Universal health coverage (UHC) ensures that all people can have access to quality health services without financial hardship. Paying for healthcare is one of the main reasons why people fall into poverty in Bangladesh. In addition, many people, especially the poor, are afraid of the high costs which healthcare inflicts and do not seek medical attention at all. In Bangladesh, less than 1.0 per cent of the population has a health coverage scheme which protects them against catastrophic health expenditures. In Bangladesh, approximately 3.8 per cent of the total population, or 6.0 million people, are pushed into poverty because of out-of-pocket payments for health services every year. Bangladesh needs Universal Health Coverage because it has a direct impact on health of the people.
Bangladesh has made substantial progress over the last two decades. Bangladesh is a country that has seen remarkable health improvements since gaining independence in 1971, and has evolved from being a “basket case”, to an exemplar of “good health at low cost.” However, still 64 per cent of health expenditure are made out of pocket which is very alarming. As a result, thousands of poor households are being pushed into poverty which we call catastrophic expenditure. Bangladesh is experiencing the highest (15 per cent catastrophic expenditure whereas India is experiencing around 10-12 per cent and Thailand is experiencing lower than 2.0 per cent.
So far there are a lot of challenges for achieving UHC. First one is mobilising resources for health. It does not mean that a country has to have more wealth. Actually it is the process of mobilising resources. Cuba and Rwanda are very good examples for this. The second challenge is reducing the out-of-pocket expenditure. The third is reducing inefficient and inequitable use of resources. Other challenges are improving the responsiveness, equity, quality of healthcare services, and use of IT for achieving UHC, etc. WHO report proposes three interrelated health financing strategic options: 1. Raising sufficient fund for health, 2. Reducing heavy reliance on direct out-of-pocket money, 3. Reducing and eliminating inefficient and inequitable use of resources.
Bangladesh has one of the best government health infrastructure in south Asia. In addition to medical college hospitals and tertiary care hospitals, it has about 500 upazila health complexes, around 5,000 union sub centres and 13,000 satellite clinics. Trained health care professionals are quite inadequate at these rural centres. Those who are working there are facing resource constraints in terms of facilities and financial space. Quacks and traditional medicine practitioners are doing random malpractices. Activities of quacks are not monitored by concerned health officials. There are many low standard private clinics at every corner of a rural area providing poor services at high costs. Some registered doctors are also doing malpractices compelling poor people to get services at high costs. Most of them are not satisfied with government health services for many reasons including negligence and supplies. Investigation facilities are mostly unavailable and sometimes not reliable. Rates of investigations are also very high at private clinics and there are seldom monitoring by concerned government authorities. Patients have to pay all from their pocket when getting treatment from the private sector. Poor people have difficulty with access to the government secondary or tertiary care hospitals. Non-government secondary or tertiary care hospitals available in large cities are very costly. These are the realities in our perspectives. Universal health coverage can ameliorate the financial sufferings of these communities and can help reduce poverty but implementation is difficult. Stakeholders in private health care sector may produce obstacles. People at low resource centres will go to government health centres, if they get doctors, drugs and other facilities available. We do not discourage the private health sector, but they should be quality-based, compliant with the patients’ need, cost-effective and monitored by independent quality assurance cells of government.
Goals of UHC
Although initially cautious about rallying around the goal of UHC, its 2012–22 Health Care Financing Strategy provides an initial roadmap that recognises the complexities of universal coverage in a largely informal economy with a pluralistic health system and limited fiscal space.
Situating their modeling exercise in this context, Rahman and colleagues (Lancet Globe Health 2018; 6: e84–94.) extracted available UHC indicators from 17 nationally representative (in terms of epidemiology and health systems) surveys from Bangladesh. They projected that the goal of 80 per cent coverage would not be achieved for eight of 13 prevention indicators by 2030 under ceteris paribus conditions (with wide socioeconomic inequality in four of these indicators). The next 15 years, however, are likely to be characterised by rapid socioeconomic, climatic, and geopolitical forces of disruption and innovation that challenge ceteris paribus assumptions.
A first observation is that simple, preventive interventions were more likely to hit the UHC 2030 target of 80 per cent coverage, whereas coverage of complex ones, such as institutional delivery by a skilled attendant, were marked by lower coverage and high inequalities. It follows that issues of access to, and quality of, complex and comprehensive interventions need increased policy attention. With respect to the projected failure to reach the target of 100% financial protection, a lot needs to be done, especially in view of the latest Bangladesh National Health Accounts 1997–2015, which show an increase in the proportion of total expenditure accounted for by out-of-pocket payments from 63 per cent in 2012 to 67 per cent in 2015—pushing 4-5 million people per year into poverty.
Engagement of the rapidly growing private sector and the role of other sectors for health such as urban development, transportation, and water, sanitation, and hygiene need attention. Better supply of services, including performance measures, health workforce development, and procurement of supplies, is sorely lacking. Bangladesh should look to similar contexts of high informality and low government financing to develop its own path forward. Implementation and operations research will also provide relevant evidence for policy makers. When the government has limited resources for 100% coverage, sincere monitoring of the private health sector is essential in order to augment the UHC coverage.
In the 21st century information age, people’s aspirations for their health and access to high-quality services are rapidly increasing. Public demand for health should be coupled with enlightened leadership that acts on irrefutable evidence that better health accelerates inclusive growth, and acknowledges the health sector as a growing source of employment. Mobilization of this demand for UHC could amplify Bangladesh’s intrinsic character of resourcefulness and resilience, and propel progress towards UHC, and a healthier society and economy.
We believe that despite the challenges towards establishing UHC, policy makers should not give up their commitment to UHC as this is the most effective way to free the people from catastrophic health expenditure. Experiences from successful countries suggest that UHC can effectively be achieved through the concerted effort of the people guided by civil society activists. Social movements, motivated by the need for social justice in health care, can push political leaders to opt for UHC.
Community Empowerment: A Way to Overcome the Challenges
By Community Empowerment (CE) we mean the process by which relatively powerless people in the community work together to attain control over the events influencing their life. The term ‘community empowerment’ has a tendency to be mentioned loosely, especially by the policy makers as well as the NGO movers. In several literature community participation/involvement, social capital, community capacity, human capability, community competence, community cohesiveness etc. have been used either synonymously, or with subtle distinctions.
One of the largest NGOs of the world, Bangladesh Rural Advancement Committee (BRAC) has been carrying out empowering activities since its initiation after the liberation war of Bangladesh in 1971. In addition to its nationwide education program, women empowerment approaches, legal aid services, and micro-credit programs, BRAC has been running massive health programs throughout the country. Bangladesh has a very successful immunization program with 96% DPT and measles vaccine, and 94% tetanus toxoid immunization coverage, which are one of the highest in South Asia. The Expanded Program on Immunization (EPI) program in Bangladesh successfully incorporated the contributions from the NGOs, local commercial enterprises, and even community volunteers. This inclusive nature of the EPI program is indicative of people’s involvement from different spheres and eventually empowering them. The Directly Observed Treatment Short-course (DOTS) program to treat tuberculosis (TB) is another such example of partnership of the people with the government. Another initiative, the Community Clinic approach of Government of Bangladesh, although too early to comment on its success, has already created enthusiasm and optimism among the communities.
Policy making propensity: UHC is right to health that means every person everywhere should have access to quality healthcare without suffering financial hardship. It offers a range of essential services of good quality. It says about reducing the out of pocket expenditure through the cost sharing or pre-payment mechanism.. To ensure efficient and effective health care UHC must be accompanied with the political commitment and political commitment must be reflected on the health budget and public administration. Quality of the health care, transparency and accountability in the health sector are also much needed requirements. At the action level the government has increased the manpower for hospitals and health centers to provide better health care services. The government has already established and revitalized 13,000 community health clinics. In the question of whether the commitment is reflecting in the budget we see that share of budget for health ministry is decreasing. So we should look into the issue of increasing budget for health sector.
The path to universal health coverage in Bangladesh: bridging the gap of human resources for health.
Bangladesh is committed to achieving universal health coverage (UHC) by 2032; to this end, the government of Bangladesh is exploring policy options to increase fiscal space for health and expand coverage while improving service quality and availability. Despite Bangladesh’s impressive strides in improving its economic and social development outcomes, the government still confronts health financing and service delivery challenges. The crisis in the country’s human resources for health (HRH) compounds public health service delivery inefficiencies. As the government explores options to finance its UHC plan, it must recognize that reform of its service delivery system with particular focus on HRH has to be the centerpiece of any policy initiative. The Path to Universal Health Coverage in Bangladesh assesses the current status of HRH in terms of production, recruitment, and deployment as well as related policy-making processes. It then explores policy options based on evidence from international experience that will help Bangladesh improve the availability and skill of its health workforce. To reach its goal of UHC by 2032, the government will have to commit itself to policies to expand health financing options and, at the same time, tackle HRH challenges head on.
Universal Health Coverage contributes to people being more productive and active contributors to their families and communities. It can minimize the out of pocket money as health expenditures. It also ensures that children can go to school and learn. Universal Health Coverage could transform the lives of millions of people by bringing life-saving health care to those who need it most. The Health Care Financing Strategy of the Ministry of Health and Family Welfare is the foundation on which Universal Health Coverage will be established in Bangladesh. The ultimate aim of the Health Care Financing Strategy is to achieve Universal Health Coverage by 2032 and ensure access to affordable, equitable and quality health services for the people of Bangladesh. The Health Care Financing Strategy provides a framework for developing and advancing health financing in Bangladesh.
Patients at low resource centres in rural and slum areas need to have a door-to-door approach. Malpractices and fraudulence by quacks and others need to be tightly controlled. Policy makers must curb the corruption in the public health sector and provide adequate facilities in terms of human resources and amenities in all government healthcare centres. This agenda should draw on the experience of the first generation of innovations that underlie the country’s impressive health achievements and creatively address future health challenges. Central to the reform process will be the development of a multi-pronged strategic approach that responds to the existing demand in a way that ensures affordable, equitable, high-quality health care under a pluralistic health system, anticipates health-care needs during a period of rapid health and social transition and addresses underlying structural issues that otherwise might hamper progress. A pragmatic reform agenda for achieving universal health coverage in Bangladesh should include development of a long-term national human resource policy and action plan, establishment of a national insurance system, building of an interoperable electronic health information system and investment to strengthen the capacity of the Ministry of Health and Family Welfare.
The writer is a professor of physical medicine and rehabilitation at Bangabandhu Sheikh Mujib Medical University.