A healthy future to hope for

As Bangladesh turns 50, the pandemic has not only affected our celebrations but also exposed some of the weaknesses of the health sector. At this point, however, we may try to draw a logical picture of where we can reach in terms of public healthcare system in another 50 years from now.

The dream is simple: to achieve a system of universal health coverage (UHC) for the citizens,to be financed mostly by the public sector where the needs of the vulnerable and the poorer sections of the society will be adequately met.

Though far from such a goal, the government has optimistically made healthcare sector a top priority among others, dedicating resources to build and develop infrastructure in the first place.

So, in 2071, Bangladesh will be at the cusp of achieving the goal of healthcare for all as set in the United Nations Millennium Development Goals (MDG) and the subsequent Sustainable development Goals (SDG).

The UHC implies that people from all strata of society will have access to the same quality of healthcare services without financial difficulties. This is an integral part of SDG, of which Bangladesh is a signatory and which sets 2030 as the target for realising that goal.

Bangladesh has made progress in health-related SDG goals, as described in a World Bank report published in 2018.  But there are challenges as well.

In order to realise universal healthcare by 2071, promoting Bangladesh as a model in front of the whole world we must first define the areas where we need to improve.

Lack of a strongly regulated, coordinated system

Public healthcare consists of hospitals, medical colleges, satellite clinics and other healthcare centres. These are subsidised by the government and are the primary sources of service delivery for the poorer and vulnerable groups of people.

The private sector hospitals require a large sum of money and mostly cater to those who afford the cost. According to the Centre for Research and Information (CRI) in Dhaka, there are currently over 600 public hospitals with 16,438 community clinics and health centres and 30,000 satellite clinics for child and maternal healthcare.

Shortage of adequate number of qualified health professionals

A big portion of health services is provided by qualified practitioners and also traditional sources, e.g. village doctors and other different unqualified providers. There is a general shortage of healthcare professionals, especially in the public sector. CRI data showed that there are only 0.47 doctors per 1,000 population.

This is lower than the percentage in neighbouring India (0.76 per 1,000) and even Pakistan (0.98 per 1,000). There is a grave shortage of nurses, particularly in public hospitals. CRI data revealed the ratio to be one nurse against three doctors in 2015, which should have been the reverse.

Financing

Another major obstacle in reaching every citizen with proper medical care they need is the lack of financing. Unlike many countries, our healthcare is mostly paid out of the pocket, a reality which means people pay for their own care and there is no public health insurance.

Private health insurance exists but it is out of scope for the majority. About 93 per cent of the health expenditure is borne by people themselves, which is higher than in India (~90%) and Nepal (~80%).

The government’s spending on health, while increasing, still lags behind other countries of Southeast Asia. Bangladesh spends on an average of 3.4 per cent of its GDP on health, which is lower than the regional average of 3.8 per cent.

A health sector report found that 9.0 per cent of local households have to pay catastrophic health payment, 5.6 per cent of households become impoverished because of health-related costs, 7.0 per cent of households may even sell all their properties including houses just to survive healthcare challenges.

Centralised care

One of the biggest challenges to reach the coveted UHC for everyone in Bangladesh is the Dhaka-centric system, despite steps to decentralise it. People from the remote areas are referred on a daily basis to the capital for even the slightest health issue.

This is exacerbated by the fact that most of our health care professionals are concentrated in the big cities. Official statistics show that 35 per cent of doctors and the same percentage of nurses are working in Dhaka, Chattagram, Rajshahi and Khulna, serving only 15 per cent of the population. Only 20 per cent of health workers are in the periphery trying to meet the needs of the rest.

Still Bangladesh has made some progress. In the 2016 Healthcare Access and Quality Index (HAQ), Bangladesh was ranked 133rd among 195 countries in providing access to quality healthcare to the citizens, ahead of the South Asian peers.

Our pharmaceutical sector is booming with modern drugs being made available as soon as it hits the global market. Our physicians are collaborating at the international level with renowned institutions. New technologies for healthcare are also being launched regularly.

Now, we can expect that the work we are putting in would bear the fruit 50 years from now. If 100 per cent of the people are not brought under the UHC, at least 80 per cent should be, by then.

At the centennial of our independence, we can definitely envisage a strong and coordinated public-private partnership in the health sector, where public health insurance would guarantee the wellbeing of every citizen with modern hospitals and technologies abound.

By 2071, Bangladesh should be a role model in delivering healthcare services if we can address the current deficiencies and accelerate our existing momentum.

How would healthcare system look like by 2071? We can expect a system of public health insurance for at least 50 per cent of the population, and some sort of formal government support on a wider scale for all others. As a result, all the citizens would some be covered by the health insurance.

Telemedicine may become an integral part of overall service delivery. This has already become popular during the pandemic. So by 2071, the whole country should be covered by telemedicine. In fact, we may achieve that within a decade.

Also, doctors’ appointment, referral system and prescriptions should all be completely automated and data instantly generated and stored in a central server. Policymakers can use this data to review the impact of the policies.

With the rise in robotic surgeries around the world, it is not too presumptuous to think that the same will be available on a wide scale in our country too. The future generation of doctors are going to be very much tech savvy, and technology will become a part of their education.

There will be software to help make diagnosis faster and facilitate formulation of treatment for patients. Personalised medicine, focusing on individual differences of each patient, as well as genetic therapies have already started in many countries and by 2071 Bangladesh is very likely going to have such innovations in healthcare.

Overall, we expect to see a more specialised system, with more branching of current specialties, highly advanced hospitals with fully computerised service delivery and all the amenities for latest treatment.

We have reasons to be confident that there will be a world class pharmaceutical industry based on research and innovation, developing newer and better medicines. No people will go out of the country to seek healthcare. Rather, we can hope that patients from other countries will come to Bangladesh for treatment. Our medical colleges and post-graduate medical institutions will also become the seats of excellence with global outreach.

In order to achieve all such goals, we must accelerate the current pace of development in the health sector. A larger portion of GDP, at least 4-5 per cent, should be dedicated to healthcare, and there has to be a concrete plan on how that money will be utilised with a clear vision for 2071.

A practical way to do this may be to develop and implement several 10-year plans in phases. Decentralisation of healthcare is a must, and it has to be implemented without any delay. Public health insurance is another thing which must be thought of. There are political and economic issues related to it.

However, a framework can be generated and implemented on a small scale. We can also improve our medical education system and incentivise research and innovation in our academic institutions. We can develop our institutes like DMCH and BSMMU in a way that they become the centre of excellence for health research and treatment.

Standing at the 50th anniversary of our independence, if we look back, we have already travelled a long way. We conquered a lot of obstacles and our people are getting the benefits of some achievements. And if we look forward, at the centenary of the country, it is full of potential and hope of excellence and pride.

Imtiaz Ahmed completed MBBS from Dhaka Medical College.

[email protected]