Written by Dr Lisanul Hasan.
At the 50th anniversary of the independence of Bangladesh, Youth Policy Forum, as the pioneer youth-led policy platform, intends to create a reform matrix for different sectors of our national policy through its Road to Reform (RtR) project. The objective is to look back and observe how far we have come in terms of policy since our inception as an independent nation and visualize where we want to be in the upcoming years.
In the second episode of our RtR- “Health Policy: Challenges and Expectations,” we wanted to examine the current health policy of Bangladesh with the help of renowned health administrators, public health specialists, and health economists to understand how our health system has evolved and to propose possible reforms for an equitable health system that we all aspire to have. Our guests for this session were Dr. Md Khairul Islam (Regional Director, WaterAid Asia), Dr. Rumana Hoque (Professor of Economics, University of Dhaka), and Dr. Taufique Joarder (Vice-Chairperson, Public Health Foundation of Bangladesh), and it was moderated by Dr. Zahidul Quayuum (YPF Senior Fellow, Economics, Health and Wellbeing, Professor at BRAC James P Grant School of Public Health, BRAC University).
The evolution of the health system and health policy in Bangladesh
Let’s look back to understand how the health system of Bangladesh has evolved over the years. We see a pluralistic health system where government institutions, the private sector, and international organizations have complex interplay under a centralized government. The Ministry of Health and Family Welfare (MoHFW) is the primary decision-making and implementing body. Over the years, the MoHFW has focused on community-driven PHC, controlling population growth, and improving maternal and child healthcare. While Bangladesh has witnessed the continuous growth of the private health sector since 1980, the yearly budget allocation for the health sector has always remained below 1% of the country’s GDP. The privatization trend is supported by multiple factors, including state patronage, grants, subsidies, funds, and international and UN organizations like the World Bank and International Monetary Fund (IMF). As a result, the private sector now provides 2/3rd of the rapidly growing urban health services, accompanied by a concurrent rise in out-of-pocket expenditure. These challenges have only been exacerbated with the ongoing COVID-19 pandemic.
The inception of Bangladesh’s health policy came with the first five-year plan back in 1973. In the first decade of independence, Bangladesh signed up on several important initiatives- the signing of Alma Ata (1978) and the National Immunization Program (1979) is worth mentioning. In the last 40 years, Bangladesh has also formulated the National Drug Policy (1982), the First Sector Wide Approach plan (SWAp) (1998-2003), and the National Health Policy (2011). These strategies and approaches have led to Bangladesh achieving the Millennium Development Goals for maternal and child health.
Like the rest of the world, Bangladesh has also pledged to achieve Universal Health Coverage (UHC) by 2030. Shasthyo Shurokkha Karmashuchi (SSK)- a pilot health protection scheme, was initiated back in 2011 and is backed by the goodwill of the current finance minister aims to protect people’s healthcare rights below the poverty line. In the last 10 years, Bangladesh has simultaneously introduced strategies for tackling infectious diseases, Non-Communicable Diseases (NCDs), mental health and focused on streamlining the healthcare services in light of UHC and related SDG goals. Moreover, decreasing under-5 mortality, maternal mortality indicators, and improving the vaccination rate under EPI demonstrates our appreciable success in the healthcare sector. If we further examine these successes, some initiatives prove to be monumental in guiding the change in the right direction. Embracing collaborative pluralism, focusing on community-driven health initiatives, and gender equity are some of them.
The challenges faced by Bangladesh and the way forward
In the second episode of RTR, our esteemed panelists discussed the various aspects of our health policy after the initial presentation.
Dr. Md. Khairul Islam emphasized the lack of capacity in utilizing the allocated health budget. After giving an overview of health system changes that happened over the years, Dr. Islam identified our independence as the most powerful motivator behind our progress in the health sector, citing the 2013 Bangladesh series published by The Lancet. Moreover, he believes we should focus more on effectively utilizing our informal sector, especially the informal drug sellers. He stated that almost 70% of our out-of-pocket expenditure (OOPE) goes into buying medicine for various conditions, especially Non-Communicable diseases. In his opinion, if the informal drug-sellers were trained and regulated, it could become one of the major strengths of our health system. His third suggestion was that Bangladesh needs a Health Commission whose primary responsibility would be to identify the areas that require reforms and collaboration with other sectors.
Our other eminent panelist, Dr. Rumana Huque, emphasized that identifying the barriers to implementation is crucial. She urged to focus on policy reform and laws that could support the policies to ensure the implementation. She also pointed out the gap in the transition from a tax-based system to an insurance-based system. Giving the examples of Thailand and the Philippines, she opined that different countries have different models, and Bangladesh should adopt one suitable for our context. She highlighted that the bureaucratic red tape is a major obstacle in regulating and implementing policy guidelines, especially for private health ventures in Bangladesh. She suggested that we strive for evidence-informed policymaking and incentivize public-private partnerships under strict regulation from an independent authority.
Dr. Taufique Joarder highlighted the issue of regulation of our health system and health policy. He appreciated the health policy adopted in the 1980s, including the Drug Policy of 1982 aligned with the Alma Ata Declaration of 1978. He highlighted the need for regular audits and the importance of decentralization of medicine management to reach the grassroots-level people who need them. Dr. Joarder opined that rising participation of the private sector in the health system is not the main concerning issue, but their lack of its regulation is. Citing the example of Japan, he said that even though they have a largely privatized health system, only 12% of the health expenses are out-of-pocket expenditures. He suggested that we identify how to regulate the system better to decrease the cost of affording healthcare. He also highlighted that complete physical, mental and social well-being is our right, not just treatment of the illnesses. He echoed Dr. Islam and reiterated the importance of having a Health Commission that would incorporate the political, economic, and legal aspects for a more comprehensive healthcare service delivery.
Both Dr. Rumana Huque and Dr. Taufique Joarder agreed that analysis of current political economy analysis is a crucial aspect of evaluating health policy, which is largely missing in Bangladesh. There was unanimous support from all the panelists regarding evidence-informed decision-making when it comes to health policy.
Conclusion
In conclusion, this episode of RtR has been an enormous opportunity to examine our health policy from various angles. From our background research and the perspectives shared by our panelists, it is evident that the most pressing issues are – lack of capacity in resource utilization, lack of active referral system, high out-of-pocket expenditure, lack of regulation in the private and informal healthcare sector, and lack of evidence-based decision making. As the current government has the political will and is focused on the healthcare system due to the ongoing pandemic, it is suggested that political economy analysis, involvement of public health professionals and health economists in health policy development and health service, utilizing informal providers after proper training, blending a model of public and private health initiatives to reduce the cost of affording healthcare should be prioritized by the government. Moreover, we recommend introducing health protection schemes for people of different economic statuses, forming a national health council, and updating relevant health-related laws and ordinances to bring the private sector under strict regulation.
Acknowledgment
We acknowledge the generous contribution of our advisor Dr. Senjuti Saha & fellows- Prof. Zahidul Quayyum , Dr. Md. Marufur Rahman, Dr. Mohib Nirob, Dr. Md Mahbub Hossain, Dr. Tasdik Hassan Dip during the whole process.
We also acknowledge the contribution of our Health Policy Network Team- Dr. Lisanul Hasan, Dr. Pritom Das, Dr. Saadi Abdullah, Dr. Puspita Hossain, Auddithio Nag, K.M Abiduzzaman, Hridita Islam, Kaberi Halder, and Shakila Nahar.