Background and Context

Over the past five decades, Bangladesh has made significant progress in a number of important health sector areas. Maternal mortality rate has come down by almost two-thirds, and infant and child mortality rates were reduced by 44 per cent and 35 per cent, respectively; Bangladesh’s total fertility rate is currently approaching replacement level and is the lowest in South Asia (except for Sri Lanka). A number of diseases have either been eradicated or brought under control, e.g., smallpox, malaria and diarrhoeal diseases; blindness prevention has been reduced by 35 per cent. With the mainstreaming of nutrition interventions in the public sector, growing agricultural self-sufficiency and supportive policies, wasting among children has been brought down by half, while stunting and underweight prevalence have also come down to some extent. Earlier, Bangladesh met many of the health-related Millennium Development Goals (MDGs) targets including in areas of water and sanitation.

A number of factors have contributed to the aforesaid achievements: timely policies, low-cost solutions, large-scale and innovative public health interventions, engagement of NGOs as delivery agents, use of technology and active involvement of the private sector in health service delivery, to name only a few. However, presumably, the low-hanging fruits have already been reaped, and the country now faces the challenges of covering the ‘last mile’ and ensuring the quality of health-related service delivery.

The ‘last mile’ and quality assurance are, in all likelihood, going to be uphill tasks. Besides issues and challenges that are internal to the health sector, the ecosystem within which the sector operates has emerged as a key concern, plagued by a number of problems including lack of good governance, growing inequities and rising inequality, a poverty rate which still stands at about 18 per cent and stressed macro-economic environment following the Covid pandemic and the war in Ukraine.

Bangladesh has a pluralistic and fragmented structure in the delivery of health services where public and private facilities, formal and informal service providers, and rural and urban health systems exist simultaneously, without a formal interfacing and defined point of accountability. The current health structure and health system had evolved during a time when the country’s population was predominantly rural, literacy rate was low, and financial affordability was rather limited. In this backdrop, a multi-tier rural based health infrastructure was put into place supported by an extensive doorstep delivery of services and information. However, times have changed, and it is now important to think about introducing universal health coverage (UHC) in line with the SDGs (Goal 3) and Bangladesh’s aspiration to be a developed country by 2041.

The UHC envisages that all people have access to the full range of quality health services they need, when and where they need those, without being impeded by financial and other obstacles. Here there are many challenges though: rapid rural-to-urban migration, changing disease patterns, changing needs and expectations of patients/clients as a result of increased economic capacity and lifestyle changes and needs, a burgeoning private sector primarily motivated by profit and a host of other social, economic, climatological and geographical factors. These are pressing challenges that stand in the way of achieving UHC through the prevailing health sector system. Achieving the ambitious goal of UHC by 2030 is indeed going to be a formidable challenge also in view of the limited time span to the target timeline, resource constraints and the complexity of the issues that will need to be addressed. Consequently, hard choices will have to be made. In this backdrop, programmes targeting the most vulnerable with the highest impact will need to be prioritised in sequencing the actions to be taken.

The Policy Brief has been developed on the basis of existing knowledge, literature review and expert opinion, and aims to review the relevant issues and identify the challenges and opportunities. The Brief puts forward a set of concrete proposals to attain UHC in Bangladesh in alignment with SDG 3.

Two critically important issues at present stand as major barriers to achieving UHC: the issue of out-of-pocket (OOP) expenditure and addressing the needs of the left behind communities.

The largest chunk of total health expenditure (THE) in Bangladesh is financed by OOP expenditure which rose from 55 per cent in 1997 to 67 per cent at present. According to the National Health Account Database of the WHO, OOP expenditure is defined as any direct outlay of households, including gratuities and in-kind payments, paid to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services, whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups. In practice, OOP is a part of private health expenditure. To put it in perspective, Bangladesh’s high OOP expenditure compares quite unfavourably with the global average of 32 per cent and is highest in South Asia.

The largest share of OOP expenditure in Bangladesh is on medicine (64 per cent), followed by hospital services (14 per cent) and diagnostics (8 per cent). This significantly large amount creates financial stress and distress for about 9 per cent of households in Bangladesh; this is four times higher for the poorest households compared to the richest ones. Indeed, this scenario somewhat takes the shine off the country’s poverty alleviation successes of the last three decades. If several other expenditures associated with accessing health services that are not captured by the survey are added, including money spent on, e.g., transportation, accommodation, communication, food etc. of the patient and caregiver(s), the actual financial burden would be much bigger. As a matter of fact, the 2016 household survey data reveal that 4.5 per cent of the population (8.61 million people) fell into poverty because of the high health related expenditures (Sayem Ahmed et al., International Health, Volume 14, Issue 1, January 2022, Pages 84–96).

As is well known, a core element of the SDG agenda is to ‘leave no one behind’. This concept envisages “a world of universal respect for equality and non-discrimination” between and within countries, including gender equality, by reaffirming the responsibilities of all States to “respect, protect and promote human rights, without distinction of any kind”. A core aspect of ensuring equality is concerned with ensuring access to quality health services for all, without exception. In this backdrop, the SDG agenda invokes the challenge of reaching the marginalised, vulnerable, and excluded groups and addressing the many facets of marginalisation, vulnerabilities exclusion. The Centre for Policy Dialogue (CPD), in a 2017 study, identified thirteen facets of marginalisation: income, gender, geographic location, life cycle, civil identity, disability, education and skills, health, occupation, religion and ethnicity, sexual orientation and shock-induced vulnerability (Quest for Inclusive Transformation of Bangladesh- Who Not to Be Left Behind; Citizen’s Platform for SDGs, Bangladesh; Centre for Policy Dialogue; Dec 2017).

Taking the above into account, and in view of providing the necessary health care services, there is an urgent need to prioritise the needs of women and children, along with people living in hard-to-reach and climate-affected areas (haor, chars, coastal areas), indigenous communities (CHT residents, Santals, Garos, tea estate workers), slum dwellers, people living with disabilities including mental health disabilities, LGBTQ and religiously ostracised groups (e.g., Dalits). In addition to these groups, a growing number of workers also constitute vulnerable groups at the risk of exclusion due to their work environment and the labour market scenario in Bangladesh- men and women and young boys and girls belonging to the workforce in factories and establishments in the formal (e.g., garments) and informal sectors (e.g., households, restaurants, car garages, micro-enterprises) and in hazardous industries (e.g., ship breaking, lathe machines). Health-related needs of these groups also demand attention.

Published: May 2024