Health sector governance and UHC in Bangladesh: challenges and opportunities

1) For Bangladesh, UHC has been a priority goal for the government since 2010, with political commitment from the highest level (PM in 64^th WHA 17 may 2011: “In Bangladesh, we have planned universal health coverage for all citizens… Let us renew our commitment to “Health for All” as an essential precondition to transforming people as human assets. Only then will we be able to promote human dignity and enhance their quality of life”).

o   7^th 5-Year Plan 2016 - 2021

o   Strategic Investment Plan for HPN 2016-2021

o   National Health Policy 2015

o   Health Care Financing Strategy 2012-2032

o   Health Workforce Strategy 2015

o   Communication Strategy for Universal Health Coverage 2014 – 2016

o   National Social Security Strategy 2015

o   Quality Improvement Strategy 2015 etc.

2) During 2010 –’11, the non-state actors in Bangladesh played a key role in advancing the UHC agenda when the concept was relatively new in the country, especially in the public sector. In this early stage, support from the Rockefeller Foundation in the form of strategic grants to different institutions and individuals in the public and non-state sectors was crucial. (examples include: establishment of a deptt. of public health and informatics in the country’s only medical university including launching of an MSc. course in health informatics in a private not-for-profit university; a Centre of Excellence for UHC (www.coe-uhc.org) established in 2011 for necessary research, advocacy and capacity building efforts for UHC; in the public sector, grants were made to the health ministry for designing a health financing strategy for UHC; and test and develop integrated health information systems for UHC. Funding was also provided to a broad range of civil society/non-government organizations and research institutions for raising awareness on UHC, and develop a ‘critical mass’ of advocates of UHC, Together, these investments were expected to generate a momentum for UHC, involving different stakeholders in the public and non-state sectors It initiated building a consensus regarding UHC core concepts and components.

3) Challenges

 a) consensus-building for a shared understanding of the core concepts, components and priorities in the context of Bangladesh

b) eliciting commitment from all relevant sections of the Health aministry as well as relevant sectors beyond it involved with human and physical development  of the country

c) finding the most appropriate model of pre-payment and risk-pooling which is culturally sensitive in the fatalistc mindset of the people

d) mobilizing resources including efficient utilization of resources and stoppage of ‘system losses’

e) raising awareness about ‘health rights’ and creating demand for the bottom; ensuring ‘transparency and accountability’ through pro-active participation of the people

f) Strengthening of health services so that it is equitable, responsive, and of acceptable quality

g) shortage, inappropriate skills-mix and inequitable distribution of human resources for health (doctors, nurses, technicians); Lack of transparency in recruitment, deployments, transfers, promotion and career paths for different cadres of HRH

h) Use of IT for UHC

4) Issues with governance

          a) a pluralistic health system with multiple systems of medicine and of providers , and a large informal sector

          b) highly centralized bureaucracy with little scope for solving local problems locally, little room for innovation

          c) highly politicized bureaucracy with strong professional bodies (BMA, BD Pharmaceutical Assoc. etc.) influencing decision-making for coterie interests

          d) all pervading corruption and weak regulatory regime;  weak consumer pressure groups etc.

f) problems of, and with, ‘role models’, ‘chamge-makers’, ‘stewardship’ etc.

5) Points to ponder

          a) Consultation and Coordination at the policy and practitioners levels, across sectors and ministries, for a unique orientation towards of UHC/health at the core of the SDG agenda

          b) decentralization of the health governance; autonomy at the local level

          c) finding effective ways to bring the large informal sector in the mainstream

          d) making health system ‘humane’ and ‘responsive’

          c) ‘carrot and stick’ approach to contain corruption has largely failed

[jotted down discussion points for a panel discussion]