The long road to better health
If we are serious about making health facilities more accessible and reducing inequalities, increasing public health expenditure is essential
The Sustainable Development Goals (SDGs) have 17 goals and 169 targets. Goal 3 aims to ensure health and well-being for all at all ages by improving reproductive, maternal and child health; end the epidemics of major communicable diseases; reduce non-communicable and environmental diseases; achieve universal health coverage; and ensure access to safe, affordable and effective medicines and vaccines for all by 2030. There are 13 targets and 26 indicators under this goal.
Better health of the population is important since it contributes to the development of human capital and promotes economic growth. With better health, people enjoy higher life expectancy, become more productive and save more. The cross-country evidence suggests that income and health are highly correlated. Countries with higher per capita income tend to also have higher life expectancy at birth, and improvements in numerous other health-related indicators. Access to better health facilities affects the inequality status between countries as well as within country.
If we look at the state of some leading health indicators, Bangladesh has made considerable progress between 1990 and 2015. Especially, the progress in maternal mortality, infant and child mortality and life expectancy are noteworthy. In 2015, Bangladesh's status was better than India and Pakistan in the cases of child mortality, infant mortality and life expectancy at birth. In the case of maternal mortality, Bangladesh was better than Pakistan. However, in all these indicators, Bangladesh was considerably lagging behind Sri Lanka, China, and Malaysia.
To achieve the targets under Goal 3 by 2030, Bangladesh has to reduce the maternal mortality ratio from 176 to less than 70, reduce the under-5 mortality rate from 37.6 to 25, and reduce infant mortality rate from 30.7 to 12. Also, since Goal 6 (clean water and sanitation) of the SDGs is closely linked to Goal 3, we see that despite notable progress between 1990 and 2015, Bangladesh was far behind Sri Lanka, China, and Malaysia in 2015. However, in the case of improved sanitation facilities, Bangladesh was ahead of India. In order to achieve 100 percent access to improved water and sanitation facilities by 2030, Bangladesh has to make definite progress in the next 13 years.
There are numerous challenges for Bangladesh in achieving the aforementioned targets by 2030. Public health expenditure as a percentage of gross domestic product (GDP) is only 0.8 percent in Bangladesh which is one of the lowest in South Asia. For this reason, the share of out-of-pocket health expenditure in total health expenditure in Bangladesh is one of the highest in South Asia. In 2015, this ratio was as high as 67 percent in Bangladesh in comparison with only 32 percent in China or 35 percent in Malaysia. In South Asia, Sri Lanka has the lowest ratio of 42 percent. This suggests that the burden of health expenditure heavily falls on the households in Bangladesh where the government has taken much lesser share.
One interesting question could be, with the low ratio of public health expenditure in GDP how can Bangladesh make noticeable achievements in some health-related indicators? There is evidence that over the past few decades, Bangladesh opted for low-cost solutions to some vital health-related problems. Also, widespread activities of NGOs created some necessary awareness. The large inflow of remittances too played an important role in increasing the capacities of the households for high out-of-pocket health expenditure.
However, in future, such options are likely to be limited as health systems in Bangladesh are increasingly facing hard and multifaceted challenges. This is due to the new pressures originating from an aging population, rising prevalence of chronic diseases, and the growing need for intensive uses of expensive and critical health-related equipment. Furthermore, financing health-related problems through out-of-pocket expenditures increases inequality within society, as this places a huge cost burden on the poorer people and thus keeps the vicious cycle of disease-poverty alive. Investment in health is thus not only desirable but also an essential policy priority.
Therefore, Bangladesh has to increase public health expenditure as the percentage of GDP from its current meagre level of 0.8 percent to at least 2.5 percent in the coming years and make such spending more efficient. Also, efforts need to be in place to deal with growing expectations of the people and to reduce persistent inequalities in access to better health facilities.
Dr Selim Raihan is Professor, Department of Economics, University of Dhaka, Bangladesh, and Executive Director, South Asian Network on Economic Modeling (SANEM). Email: selim.raihan@econdu.ac.bd