Pride, Prejudice and Future

THE recent Lancet series on Bangladesh is a matter of national pride. The articles thoroughly analyse factors leading to the commendable health outcomes attained by the country despite poor economy. However it is equally important to consider the complementary role played by the non-health sectors along-side the successes of the health sector itself. For example, a part of the gain especially in child health can be attributed to reduction in diarrhea among the under-five children due to improved access to water and significant reduction in open defecation from 32% in 1990 to 4% in 2011. It can be safely mentioned that the massive improvement in road density and network throughout the country and the introduction of the motorized boat since the late eighties have greatly reduced the time to reach health facilities. Another key contributing factor has been the rapid growth in cell phone subscription from 2.7million in 2004 to over 97million in 2012.
The paper Call to Action in this series highlights the double burden of diseases, Bangladesh is experiencing with communicable and non-communicable diseases; the latter a recent phenomenon with potential to further increase the already high out of pocket expenditure (OoP) if business continues as usual. Private health sector, accounting for over 80% of the total healthcare provision, is rapidly filling the gap in addressing emerging and chronic illnesses. However quality of private health services can be questionable. In the private sector medicines are largely sold by almost 200,000 vendors-cum-informal health providers, the main conduit to retail the $1.25 billion pharmaceutical industry. The national health policy 2011 regards the "unskilled" informal providers as the first contact point but remains silent on their regulation. Aggressive and unethical marketing by the 20,000+ medical representatives and unregulated care provision coupled with low citizen awareness are driving up health expenditure.
The notion Bangladesh achieved "good health at low cost" conveys false complacence and lack of urgency for health financing. Though per capita total health expenditure continued to escalate, health expenditure in public sector as percentage of GDP hardly increased over the decades (less than 1%). Consequently, out of Pocket expenditure in Bangladesh is one of highest in the region (64%). Cost of medicine, accounting for almost 70% of the OoP, is one of the major barriers to risk pooling necessary for financing universal health coverage.
The recently approved Health Care Financing Strategy, 2012-2032, aims to enhance efficiency, promote equity and generate resources for universal health coverage mainly through health insurance schemes, over a period of 20 years. The Government of Bangladesh currently finances a number of social protection schemes amounting to almost USD 3billion annually however unfortunately none of these cover health emergencies, a well-established cause of catastrophic expenditure incurred by the poor. On the other hand, the government's capacity to roll out major reforms is demonstrated by successful examples like the female education scholarship program, started with donor support and later expanded universally by the Government; the absorption of the over 20,000 family planning workers etc.
We apprehend that if the trend continues, access to health services by the poor will be limited and equity and social justice greatly compromised. There is no alternative to increasing financing for health if the 48million population below the poverty line are to be reached and universal health coverage is to be achieved. Also the emerging public health problems clearly call for more and equitable investments in health to sustain the gains and to move on. Strong and persistent civil society advocacy, as in the past, for additional and equitable financing coupled with consistent political commitment are essential to usher in the change.

Writers are Public Health and Development Professionals. Opinions are personal; and do not reflect the views of their employers.
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