Health sector cannot be improved only by resources

Increasing allocation for the health sector is a common and justified demand in Bangladesh. With an allocation of 0.9 percent of gross domestic product and less than five percent of total budget expenditure the country has very little healthcare investment for its citizens. In the current fiscal year (FY 2020) per capita allocation is only Tk 1,537. As a result, out of pocket expenditure is as high as 66 percent. That is, if the health cost is Tk 100, government's support is Taka 34 and the patient spends Tk 66. This may not be a problem for those having the ability and access to private healthcare services, but the larger section of the population find it hard to finance their health needs.  

Of course, the commendable progress made by Bangladesh in achieving some of the health related targets cannot be overlooked. For example, life expectancy at birth has increased to 72 years in 2017 compared to 65.2 years in 2005, infant mortality rate per 1,000 live births has reduced from 50 in 2005 to 24 in 2017, under five mortality rate per 1,000 live births has reduced from 68 in 2005 to 31 in 2017, and maternal mortality ratio per 100,000 live births has reduced from 348 in 2005 to 172 in 2017. Increased immunisation coverage, and contraceptive prevalence rate, control of diarrhoea and tuberculosis are also among the remarkable advancements in the health sector.

These have been possible due to targeted policies and investment in the sector by the government, the private sector, non-government organisations and development partners. Among the recent policies, the National Health Policy 2011 recognises health as a right of citizens. It aims to achieve better health for all and strengthen primary health and emergency care for all. It also advocates for equitable access to healthcare by gender, disability and poverty. The other important initiative—the Health, Population and Nutrition Sector Programme covering the period 2017-2022 aims to move towards "Universal Health Coverage" and achieve health-related Sustainable Development Goals. Moreover, the Health Care Financing Strategy for the period 2012-2032 has the objective to reduce out of pocket payments to 32 percent by 2032, and raise the health budget to 15 percent of the national budget by 2032. One of the major initiatives for bringing primary healthcare services to the doorsteps of the people in rural areas has been the establishment of community clinics.

But resource allocation and policy formulation are only a part of the solution to the health challenges in Bangladesh. There are larger issues related to the sector, such as what is the quality of the expenditure, who gets how much, how much is wasted, what is the human resource situation, what type of management, regulatory and governance are in place and what is the accountability mechanism. 

Currently, health outcomes across various sections of the society indicate that everyone does not benefit equally from the existing public healthcare system. The poor are more exposed to diseases because of their living conditions, lack of access to safe and clean environments, and poor-quality healthcare. Therefore, during health crisis such as COVID-19 they are the ones who are most vulnerable. However, they do not get any priority in accessing healthcare.

Management is another key issue in the health sector. Shortages of nurses, midwives and medical technologists are acute. There is one registered doctor for 1,581 people. The vacancy rate of doctors in rural, remote and hard-to-reach areas is high. Absenteeism is also common. Higher salaries alone cannot attract doctors to stay at their duty stations unless there are provisions of good education for their children and other public amenities. This is related to the bigger issue of decentralised development policy which is absent at present. In many public hospitals, equipment is available but positions of technicians or anaesthetists are vacant. Recruitment and retention is important. Equally important is training and development of health workers. There are incidences when hospitals have machines but no one knows how to operate those. While the machine loses life under the dust, patients die due to such negligence.

Actual benefit from budget allocation by patients is low since a significant part of the allocated resource goes for physical infrastructure development, salary and allowances. Procurement and budget for construction of infrastructure are often sources of misappropriation of the health budget. Doctors and health professionals would know better how the procurement of medical equipment is done, who gets the contracts, what prices are quoted for equipment and how much resources are wasted. Doctors who try to point out any irregularity are often given punishment posting.

But for ensuring efficiency of resource utilisation, wastes of resources should be reduced and budget management should be improved. It would be a good idea to undertake an audit of all health related procurements during the last five years. The Parliamentary Standing Committee on Health or on Public Accounts may initiate this noble process to establish the culture of accountability of public resources. Unless the vicious cycle of corruption is destroyed and a system of accountability in healthcare services is established, there is little hope to improve the healthcare services. 

As the economy of Bangladesh is progressing healthcare services through the private sector is expanding. These should be regulated and monitored effectively by the government to ensure the quality. Because the quality and cost of health services varies across the unregulated private health providers. Private healthcare system should be integrated within the overall national health system. Quality of pharmaceutical products also need to be monitored through strong oversight mechanism by the Ministry of Health and Family Welfare.

A related issue is improving the governance of the health system. Oversight of the multiple actors in the health system is critical. A decentralised governance structure should be put in place which will be able to respond to local needs and be accountable to stakeholders.

Another neglected area within the health system is negligible resources for advanced health research. Health research institutes and medical colleges should be equipped with high-quality state-of-the-art technologies.

Data is the "new oil". It provides a true picture on the current situation and helps to formulate better policies. There is a huge data gap in the health sector. Most health related data are not updated regularly. Hence, the true condition of the health sector cannot be understood and monitored. Data limitations also constrain research and analysis on health-related issues.

COVID-19 crisis testifies how ill prepared we have been to tackle a health crisis. Limitations are evident in many areas—from facilities such as testing kits, ventilators, hospital beds, and intensive care unit in hospitals to number of doctors and health workers. This surely indicates the need for higher investment in the health sector. Without major investment by the government, affordable and accessible healthcare for all cannot be ensured and the inequity in healthcare outcomes cannot be reduced. If we want to sustain the economic growth, the country must provide universal and good-quality healthcare services to each and every one. But the COVID-19 crisis also revealed our weaknesses in management and coordination capacity. The improvement of the health sector should be looked at holistically. And we have an arduous path to get there.

Dr Fahmida Khatun is the Executive Director at the Centre for Policy Dialogue.