Covid-19 silver lining: Prime Minister’s Suborna Sheba for all?
The coronavirus rage is showing early signs of slowdown in most parts of Europe and South East Asia. Strict regimes of social distancing are being eased with reopening of schools and selected businesses, not without controversy though. But it is still advancing in the rest of the world and until an effective vaccine is universally available, it remains a threat to us all.
In Bangladesh, the number of identified cases continues to rise every day. The government is taking steps to push social distancing as a new norm but, for understandable reasons, finding it difficult to fully enforce it. The effect of these measures on vulnerable people is devastating and potentially has a greater impact on their lives and wellbeing than the virus itself.
As in many other countries, Covid-19 has revealed the weaknesses in Bangladesh's health systems. These include: inadequate surveillance systems and capacity to track the spread of the virus, shortages of health human resources of all categories, lack of essential facilities and equipment (e.g. functioning primary care centres, hospitals and ICUs), insufficient specialised equipment (ventilators, testing kits and PPEs), and lack of necessary drugs. Bangladesh has successfully faced many natural disasters in the past but in this particular case, we, like others, were overwhelmed. The head of the government firmly took over the helm but others seemed ill-prepared, leading to poor or little coordination among the different arms of the state. Efforts to get citizens on board were tragically missing. It also showed how poverty and vulnerability deterred enforcement of tough actions in protecting citizens' health. Added to this is the inherent crisis of valid, relevant and timely data.
Despite Bangladesh's acclaimed progress towards the MDGs, in terms of improved socio-economic status for its people, the Covid-19 shock will definitely threaten its performance in the SDGs. It is clear that the principle of "leave no one behind" will have to be enormously reinforced if Bangladesh has to move into a "developed country" status in 2041.
The Covid-19 crisis has set the ground for a "new" health system. Bangladesh has about 30-40 million people who are poor by any standard. With rising poverty and unemployment due to the crisis, this number is likely to rise to about 50 million in the next two to three years. They, in addition to the remaining population, will need publicly-financed healthcare. With such a deadly disease ever-present and able to flare up quickly, it is in all our interests that there is truly universal access to a full range of health services needed to tackle the disease and other conditions. Covid-19 is, therefore, perhaps the ultimate example of why we need universal health coverage (UHC)—if anyone is left out, it threatens the health security of everyone.
The government led by Prime Minister Sheikh Hasina has committed itself to achieving UHC for Bangladesh in several international forums, including signing a United Nations General Assembly resolution on UHC in December 2012 and a political resolution on UHC at the High Level Meeting for UHC in New York last September. Unfortunately, this is one of the few commitments made by the highest office which has, until now, remained unimplemented. But perhaps Covid-19 and its aftermath might give the government the impetus it needs to change this and bring universal healthcare to everyone in Bangladesh. In particular, the government can use the opportunity of this major health disaster to garner support for more investment in the health sector.
According to the World Health Organization, Bangladesh spends only 0.4 percent of its GDP through public health spending, the lowest in the world. Our South Asian neighbour Sri Lanka, for example, spends four times as us; 74 percent of our nation's health expenditures are by people from their own pocket, leading 3-4 million people sliding into poverty every year. This will inevitably increase as a result of the Covid-19 fallout. The generous allocation of new resources to meet the pandemic-related challenges gives the conviction that the government, if committed, can make more money available for health. A phased increase of public health spending to 2.5 percent of GDP over the next 2-3 years would give Bangladesh enough resources to accelerate progress towards UHC based on the principles of primary health care, and give the population better protection from future outbreaks of infectious diseases.
The key to achieving UHC is through reforming the health financing system. In particular, it requires switching from a system of private voluntary financing (mostly people paying fees for services) to a compulsory public system. This has happened in every developed country in the world, with the exception of the US, which has famously failed to reach UHC. Many countries at Bangladesh's income level have made tremendous progress towards UHC including Sri Lanka, the Philippines, Vietnam and Morocco. Thailand achieved UHC in 2002 when its GDP per capita was almost exactly the same as Bangladesh's today. UHC is, therefore, perfectly affordable in Bangladesh if there is the political will to implement it.
Because UHC reforms always require significant increases in public financing, they tend to be led by heads of state who have the power to reallocate public budgets. Progressive leaders often take this initiative because UHC reforms are extremely popular. Across the world, politicians that have delivered UHC to their people have become national heroes. This was the case in Germany, UK, France, Australia, Japan, Canada, Korea, Thailand, Brazil, Mexico, and Indonesia. It is also interesting to note how many of these great UHC reforms emerged out of national crises—including the UK, France and Japan after WWII, Thailand in 2001 after the Asian financial crisis, and Rwanda after the genocide in 1994. And yet again, in 2020, we are seeing early signs of some leaders recognising the opportunity that the Covid-19 crisis might give them to launch popular UHC reforms—notably in Ireland and South Africa. Might this crisis even precipitate a change of government in the United States where it is highly likely that the Democrats are going to campaign on a pro-UHC platform?
Prime Minister Sheikh Hasina has the political capital to go for a big push on UHC. Given global trends, it is inevitable that Bangladesh will make the transition to publicly financed UHC at some point in the next 20 years. As there are sufficient resources in the country to achieve this now, there is no reason why the prime minister shouldn't become Bangladesh's national UHC hero and write her name into the history books in the next five years. What a wonderful gift this would be during the Mujib Borsho and on the golden jubilee year of Bangladesh's independence! This new transformative initiative in healthcare could proudly be called "Bangabandhu-Sheba" or "Suborna-Sheba". It will be an essential step in living with the ongoing threat of Covid-19 and achieving the long-term sustainable development goal target of universal health coverage.
Mushtaque Chowdhury is Professor of Population and Family Health at Columbia University and founding Dean of BRAC School of Public Health. Robert Yates is Executive Director of Centre for Universal Health at Chatham House, UK.