Out-of-pocket spending on treatment rises further

Infographic: TBS

Bangladeshis have been paying over two-thirds of their treatment cost out of their own pockets, according to the sixth Bangladesh National Health Accounts published yesterday.

The share of out-of-pocket health expenditure in the country was 56% in 1997, the year the report was first published, which jumped to around 69% in 2020, according to the latest report prepared by the Health Economics Unit of the health ministry.

According to the Health Economics Unit, the rate of out-of-pocket expenditure in the country was quite high compared to the world perspective. The study did not include the purchase of vaccines and other expenses carried by the government to tackle Covid-19 pandemic.

In 2012, Bangladeshis paid 62% of the total health expenditure out of their pockets. That year, the authorities formulated the "Health Care Financing Strategy 2012-32" aiming to reduce the out-of-pocket health expenditure to 32% by 2032. However, instead of coming down, the rate increased to 67% in 2015 and increased further in the recent years.

In 2020, 68.5% of the total health expenditure in Bangladesh was paid out-of-pocket by treatment seekers, while the development aid agencies paid 5%, said Dr Subrata Paul, Bangladesh National Health Accounts Cell focal person, at the report publication ceremony at Hotel Intercontinental in the capital.

According to Bangladesh National Health Accounts, public sector expenditure accounted for 22.8% of total health expenditure in 2015, which increased slightly to 23.1% in 2020.

The Health Economics Unit said patients spent a whopping Tk34,400 crore or 64.6% of their health expenses on drugs, followed by Tk7,200 crore or 13.4% on ambulatory medical service providers like general physicians, dentists and other health care practitioners. Households also spent a significant portion – Tk6240 crore or 11.7% – of their out-of-pocket payment at the medical and diagnostic facilities.

Share of out-of-pocket expenditure to medical and diagnostic laboratories has increased mostly in the last two decades, jumping from 3.8% in 1997 to 11.7% in 2020.

The government's average per capita expenditure on healthcare in 2020 was Tk4,578 or $54.

Analysis shows that the poorest of the population spend Tk200 per capita for their health, whereas the richest spend eight times more – Tk1,714. A comparison of per capita health expenditure within the same area or group shows that the richest households spend five times more than the poorest, said Dr Subrata Paul.

In a programme titled "Pathways to reduce household out-of-pocket expenditure" in November 2021, the Health Economics Unit said every year around 16% of patients refrain from taking necessary healthcare services due to the continuous rise in out-of-pocket expenditure. However, the report published yesterday did not mention the issue.

Out-of-pocket expenditure is a payment made by households to obtain healthcare goods and services. According to the Global Spending on Health, "In general, when a health care system relies largely on out-of-pocket payment to finance its services, more households face catastrophic spending".

Under the Sustainable Development Goals (SDG) monitoring framework, out-of-pocket payments as a share of total household consumption exceeding 10% (lower threshold) or 25% (upper threshold) is considered catastrophic.

Maya Vandenent, chief of health of Unicef Bangladesh, said, "Due to increasing out-of-pocket health expenditure, people are facing catastrophic situations while seeking treatment. This should be given importance."

At yesterday's event, Major General Mohammad Yousuf, director general of Directorate General of Drug Administration, said, "The dollar crisis has arisen as a result of the Covid-19 pandemic and the Russia-Ukraine war. Consequently, the process of importing raw materials is being hampered and we are under pressure to increase drug prices.

"However, only 2% of the medicine needed in the country has to be brought from outside, so it should not be a problem. We have been holding discussions with the policy makers to deal with the pressure. At the same time, gifts to doctors from various pharmaceutical companies should be reduced to deal with the crisis."

Health Minister Zahid Maleque said a number of measures including stopping over-the-counter sale of antibiotics will reduce healthcare expenses.

"Prescribing unnecessary tests should be stopped and health insurance should be strengthened. There is a pilot project regarding health insurance that is to be rolled out across the country," he added.

Health expenditure breakdown by divisions

Dhaka division with the largest population and highest number of health facilities has the highest healthcare expenditure.

In 2020, Dhaka division's healthcare expenditure – Tk28,560 crore (37.7%) – was the highest while that of Mymensingh division – Tk2,570 crore (3.2%) – was the lowest.

Private healthcare expenditure was also the highest in Dhaka division – Tk21,200 crore – in 2020. It amounts to 36% of total private sector expenditure across the eight divisions.

Chattogram division's share in private healthcare expenditure for the same period is 28%, Barishal (4%), Rangpur (4%) and Mymensingh (2%).