Health sector must focus more on budget implementation

The national budget for the fiscal year 2021-22 (FY22) does not offer much for the public health sector of Bangladesh. However, it does not come as much of a surprise as the sector generally remains neglected in national budgetary allocations. Despite having one of the highest out-of-pocket health expenditures (74 per cent of total health expenditure) in the region, the budget share for the health sector of Bangladesh has been less than 1.0 per cent of Gross Domestic Product (GDP) for over a decade. 

The country's public health expenditure per capita is also the lowest in South Asia. The per capita health expenditure of Bangladesh is US$110. On the other hand, the average per capita health expenditure of South Asia is US$401. The health sector has received only 5.42 per cent of the total budget for FY22, and the share in terms of GDP is only 0.95 per cent. The allocation has been increased meagerly compared to the outgoing fiscal year. However, the allocated amount should have been much higher considering the health crisis prevailing in the country due to the pandemic.

The fragility inherent in the public health system of Bangladesh became more evident with the advent of Covid-19. We have seen how inadequate and incapacitated our health facilities are. The pandemic has exposed the dire situation of the government-run health complexes in the district and upazila levels. Still, necessary resources have not been directed towards the health sector. But the budgetary allocations are not our only concern.

Our health authorities have persistently failed to utilise even this meager amount of budget allocation. According to a report by the Implementation, Monitoring and Evaluation Division (IMED) of the government, the health sector is the lowest performer among the top 15 ministries in implementing the Annual Development Program (ADP). The Ministry of Health and Family Welfare (MOHFW) has been unable to spend 74 per cent of the ADP allocation in the first ten months of FY21. It shows the lack of capacity of the public health authorities in utilising the budget allocation efficiently.

For the FY22, we must primarily prioritise implementing the budgetary allocation more effectively. In the budget speech, the finance minister has mentioned a few priority areas for government expenditure in the health sector. However, many other important areas need attention from policymakers.

The country right now needs to focus on handling the Covid-19 situation better. Keeping in mind the second wave and many other waves that may hit us in the future, we need to prepare ourselves adequately. To tackle the Covid-19 transmission, it is of utmost importance that we vaccinate as many eligible people as possible, free of cost. As such, the government must focus on procuring vaccines from all available sources.

Although the budget mentions vaccinating 80 per cent of the population, it does not declare a specific allocation for the purpose. A block allocation of Tk 100 billion has been kept in the budget to manage emergencies like Covid-19. But proper utilisation of this block allocation remains a challenge due to procedural obstacles.

It has been more than one year since the pandemic struck us, but our effort towards increasing the number of hospital beds, ICU beds, and oxygen in public hospitals has been very little. Despite having time in our hands, we did not take much preparation to tackle the second wave. This is even more surprising as a large proportion of the health budget each year is spent on physical infrastructure development. We have suffered throughout the pandemic due to the unavailability of these resources. We need to effectively utilise our resources on an emergency basis for enhancing the numbers of physical infrastructures and supplies. We see some allocations for increasing oxygen supply and ICU beds in the proposed budget through donor-funded projects, but we also need to focus on the effective utilisation of these resources.

Besides, we also need to increase the number of health support staff to ensure rapid treatment of covid patients in the public hospitals and health complexes. The recent steep rise in the number of covid patients in the bordering districts exposes how outnumbered our health workers are in the district and upazila level health facilities. A combination of inadequate physical infrastructures and human resources has turned out to be a nightmare for these bordering areas. But the shortage in health allocation remains a primary challenge in increasing the number of health workers. Moreover, a proper health need assessment should be carried out in those areas so that funds can be utilised more effectively.

Mass awareness campaigns remain crucial to tackling covid-19. We have not seen any specific allocations for this purpose in the proposed budget. But necessary resources should be directed toward continuous campaigns like free mask distribution, awareness-raising etc. The emergency block allocation proposed in the budget can help to do so. Apart from Covid-19, it is also important that we focus on mental health services. Despite 17 per cent of adults suffering from mental health issues, our public spending for mental health services is only around 0.05 per cent of the total health budget or US$0.08 per capita.

We need to allocate more resources from our health budget to disseminate mental health services extensively. The mental health issues became more acute with Covid-19 significantly affecting us with lost lives, widespread job losses, reduced income, halted education, and so on. As such, it is high time we started giving attention to this sector through increasing human and physical resources along with mass awareness creation.

On average, we usually spend around 25 per cent of our health budget on primary health care services. Since most of the people visiting public hospitals mainly seek primary health care, there is a need to increase our expenditure in this sector. This will benefit people from lower-income levels by reducing their out-of-pocket health expenditures. To make health care services more accessible for people it is a must that we strengthen our health infrastructures through allocating more resources from the budget, or at least, to ensure utilisation of the allocated funds.

A growing concern regarding public health has been the over-the-counter sale of antibiotics. People are increasingly buying antibiotics from pharmacies without any prescriptions. The phenomenon is more common in rural areas. This puts the health of the public at great risk as the unnecessary usage of antibiotics makes people antimicrobial resistant. A survey jointly carried out by the Directorate General of Drug Administration (DGDA) and the WHO shows that antibiotics consumption in Bangladesh has increased by 30.81 per cent in the last two years. The MOHFW should use its budgetary resources to create mass awareness regarding the proper usage of antibiotics and antimicrobial resistance.

An allocation of Tk 1.0 billion was made for research and innovation in the outgoing fiscal year's health budget. But most of it remained unused due to procedural issues. Similar allocation has been made this year as well for research and innovation. To ensure proper utilisation of this fund, we must work on easing the existing complex bureaucratic procedures. If utilised properly, this fund will help improve the quality of health services in the country.

Steps like tax breaks for establishing healthcare facilities in the rural areas, compensation for front-level health workers, R&D allocation, and emergency block allocations in the proposed budget are indeed praiseworthy. But all of this comes down to the implementation.

The limitations in our health structure have always been there. But it became clearer to us with the advent of Covid-19. We now know how vulnerable we are to emergencies. Besides, growing urbanisation and an increasing number of the elderly population along with the risks of sudden emergencies will create pressure on the health system soon. We need more resources, but only higher budgetary allocation cannot solve the problems. The fact that a quarter of the allocated budget in the health sector remains unutilised each year contributes to the finance ministry's position on not increasing the share of the health budget. To ensure proper implementation of the budget, the MOHFW must strengthen its health governance system and ensure accountability at all levels.

Dr Rumana Huque, Professor, Department of Economics, University of Dhaka and

Executive Director, ARK Foundation. [email protected]

Tahmid Hasan, Research and Communications Officer, ARK Foundation.