Health seeks big reforms, 29% out-of-pocket cost cut in 5 years

Infographic: TBS

The Ministry of Health and Family Welfare has taken up a healthcare improvement programme that seeks to cut out-of-pocket healthcare expenses of patients by 29% among other goals within five to six years through sweeping reforms with a two-fold increase in the budget allocation. 

The out-of-pocket health expenditure – which has jumped to 69% from 62% in 2012 when a national action plan was formulated to tame the rise – has been a big financial burden on the low-and-middle-income people, locking them in the poverty trap.

The health ministry has proposed the budget allocation for the Fifth Health, Population and Nutrition Sector Programme (5th HPNSP) to Tk2,90,370 crore from Tk1,45,935 crore allocated for the ongoing 4th HPNSP. 

The 5th HPNSP will focus on urban primary healthcare for underserved urban populations.

The health ministry wants to strengthen the rural healthcare facilities addressing the shortages of doctors, nurses, and other staff, and ensuring the availability of over 70% of essential medicines free of cost. 

The ministry wants to fill 90% of the doctor and nurse positions in these government facilities within the next six years.

The draft report on the 5th HPNSP also identifies some major focus areas for action that would improve management of healthcare.

Through these measures – outlined in the draft of the programme, the ministry also wants to raise the rate of births taking place in a health facility and reduce the maternal and child mortality rates.

Challenges in foreign financing

According to the draft report, 40% of the total allocation for the 5th HPNSP is proposed to be received from development partners. 

Dr Muhammod Abdus Sabur, one of the consultants of the Strategic Investment Plan for the 5th HPNSP, identified managing funding from the development partners as the key challenge in implementing the 5th HPNSP. 

The World Bank was approached to provide up to $900 million and the Asian Infrastructure Investment Bank (AIIB) is expected to co-finance $500 million with the World Bank. It is also expected that the Asian Development Bank (ADB) would finance at least $500 million. 

However, there is uncertainty as to whether all the amount would be available from the development partners.

Sources said even though $900 billion in financial assistance has been sought from the World Bank, the global lender has told the Health Services Division that it would provide $350 million.

There is also uncertainty about funding availability from other development aid agencies, they added.

Dr Sabur, a consultant of the plan, however, said if the programme could be shown to be robust and the performance were good, donors would provide funds. 

Besides, corruption and inefficiency in budget implementations are major challenges. Health budget often remains partially unspent, he noted, adding that development partners will give money if the budget is spent properly.

Receiving commitments from development partners will depend on the implementation and spending of the 4th HPNSP budget, he said.

Officials concerned, however, could not provide information about how much of the 4th HPNSP budget has been spent thus far.

To be implemented over 5 years

The 5th HPNSP – to be implemented over five years starting from 1 July 2024 – will have to utilise the opportunity to realise the objectives of universal health coverage by 2032 and health-related sustainable development goals (SDGs) by 2030 although time is constrained and challenges are manifold, says the report. 

"To move towards the universal health coverage, the health and nutrition programme budget will need to be increased significantly," it added.

The ministry also wants to reduce the prevalence of stunting and wasting among children aged under five years and bring down the mortality rate from non-communicable diseases (NDCs) among people in the 45-59 years age group. 

The report proposes three types of budget allocation for the 5th HPNSP – Tk2,62,542 crore in the low scenario, Tk2,75,827.21 crore in a moderate scenario, and Tk2,90,370.40 crore in an optimistic scenario.

Md Jahangir Hossain, additional secretary (Planning Wing) of the Health Services Division, stated that the government will finalise one of the three types of financing proposed by the health ministry.

Experts have, however, told TBS that increasing the budget allocation alone will not be sufficient to achieve the desired outcome. 

They have recommended that the government ensure proper monitoring and develop the capacity of health officials to spend money in a corruption-free and transparent manner.

At present, district-level public hospitals are operating with around 64% of the doctor posts, and 34% of the nurse posts vacant, while the rate is 83% and 71% in upazila health complexes.

Experts for creating skilled manpower

The Ministry of Health and Family Welfare adopted a sector-wide approach (SWAp) in 1998 and implemented three SWAps between 1998 and 2016. 

The ministry is currently implementing the fourth SWAp titled "4th Health, Population and Nutrition Sector Programme".

The health ministry is expected to send the draft 5th HPNSP to the National Economic Council (NEC) within four-five months for its approval after holding discussions with all stakeholders and taking their opinions on it.

Experts said the health sector is huge. Before 1998, there were hundreds of projects with project directors appointed accordingly. But these project directors had no coordination among them, resulting in resources being wasted. Thirty-two operational plans were made under a sectoral programme  in 1998 to solve the problems of the entire health sector which reduced the wastage of resources.

However, Dr Syed Abdul Hamid, professor at the Institute of Health Economics at Dhaka University, believes that full benefits could not be reaped as the sectoral programme failed to function properly.

He told TBS, "The sectoral programme was a good idea. We managed to get 50% of its benefits. Whether the programme works properly depends on the line project directors' qualifications, training, and whether he is provided with sufficient manpower. Funding should be properly determined. But consultant tasks are fixed by one person while the budget is fixed by another one. The budget does not match with the programme."

The implementation of health sector projects requires doctors who have knowledge. Health administration cadres should be appointed in the BCS health wing to create such skilled manpower, he said.

Dr Abdul Hamid said the health ministry is officially taking charge of urban healthcare in the 5th HPNSP, which is a good decision. Besides, there are plans to reduce out-of-pocket expenditures. 

"Allocation to the health sector is very low compared to GDP. But even the allocated amount remains unspent. In the first nine months of the current financial year, the Directorate General of Health Services has managed to spend only 15% of the allocation, which is the lowest among the 15 ministries and departments that received the highest allocations," the professor added.