Some thoughts on health budget

By all accounts, healthcare is a policy priority for Bangladesh but compared to other sectors, resource allocation in this sector is quite insufficient. The per capita health expenditure is also quite insufficient in the country, compared to other developing economies. For instance, the per capita health expenditure in Bangladesh stands at USD 32 while it is USD 61 in India, USD 111 in Vietnam, USD 39 in Nepal, USD 76 in Cambodia, and USD 720 in the Maldives.

Each national budget in Bangladesh usually comes with a renewed pledge to expand the coverage—as well as improve quality—of health services for the people. The proposed budgetary allocation for health and family welfare sector for the fiscal year 2017-18 is Tk 20,679 crore, which amounts to 5.2 percent of the total budget. This is much lower than the 15 percent budgetary allocation recommended by the World Health Organisation (WHO). And it doesn't indeed represent a healthy scenario for a country of over 160 million people.

However, there has been an increase in this year's allocation compared to last fiscal year's, but the increase rate is still quite low (almost half compared to the rate of increase in the allocated money between FY 2015-16 and FY 2016-17). The proposed public investment in health indicated little improvement over public spending trends in the last five fiscal years. A study of budget trends in Bangladesh shows that, on an average,1.02 percent of proposed budgetary allocation usually remains as revised budget for this sector. Based upon the calculation of weighted mean, it can be predicted that from the proposed allocation of Tk 20,679 crore, approximately Tk 21007 crore may remain as revised budget for the health and family welfare sector.

Experts say public expenditure in the country's health sector has been suffering mainly from two problems. On the one hand, expenditure in the sector is inadequate for achieving the objectives of the Sustainable Development Goals (SDG). On the other hand, there has been a consistently poor performance in utilising the funds and resources (ADP). Both these factors deserve a critical attention from the policymakers.

There's no denying that to ensure quality healthcare for all, public investment in the sector needs to be increased. Bangladesh lags behind other developing countries in accumulating public spending adequately to provide its citizens with necessary social services, while the allocations for social sectors, particularly health, have been on the decline in recent years. The lower budgetary allocations for the health sector accelerate the out-of-pocket expenditure. The out-of-pocket (OOP) health expenditure in Bangladesh is 63 percent of the total health expenditure, which is much higher than that of the world average of 32 percent. According to National Health Account reports, every year the out-of-pocket health expenditure pushes four to five million people into poverty, while many of the poor fail to afford minimum healthcare. The poor are punished by the OPP expenditure and this discourages them from using health care services. Worryingly, as seen in many other developing countries, out-of-pocket expenditure has been increasing in Bangladesh. Reaching the target of universal health coverage would be extremely difficult unless this trend is reversed.

Along with the low budgetary allocations, the health sector in Bangladesh is facing a number of obstacles including widespread corruption, reduced foreign aid flow, lack of fiscal accountability, poor development planning and absorptive capacity, manpower shortage, etc. The sector's failure to ensure equitable allocation and disbursement of resources at the national and local levels is another major barrier to ensuring quality healthcare for the members of various socioeconomic groups in the country.

Given the current state of affairs in the sector, there are three major issues that need to be addressed: structural inequality emanating from socioeconomic differentials, lack of universal coverage in the provision of social services, and social inequality due to citizens' lack of access to social services.

It's important to recognise that Bangladesh has achieved commendable progress in health and socioeconomic development over the last few decades. These achievements are results of our overall development plan. In recent years, the country has made progress in basic health indicators; for example, infant and maternal mortality rates have declined, immunisation coverage has increased, a number of epidemic diseases have been eradicated, and overall morbidity has declined. Life expectancy at birth for both males and females has gone up since the 1980s. Most importantly, gender gap in life expectancy at birth—so prevalent since the independence of the country—has completely disappeared in recent years. 

Despite these achievements, Bangladesh faces diverse challenges in ensuring universal access to basic healthcare and providing services of acceptable quality like improvement in nutritional status (particularly of mothers and children); prevention and control of major communicable and non-communicable diseases; supply and distribution of essential drugs and vaccines; survival and healthy development of children; the health and well-being of women; reducing financial burden on households due to increasing healthcare costs (especially out-of-pocket health expenditure) and the adoption and maintenance of healthy lifestyles. 

Health is one of the basic needs of people. A healthy nation means a healthy workforce that can add fuel to the economic progress of a country like Bangladesh. Therefore, the government should increase cash and resource allocations in the health sector. Importantly, quality healthcare for all citizens cannot be ensured unless the rural-urban disparity in disbursement of resources is not eradicated. The government needs to revisit and revise all health-related policies and programmes to make them more inclusive and in line with the people's expectations. The sooner it happens, the better for all of us.

KM MustafizurRahman heads the Rajshahi-based Research Institute for Social Transformation (RIST). 

E-mail: mustafizn@ristbd.org