Achieving universal healthcare goal

The adage 'health is wealth' or Amartya Sen's seminal remark 'good health is an end in itself' possibly points to human development as a key to economic growth. The relation between health and standard of living or long life is quite well-known when good health leads to increased productivity, wage and well-being. It is thus no wonder that the Human Development Index (HDI), as developed by the United Nations Development Programme (UNDP), puts health status at the helm of human development. 

In a broader perspective, health of a population is viewed more as an essential force in promoting socio-economic progress in a society. On the flip side, poor health imposes direct burden on society/household on two major counts:  putting an extra pressure on health care cost and harbouring a vicious circle of poverty.

The Bangladesh Health Watch Report 2016 was released recently with the title: 'Non-Communicable Diseases in Bangladesh: Current Scenario and Future Directions.' The working group for the exercise comprised Faruque Ahmed, Syed Masud Ahmed, Ahmed Mustaque Raja Chowdhury, Simeen Mahmud and others. A glance at the report suggests that Bangladesh is passing through a phase of shift in disease pattern from communicable to non-communicable ones.

Malabika Sarker and others draw upon existing studies to give a picture of global growth of disease burden. The report reveals eyebrow-raising information that spread of non-communicable diseases (henceforth NCDs) worldwide has been growing fast and has silently reached a 'pandemic proportion' accounting for almost two-thirds of the total deaths globally. Further, four-fifths of these deaths occur in low and middle-income countries. "What is even more significant is the fact that over 40 per cent or 16 million of these deaths are premature occurring under the age of 70 years." 

Major contributors to miseries are diabetes, hypertension, cardio-vascular diseases, and certain cancers claiming half of the NCD-related annual mortality and morbidity. Despite overall reduction in mortality, NCDs, including injuries, it is claimed that about 60 per cent of total disease burden in Bangladesh, is mostly attributed to ageing population, lifestyle changes and rapid urbanisation. "It is estimated that a third of the population of Bangladesh would be over 60 years by 2050, and given the limited resources and weak and fragmented health systems, the country has already begun to face significant challenges to address the problems of NCDs."

Take the case of diabetes, almost an epidemic in the present-day health context. Bangladesh is one of the top ten high-burden countries with an estimated 8.4 million  people with diabetes and another 7.8 million with pre-diabetes. Thus, about 20 million people are driven to this deadly disease. Diabetes' prevalence more than doubled from four per cent in late 1990s to nearly nine per cent during 2006-2010 period. The prevalence in rural areas rose four-fold from 2.0 per cent to about 8.0 per cent spanning almost a decade, 1999-2009. At disaggregated level, diabetes is more prevalent among males than females in urban areas and more among females than males in rural areas.  

On the other hand, about 14 per cent of Bangladeshi adults are afflicted with hypertension; the prevalence is more than double (24 per cent of population) in semi-urban areas compared to rural areas (11 per cent). The major contributors to hypertension are reported to be older age, higher education, female gender and higher socio-economic status.

Despite achievements in the healthcare service, particularly in the field of communicable diseases, it appears that insufficient control measures on NCDs pose a major threat to the country's health sector. "Particularly, there is a serious shortage in healthcare services in this regard for women and children. Insufficient infrastructure and lack of preparedness to meet the patients' demands are also part of the scenario."

To mitigate the challenges, as could be gathered from newspapers,  the report has put forward suggestions: (a) Building awareness across the society about the urgency of tackling non-communicable diseases and its consequential impact on poverty alleviation, economic development and achieving the universal healthcare policy; (b) developing an integrated, multi-sector approach to prevent and manage non-communicable diseases with the health and family welfare ministry in the lead; (c) strengthening the current health systems at all levels to address non-communicable diseases, focusing on human and physical capacity of the primary healthcare services for early diagnosis and treatment, follow-up services and disease risk reduction; (d) establishing a comprehensive national-level surveillance system for the four major non-communicable diseases; (e) generating evidence for preventive and curative service delivery regarding non-communicable diseases effectively and efficiently, keeping equity and universal coverage in focus; (f) making a 'concerted, strategic, and multi-sectoral policy approach' to tackle the emerging epidemic of non-communicable diseases in Bangladesh.

The report has also commented on the costs of treatment and associated health service hazards. There are primarily three sources of financing for health services in Bangladesh: government, out-of-pocket payment by households and external sources by development partners. The main source of finance is out-of-pocket expenses accounting for roughly two-thirds of the total followed by the government at one-fourths and roughly one-tenth by external sources. 

The Health Watch Report observes: "While basic healthcare is a right stipulated in the Bangladesh Constitution, and essential services are supposed to be provided free of cost, patients have to make informal payments to access the services. These include extra costs on diagnostics and medicines including under-the-table payments to providers at times…some forego care and use informal providers or use self-medication….about 60 per cent of the out-of-pocket expenditure is spent on drug directly bought from pharmacies, diagnostics and informal providers". 

The writer is a former Professor of Economics at Jahangirnagar University.

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