Underfunding cripples public health sector

Health facilities are the places where the two most important events of life for a large number of humans - birth and death - take place. In today's world parents want their babies are born in a hospital, not at home, to avoid childbirth complications that might risk the life of baby or mother or both. People prefer hospital care for themselves and their dear ones whenever they fall sick, particularly when they are terminally ill. Budgetary allocation and government's attitude to healthcare, however, do not reflect the priority the sector deserves.

There is no denying that the country's public healthcare system is grappling with chronic underfunding, misplaced priorities, inefficient management, and structural rigidity. Budgetary data in the last decade suggest that successive governments consistently allocated an average of just 5.0 per cent of the national budget for health. The allocation accounted for 2.0 per cent of the Gross Domestic Product (GDP). The figures are alarmingly low when compared with the recent Health Sector Reform Commission's recommendations, which suggest an allocation of at least 5.0 per cent of GDP and 15 per cent of the national budget to improve the country's healthcare system. More concerning is the fact that despite increasing public health demands the health ministry cannot fully utilise whatever allocation it receives. It is subjected to major cuts during mid-year revisions.

A critical yet often overlooked issue contributing to poor budget utilisation is the lack of administrative and financial skills among hospital managers. Most public health facilities in the country are headed by physicians. These doctors may be highly skilled in clinical care, but lack experience in financial management, project planning or administrative governance as most of them do not receive any formal training in these fields. Such skill mismatch leads to significant inefficiencies, resulting in a struggle for directors or chief executive officers with planning expenditures, preparing detailed project proposals, and executing development funds. As a result, significant portions of the development budget or Annual Development Programme for the ministry remain unused, prompting the finance ministry to downsize it towards the end of the fiscal year. Poor implementation performance affects infrastructural development, equipment procurement, and system upgrades, delays service delivery and deters international development partners from channelling aid through government systems.

Another administrative bottleneck lies in the highly centralised nature of health financing. Public health facilities are not allowed to retain or reinvest their earnings, no matter how significant they are. Government health facilities are legally bound to deposit almost all their revenues to the national exchequer within a limited time frame, leaving facility managers with no flexibility to address urgent local needs or improve service delivery. Such rigidity discourages initiative at the local level. A government hospital that earns revenue from different services cannot use that money to repair essential equipment, purchase emergency medicines or procure other emergency supplies.

The underfunding and low budget implementation in the health sector lead to overcrowded hospitals, overworked doctors, inadequate medical supplies and poor infrastructure. People often have to rely on out-of-pocket (OOP) expenditures for even basic health services, deepening inequalities. According to several surveys, Bangladesh consistently ranks among the countries with the highest OOP spending on health globally. In 2021, the World Bank reported that Bangladesh's OOP expenditure was 73 per cent while health economists estimate that the current real OOP expenditure has reached 83 per cent. Low government investment in health sector and a lack of health insurance result in so high OOP, causing financial burdens on families.

The Health Sector Reform Commission has put forward a roadmap to reverse the current state of public healthcare. It is now up to policymakers to demonstrate the will to follow through. Ensuring adequate funding, building administrative capacity of health facility managers, and decentralising financial authority are not merely technical reforms; they are essential steps towards securing the health and dignity of every Bangladesh citizen.

rahmansrdk@gmail.com