like education, is among the basic capabilities that gives value to human life. Better health translates into greater and more equitably distributed wealth by building human and social capital and increasing productivity. However, it has been found that cost of healthcare itself can be a cause of poverty in low-income countries through loss of income, catastrophic health expenditures, and potentially irreversible crisis coping mechanisms that involve asset and savings depletion. The economic consequences of ill health for the poor households, especially the bottom 15-20% is also well documented in Bangladesh.

In the absence of any risk-pooling mechanisms and pre-payments, expenditure on health is mainly met by out-of-pocket payment by the households (>60%). This mode of payment for health-expenditure is the most regressive one and exposes people, especially poor and other disadvantaged people, to great financial risk and makes the health system inequitable. Thus, improving the ability of the health system to reach the poor/disadvantaged populations is essential to mitigate the income-erosion effect of ill-health and poverty alleviation in Bangladesh. To maximize this poverty-alleviation effect, health interventions need to be designed according to the needs and priorities of the poor and the disadvantaged. Such a health system with access irrespective of the ability or willingness to pay, and responsive to their needs and priorities is called a ‘pro-poor’ health system. Knowledge and understanding about existing health-seeking behaviour including its differentials and determinants is required for this to happen.

Recent studies on health-seeking behaviour of the poor and some selected disadvantaged populations (e.g., the women, elderly, ethnic minorities, poor/ultra-poor) have found self-care as the predominant therapeutic activity (around 30-40%) undertaken by them for managing illness episodes. Self-care is regarded by WHO as ‘a primary public health resource in the health care system’. To use this resource to its full potential, its integration as an essential, informed and efficient component of the primary health care and as a cost-effective complement to the formal healthcare, is long overdue in Bangladesh.

Self-care is followed by treatment-seeking from unqualified providers (in around 20% of cases) in these studies. By far the single largest group among them is the ‘unqualified allopaths’  who are the sales people in drug retail outlets or drug vendors, with little or no professional training in either dispensing of drugs or in diagnoses and treatment. Treatment-seeking from MBBS doctors varied from around 10 to 20% only in these studies of health-seeking behaviour. The studies also noted a decrease in the use of traditional practitioners (faith healers, kabiraj/totka, and homeopathic) over time in Bangladesh.

What is interesting is the fact that a cadre of semi-qualified para-professionals (medical assistants, mid-wives, village doctors, community health workers or CHWs) emerged as the main provider of formal allopathic care to the disadvantaged groups in more than 25% of illness episodes. CHWs trained in preventive and basic curative services by the government as well as the NGOs to work at grassroots level are the largest proportion among these para-professionals. This cadre of health workers has been increasing in size since the ‘90s with the expansion of the primary health care infrastructure (government and NGO) in the country.. The medical assistants and midwives posted at the union level are a higher level cadre of para-professionals than the CHWs. The village doctors (palli chikitshaks) have received some semi-formal training from private institutions, including those trained through a short-lived government sponsored program that ended in 1982.

The overall health service consumption (from any source) in Bangladesh is low compared to other low income countries as well as level of need. Also, the number of qualified physicians and nurses in Bangladesh is quite low, compared to other low-income countries. Around 26% of professional posts in rural areas remain vacant and there are high rates of absenteeism (of about 40%), particularly among medical doctors in rural areas. In this context, the importance of para-professionals for healthcare in the rural areas of Bangladesh cannot be overemphasized.

Reducing poverty through specific targeting of the disadvantaged groups with a pro-poor health system in a country with large out-of-pocket payments for healthcare is possible, and is urgently needed in Bangladesh. The above scenario should be kept in perspective while designing such a health care system for Bangladesh.