Bangladesh health system at a cross road!

A recent review of Bangladesh health system revealed some interesting characteristics described below:

Impressive improvements in population health outcomes

Bangladesh has made enormous progress in health in recent years, surpassing its neighbours in increasing life expectancy, reducing fertility, and mortality of mothers and infants. But there is no scope for complacence: the maternal and neonatal mortality is still quite high, there are emerging and re-emerging infectious diseases (e.g., dengue, swine and bird flu etc.), problem of mass arsenicosis, emerging burden of non-communicable diseases, epidemic of road-traffic accidents, miserable condition of health and sanitation in the urban slums, and fallouts from the effect of climate change on health.

Poorly resourced public sector facilities

Bangladesh has extensive health infrastructure in the country but the problem lies with populating these with required human resources (both number and appropriate skill-mix), and its equitable distribution in the rural and urban areas, including requisite supplies such as medicine etc. The system is heavily centralized and difficult to monitor and evaluate. Even when there are health workers/providers posted in the facilities, there are the problems of absenteeism, non-responsiveness and improving quality of care. Other barriers such as lack of awareness, socio-cultural and religious obstacles, and financial in-capacity etc. hampers access to healthcare for the poor and the marginalized populations, and the “Inverse care law” is very much in operation here! To achieve universal health coverage, this problem of inequity in access based upon SES, gender, age etc. should be given urgent attention.

Significant role for diverse private sector

What is interesting in the health scenario of Bangladesh is the simultaneous existence of different systems of medicine and practitioners (‘medical pluralism’). Besides the official allopathic system, there is a large unregulated, informal sector catering to the needs of the majority of the rural population, especially in the remote and hard-to-reach areas of the country. Thus, the importance of the informal sector for healthcare of the poor in the rural areas of Bangladesh should be recognised, their capacity developed to deliver an acceptable level of care, and brought under regulatory measures so as to alley fear of malpractice. However, recognition and regulation of this sector remains a problem if they are to be mainstreamed. Bangladesh has partly managed the problem of scarce HRH through innovative means such as by training an army of community health workers both in the public and NGO sectors, and various cadres of health paramedics, delivering ‘good health at low cost’.

High Out-of-pocket expenditure

Bangladesh is one of the few countries where the dominant form of financing expenditure on health is out-of-pocket expenditure by households at the point of service delivery (64%) and is getting worse by the years. Catastrophic expenditure on health is one of the factors driving households down the road of poverty. Government spent only 26% of the total expenditure on health and only around 3.5% of the GDP is spent on health which is one of the lowest in the region. Rapid segmentation in health sector is occurring: at one end is the informal and traditional sectors catering to the needs of the poor while at the other end is the very modern and highly technical health services where poor have little access. This is increasing health care costs and the prevalence of catastrophic health shock is on the rise. To improve universal access irrespective of financial ability, health care financing needs re-thinking. Some form of pre-payment and pooling of resources (either revenue-based or insurance-based) is needed to reduce OOP and reduce the income-erosion effect of illness.

Poor quality of public health services and low accountability

Public health services at all levels are characterised by poorly motivated staff, high absenteeism, poorly maintained infrastructure, and shortages of key supplies and medicines. This results in poor quality of care, and low levels of utilisation.  It also enables the private sector to fill the gap with largely unregulated and potentially harmful diagnostic and treatment services for those who can pay, and a variety of informal and untrained providers and drug salesmen for the poor.  There is an urgent need for more investment of public funds and stronger local accountability to improve the quality of public services, and improved regulation and monitoring of services provided by the private sector.

Transition to chronic NCD management

The current Health systems is mainly focused on infectious diseases and maternal and child health which is plausible. But simultaneous with demographic changes, Bangladesh is also currently undergoing health transition and a situation of ‘double burden’ of diseases is prevailing: emerging NCDs as well as continuation of communicable diseases. The Health systems is currently not prepared to  address these emerging issues such as population ageing and NCDs, emerging and re-emerging infectious diseases, poor maternal and child nutrition, injuries related to road traffic accidents, drowning, violence etc. This needs restructuring the health systems, especially at the PHC level, so that preventive and health promotive measures can be taken through a life-cycle approach. Besides, the problems of inequity in health and nutrition and the health needs urgent attention if one is to strive for universal health coverage.

In conclusion, it can be said that Bangladesh Health System is at cross-road. It contributed to the improvement of the health of the population but it needs further miles to go. If the investment in health can be increased, out-of-pocket mode of health financing can be replaced by some form of pre-payment through e.g., health insurance, equitable access to effective healthcare can be assured, and can fulfill our mission to achieve universal health coverage within foreseeable future.