When basic necessities become your biggest expenditure

Article 15 of Bangladesh's constitution entitles the state to fundamental responsibilities of providing citizens "provision of the basic necessities of life, including… education and medical care" through "planned economic growth." 

Article 18 of the constitution says that it is the "primary duty" of the state to raise the level of nutrition and improve public health. 

However, the latest Bangladesh Bureau of Statistics (BBS) data, reported by The Business Standard, shows how soaring costs of healthcare in Bangladesh have exacerbated the disease-burdened families. 

There are examples aplenty of how the increasing medical costs have left families in deep financial trouble – and often in bankruptcy. 

According to BBS, families' average spending on health witnessed a remarkable increase of over 202%. The monthly household expenditure on health services surged to Tk2,115 in 2022 from Tk700 in 2017. 

Whereas the average total spending increased a staggering 98%, the health alone being 202% illustrates how Bangladesh's out-of-the-pocket healthcare system – which means you have treatment only if you have money – has imperilled many families with financial troubles. 

At the same time, the data also revealed how education spending reached a critical juncture as families' spending here declined to 31%. 

Now, it doesn't mean education costs were reduced because the data revealed that the average expenditure on education per student from Tk900 in 2016-17 increased to Tk1,745 in 2022 – Tk1,171 in rural areas and Tk2,927 in urban areas.

"Our budget is often a fixed figure. If our cost soared in one area, there is no way but to shrink expenditure in other areas. That is exactly what happened with the education expenditure reduction," said Dr Abdur Razzaque Sarker, a health economist and research fellow at Bangladesh Institute of Development Studies (BIDS). 

Educationist Dr Manzoor Ahmed, Professor Emeritus at Brac University, said in reality, the education cost is also much higher than what the BBS reported. "Those with children at school spend much more than what the BBS reported," he said. 

In the era of health emergencies 

Our disease burden has increased with the abundance of communicable and non-communicable diseases including Covid-19, dengue etc in recent years. 

In this health emergency period, and traditionally what we see in Bangladesh, the patients' route to healthcare is complicated. A patient would go to her/his local health centre but often the journey only starts there. 

The local doctors, most of the time, refer the patients to the district, and then from there to nearby medical hospitals, and many of them eventually turn to hospitals in Dhaka. 

This lengthy duration increases the complications in patients and leads to further expenditure on treatment, medicine, transportation, food, etc. 

We spend around 65% on medicines, according to Dr Razzaque, who said that anti-biotic prices have increased and everything else is involved in the procedure. 

"In Bangladesh, about 68.5% of health expenses come out-of-pocket of the families [according to the Health Economics Unit of the health ministry]. The World Bank or WHO data puts the figure even higher at around 75%. It means the money we spend for health is spent directly from the households," he said. 

"We target to bring this down to 32% as per universal health coverage. But we are far away from that target. If you look at Pakistan, India, Nepal or Sri Lanka, except for Afghanistan, our out-of-pocket expenditure is the highest in the region," he added. 

But does that say we get better quality after paying more for health?  

"No, we don't," said the health economist, adding, "The first goal of an effective health system is to get rid of out-of-pocket expenditure. An out-of-pocket health system suggests that only those with money can avail healthcare, meaning our poor and marginal people don't have access to proper healthcare," he replied. 

He also admitted that there is a dearth of studies on the question of quality.

"But if you look into it, why do we prefer to go to private [hospitals] instead of public? Because we feel they maintain some quality. Also, people go to India for better quality treatment. What does that say? Maybe our quality is poor, that is why people visit private [hospitals] and India," he said. 

If Bangladesh wants to ensure universal health coverage, national health insurance is a must, according to Dr Razzaque. 

"Because only that would reduce the out-of-pocket costs.  And that will help improve the quality as well. Imagine the 68% that people are spending [on healthcare] is being spent by the government, it will become the government's headache because poor quality [of healthcare] will incur losses. When the government will spend [this amount], they will have to make money."

Where are we on the education front? 

On the other hand, Dr Manzoor said that it is not like neighbours are far ahead in education. Some Indian states are better but many states have identical situations like ours. 

However, he said that there is one difference: investment per student is double that of ours. "In our country, the government spends $200 per student, which is around $400 in India."  

Our families spend a lot of money on private tutoring, coaching, guidebooks, etc. The costs hence are higher both in the primary and secondary phases. 

"It has gone beyond their [the parents'] capacity, and this is the average that I am talking about," Manzoor said, adding that, "most parents spend below the average – which doesn't bring these students standard education." 

He invites comprehensive measures to ensure free primary education – which is not quite free like policy dictates, he found. 

"We have to observe and analyse the real situation on the field and take appropriate policies so that schools and education are standard; so that students don't need to go for private tutors or guidebooks, there will be adequate teachers in school and the schools themselves will provide extra care for students who are lagging," he said. 

The expert said that we will need further investment in education to make that happen. "We have to decentralise education – make committees with NGOs, guardians and the community to watch this over – to make sure of their implementation." 

Article 17 of Bangladesh's constitution says that the state shall adopt effective measures for "…extending free and compulsory education to all children."  

The state needs to focus more on such pressing issues to help the people who are deeply troubled by price hikes and having further difficulties in dealing with mounting medical and education bills.