This was initially published in the Daily Star – a leading Newspaper in Bangladesh.
The spread of Covid-19 has critically exposed the long-standing weaknesses of Bangladesh’s health system. This is not surprising, as the health sector had always remained neglected in the government’s priorities. In the fiscal year 2019/20, the Ministry of Health and Family Welfare (MOHFW) was allocated 4.9 percent of the national budget, which is one of the lowest in South Asia. Out-of-pocket health expenditure—which is directly paid by a patient during service use and not reimbursed by any insurance coverage—is still very high in Bangladesh (74 percent of current health expenditure in 2017) compared to the global average (18 percent) and many neighbouring countries (62 percent in India, 58 percent in Nepal, and 50 percent in Sri Lanka). Some might argue that, despite spending only 0.9 percent of Gross Domestic Product (GDP) on health, our health indicators are better than many developing countries. However, this is the time to realise that all low hanging fruits in the health sector have been consumed through improved child immunisation, maternal health care and basic curative care. The government now needs to take measures to restructure the health system to cater to the health needs of our large population.
The health sector definitely needs additional budget expenditure, but unfortunately, only increasing budgetary allocation can never solve its problems. More emphasis has to be given on how the MOHFW can use the budget efficiently, especially since the government itself has announced the Health Ministry will not see a significant rise in allocation in the upcoming budget due to its lack of capacity to utilise funds. The current health budget is allocated based on the number of beds and staff in salaried posts. The Ministry needs to critically think of how to change this incremental, norm based allocation system to a “needs-based” allocation model. The first step is to assess the population health needs of districts based on size of the population, their demographic status, disease pattern, and service utilisation—and allocate resources according to “need”.
Bangladesh has an extensive network of government hospitals at community, upazila and district levels. Every year, a large proportion of the budget is spent on infrastructure development and procurement of equipment. However, according to the Bangladesh Health Facility Survey 2017, only 28 percent of health facilities have all six basic equipment—a stethoscope, thermometer, blood pressure apparatus, adult scale, child or infant scale, and light source—while 80 percent of Upazila (sub-district) Health Complexes do not have functioning x-ray machines. It is therefore not surprising that these public hospitals are not equipped with oxygen and ventilators, which have been crucial for Covid management. This needs the immediate attention of policymakers. There should have been systems in place to assess the need of equipment at hospitals at different levels, functionality of the equipment, and requirements for repair and maintenance. There needs to be district level planning for this, with budgetary allocation and capacity development of district and sub-district hospitals.
Severe shortages in the workforce is another core issue in our health system that requires immediate attention. For every 1,581 people, there is only one physician—in a country with a population of over 164 million. The number of medical technologists working under the Directorate General of Health Services (DGHS) per 10,000 populations is 0.32, and the number of community and domiciliary health workers is 2.13 per 10,000, according to the 2018 Bangladesh Health Bulletin. The MOHFW lacks all types of health professionals including medical technologists, nurses and other support staff, such as cleaners, who have all been providing crucial services during the pandemic. The shortage of the health workforce with non-functioning equipment has always been a challenge for providing quality care at government facilities. During this pandemic, where people of all ages are affected, hospitals under the MOHFW faced difficulties in providing required services with reasonable quality.
Some other functions have also received less attention. There is little emergency care in public facilities, and services are provided for limited hours at the upazila and district levels. Where will a pregnant woman in a rural area go if she has complications in the middle of the night, or if someone has a heart attack? There is no population health status monitoring, which is the bedrock of any effective public health programme. Although certain issues have been repeatedly mentioned in multiple health sector plans or programme reviews—such as institutional focus on developing mental health services and an increased focus on urban population health—they have been followed by limited investment. Urban health is another critical sector that requires attention in the new budget. Since provisions for primary healthcare for urban populations is under the ambit of the Ministry of Local Government, Rural Development and Cooperatives (LGD), the lack of coordination between the Health and LGD ministries is a challenge that needs overcoming.
It Is hight time for the Health Ministry to focus on public health under the guidance of experts. The MOHFW can negotiate with the Ministry of Public Administration and Ministry of Finance to approve the required number of “posts” at different levels within the health system and recruit public health professionals and other support staff urgently. Leadership on developing a comprehensive approach to issues of public and population health with appropriate accountability is urgent. We can then place related public health functions in groups—such as water and sanitation and waste management, and the concerned in-charges can coordinate their policies according to a comprehensive plan to address public health issues.
The private-for-profit sector plays a crucial role in healthcare, especially in urban areas. However, the role of the private sector was disappointing during the beginning of the outbreak in Bangladesh—a huge number of private hospitals refused to admit patients out of fear of coronavirus, denying care to both Covid and non-Covid patients. It is important now to clarify the role of the private sector, and hold private for-profit hospitals to account. A coordinated approach is required to ensure that the private sector plays an effective and complementary role during such emergencies. The MOHFW should develop their capacity to monitor private sector hospitals, and should consider this as a priority, and coordinate with respective ministries for proper implementation of accreditation and licensing of private-for-profit providers.
The Bangladesh government has announced incentive packages of Tk 100 crore for government physicians, nurses and health workers treating Covid-19 patients, and Tk 750 crore for health and life insurance for those affected while on duty. In the new fiscal year, there needs to be transparent mechanisms for the disbursement of these funds to beneficiaries. In addition, comprehensive Covid-19 management through long-term, sustainable investments should be reflected in the new budget.
Due to various favourable factors, such as a large number of the young population, relatively less urbanisation and varying disease patterns, the Bangladesh health sector has had certain remarkable achievements in the last two decades. However, growing urbanisation and an increasing number of the elderly population, combined with the dual burden of communicable and non-communicable disease, will create huge pressures on the health system in future. Considering these factors, the government should definitely prioritise the health sector in the development agenda, gradually increasing the budget for the health sector up to five percent of GDP in the next three years, and developing the capacity of the MOHFW to plan and implement the budget efficiently.
Dr Rumana Huque is Professor at the Department of Economics, University of Dhaka and the Executive Director of ARK Foundation.