How Bangladesh can achieve universal health coverage
Just a glimpse at the budget allocation for healthcare every year is enough to understand how terrible our indifference towards our health sector is. It has been seeing a decline in the budget allocation as a proportion of GDP, dropping to 0.83 percent in the current fiscal year. But according to the World Health Organization (WHO), it should be at least five percent. Bangladesh ranks lowest in South Asia in terms of health allocation as a proportion of GDP. Currently, we have to pay 72 percent of our medical expenses out of our own pockets.
WHO has committed all member states to ensure universal health coverage (UHC), which means everyone will have access to quality healthcare as needed, regardless of financial constraints. Global health insurance is an important regulator in achieving UHC. Many countries in the world are or have been moving towards achieving UHC through private optional health insurance, community-based health insurance, compulsory payroll-tax-based social health insurance, etc. Germany and France took more than 100 years to cover 100 percent of their populations via social insurance. Many low- and middle-income countries in Asia, Africa, and Latin America have continued efforts to implement labour-tax-based mandatory social health insurance for decades.
But the idea of achieving universal health coverage or its implementation is completely absent in Bangladesh. The ruling government did make a pledge to formulate and implement UHC in the country, but there has been little progress to this end. Despite Covid-19 and the ongoing Russia-Ukraine war, our economy has not been severely affected. In terms of macroeconomic indicators, Bangladesh should be able to increase the budget for the health sector without disrupting the dynamics of the economy.
Are our policymakers aware that sustainable development is not possible without investment in the health sector? Investing in healthcare is not just about spending; it strengthens the economy in many ways and contributes to alleviation of poverty and inequality. Investment in the health sector will lead to improved labour force availability, better contribution to school education, employment opportunities for women, and higher productivity in the economy.
Healthcare financing in Bangladesh comes entirely from the government's general taxation system. There is an opportunity to greatly increase the finance by expanding the scope for the tax base, by consolidating and redistributing the fragmented financing system, and by redistributing priorities. Tax evasion, corruption, and harassment should be prevented. Financing the health sector can be done more easily by expanding the narrow tax system than by trying to collect health insurance premiums from poor and informal sector populations.
The need to increase the government budget for our health sector is now beyond debate. In the next national budget, therefore, the health allocation should be increased to two percent of GDP. The finance minister should think about how he will allocate this money. The WHO recommends allocating at least five percent of GDP or 15 percent of the budget to the health sector. An increase in health spending per one percent of GDP would protect 0.13 percent of the population from falling into financial disaster.
The challenges of healthcare delivery are mainly twofold: financing and service delivery. Corruption in the health sector, doctors' misconduct, and the lack of capacity to implement the budget are the highlights among the issues. Prioritisation of cost management should be done by accepting the reality of the financial crisis in healthcare. Priority should be given to the inclusion of the poor and vulnerable groups to the maximum extent, and which services are possible to deliver should be taken into consideration. A strong stance should be taken against corruption. Expenditure and results in the health sector should be presented transparently in front of the people. A government survey found that 63 percent of the individual's out-of-pocket expenses were on medicines. A strong primary healthcare system plays the most cost-effective role in achieving universal health coverage.
Public healthcare programmes should be implemented through all-out initiatives to prevent diseases. The government should develop a flawless structure capable of fair understanding with drug and medical device manufacturers to procure and supply medicines, medical supplies and new technologies. Help should be provided to build non-profit private healthcare. Differences in service quality and cost between public and private healthcare systems should be reduced, if not eliminated. In addition to public and private healthcare, there should be an opportunity for NGOs to work as a complementary body with the self-sacrificing attitude and capacity to engage in healthcare. The government also must invest in the improvement of the quality of life of healthcare workers.
Universal health coverage will not be achieved overnight by some miracle. Learning from the experience of low and low-middle income countries from the last 50 years, Bangladesh should develop a healthcare system keeping in mind the historical evolution of those healthcare systems, cultural acceptance, and political-economic reality. Measuring progress in achieving the UHC requires an integrated national health database. The UHC structure should be constructed by analysing the information obtained from there, making plans, and implementing new decisions from the lessons of success and failure. The countries that have achieved UHC have consistently had high budget allocations for healthcare at the top of their political agendas. Strong political commitment is needed to expand healthcare coverage to the poor and vulnerable, and to prioritise the voice of marginalised people over that of opportunistic groups.
Our constitution mentions the pledge to establish a state based on equality. A fundamental human aspiration is that the individual or family will not be destitute or be driven into further poverty while seeking medical treatment. Otherwise, our constitution will not be able to play any regulatory role to protect the health and lives of the people of this country.
Dr Rakib Al Hasan is a physician, author, activist, and youth leader. His Twitter handle is @rakibalhasan_bd