Universal Health Coverage key to reducing healthcare inequality: Experts

To ensure healthcare for all citizens, the interim government should implement Universal Health Coverage (UHC), with increased funding focused on improving primary healthcare services and reducing urban-rural service disparities, said health experts.

Due to a low health sector budget, many people fall below the poverty line from out-of-pocket healthcare expenses, leading to societal inequality, they said at a roundtable titled "Ensuring Health through Universal Health Care in Bangladesh", organised by the Centre for Policy Dialogue (CPD) and The Business Standard.

Speakers at the event said political commitment is crucial to achieving UHC. To develop the health sector, they stressed the need to swiftly establish a National Health Security Office, reduce out-of-pocket costs by providing free medications, implement the Shasthyo Shurokhsha Karmasuchi (SSK) programme in every thana (police stations), and update the 1990 health policy to reflect current realities.

Chaired by CPD Executive Director Dr Fahmida Khatun and moderated by TBS Deputy Editor Sazzadur Rahman, the event took place at the TBS office in the capital's Eskaton Garden area on 4 November.

Currently, Bangladeshis have to pay 68.50% of their total treatment costs out of their own pockets, patients spend a whopping 64% of their health expenses on drugs, and only 3% of patients receive medication from government hospitals, according to data from the Health Economics Unit of the Ministry of Health and Family Welfare.

Dr Fahmida Khatun, Executive director, CPD

We know that good health is the foundation of all happiness. However, whether on a personal or national level, health is often our last priority. Yet, if the population does not enjoy good health, it hampers economic development. While the effects may not be immediately visible, over the years, it impacts productivity and economic growth. We invest significantly more in physical infrastructure than in social infrastructure as a nation.

As a result, the health sector always remains neglected, with costs largely shouldered by individuals through out-of-pocket expenses. Public spending on health from domestic sources is only 0.4% of GDP, and rising out-of-pocket expenditures are contributing to increasing poverty. Despite the growth in our budget and GDP, health-related expenses are making us poorer. According to World Bank data, in 2020, out-of-pocket healthcare costs pushed 3.74% of the population below the poverty line, up from 3.11% in 2016.

Poor communities bear the burden of healthcare expenses generation after generation, keeping them trapped and unable to rise above the poverty line. This perpetuates inequality in society. One of the main sources of this inequality is the lack of sufficient government spending on health, forcing individuals to cover these costs themselves. Ensuring universal healthcare would be a significant step forward for everyone.

Financial struggles to cover healthcare costs can be passed down through generations. Ensuring UFC would be a significant step forward for the welfare of individuals and the state.

Sazzadur Rahman, Deputy editor, TBS

Bangladesh lags far behind in health sector development, with lower government allocations compared to neighbouring countries. The importance of Universal Health Coverage (UHC) becomes evident when statistics show people falling below the poverty line due to healthcare expenses. 

We have seen this number steadily increase, with out-of-pocket healthcare costs rising and people often avoiding visits to the doctor until their condition becomes critical.

Dr Syed Abdul Hamid, Professor, Institute of Health Economics, University of Dhaka

The Shasthyo Shurokhsha Karmasuchi (SSK), which was launched in 2015 in Tangail as a pilot project, can be expanded. It initially offered a package of Tk50,000, but the current government could increase that to Tk100,000. This initiative should not only target the poor but all people.

Investing Tk4,000-Tk5,000 crore could be a game-changer for the health sector. This funding is already within our budget and can be allocated accordingly. If implemented, it could also facilitate the introduction of a referral system.

If the SSK is made universal, people will recognise the benefits of having their healthcare cards. When they visit hospitals with these cards, all their information will be available, ensuring accountability if they do not receive proper service. Any irregularities can be easily highlighted by journalists and researchers.

Currently, primary healthcare services in Bangladesh are divided between urban and rural areas, a system that is not seen anywhere else in the world.

At the union level, healthcare services are heavily focused on curative care. Our system emphasises treatment after illness occurs, which is why the term "clinic" is used instead of a name like "Community Wellbeing Centre". People go there expecting to receive medicine once they are already sick.

We need to integrate the three streams of healthcare services under one unified primary healthcare system.

Establishing General Practitioner (GP) centres through Public-Private Partnerships (PPP), similar to the systems in the United Kingdom, Canada, and Australia, would be beneficial. We can adapt these models to suit our needs.

For implementation, each union would have two nurses, one paramedic, a diploma pharmacist, and additional support staff. Community clinics would be integrated into this system, each with a paramedic, and Community Healthcare Providers (CHCPs) would function as health workers.

Overall, there would be nine health workers in each union and four paramedics. This system would enable quick service delivery, funded by the government, with medicine supplied initially by the government.

At the district level and in city corporation areas, primary healthcare would be provided in a similar way. In densely populated cities like Dhaka, specific SOPs would be established.

The SSK must be implemented nationwide.

Dr Khondaker A Mamun, Director, Institute of Research, Innovation, Incubation and Commercialisation (IRIIC); founder, United International University, CMED Health Ltd

Why should there be so many patients lying on the floors of government hospitals? Schools and colleges don't teach how to maintain health or that health is our greatest asset.

Each year, Bangladeshis spend around $10 billion on healthcare, with about $5 billion going to neighbouring countries for treatment. Therefore, we must focus on enhancing the quality of healthcare within our own borders. By doing so, we can keep this money in the country.

Every year, the number of patients in our hospitals increases by 22.5%. We lack interest in preventive and primary healthcare.

Over the past 10 years, after travelling to every district and working in the health sector, I've realised that people only visit doctors when they are already sick. What we need, however, is a focus on preventive measures. Everyone prioritises secondary and tertiary care, but we should be proactive in preventing problems, rather than reacting to them after they occur.

We all know that prevention is better than cure, but we don't put this into practice. We need a system where people are informed about their health right at their doorsteps. Using technology like the Internet of Things (IoT), community health workers could collect health data.

By visiting homes regularly, these workers would gather information on what each family member needs, from newborns to the elderly. This system would then signal any risks in real-time, enabling telemedicine services when necessary. Community clinics will always be available to support this effort.

At the union level, there would be GP centres providing 24-hour services with doctors, nurses, and paramedics. Urgent care would be available at the upazila health centres, which would also treat patients referred from the union level.

If further care is needed, patients could be sent to district hospitals. We have tested this method and now aim to implement it through Public-Private Partnerships (PPP). In urban areas, there would be one GP centre for every 10,000 households.

The cost for a monthly health checkup per person would be $1 in rural areas and $3 in urban areas. We need to bring healthcare directly into people's homes to ensure universal health coverage. Additionally, workplaces and universities should teach the importance of healthy living.

Dr Md Monzur Hossain, Programme manager, ANH

The number of people suffering from noncommunicable diseases (NCDs) in the country is steadily increasing. Due to unhealthy eating habits, lack of physical activity, and other factors, conditions such as high blood pressure, diabetes, heart disease, and respiratory problems are rising rapidly. This has led to a growing need for medical treatment.

In 1990, NCDs accounted for 26% of health issues, but now that figure has climbed to 74%, and it continues to rise. Many patients are falling below the poverty line due to the high costs of treatment. Therefore, raising public awareness to prevent noncommunicable diseases is essential.

In urban areas, there are 10 doctors for every 10,000 patients. In rural areas, there isn't even one doctor for the same population. How can a single doctor provide quality care to so many patients? The number of doctors must be increased, and vacant positions must be regularly filled, as many remain unoccupied.

Dr AM Zakir Hussain, Chairman of the Community Clinic Health Support Trust

Poor service quality results from several factors, including a lack of resources, insufficient technology, low motivation among health workers, inadequate prioritisation, a weak system, and poor pricing assessment and procurement skills.

The basic requirements for successful Universal Health Coverage (UHC) include effective healthcare delivery, efficient health system management, essential resources, and equitable distribution. This involves the input-process-output/outcome model, access to essential technologies, and a fair and justified approach to service provision.

In other countries, 60%-70% of their annual budget is spent on human resources, whereas in Bangladesh, 80% is spent on infrastructure development.

Dr Lelin Choudhury, Public health expert; chairman, Health and Hope Hospital

As per government estimates, around 18% of the population lives below the poverty line. Therefore, those individuals should be integrated into government services, and health cards should be issued to ensure they do not miss out on necessary care.

People seeking treatment in government hospitals often feel helpless, and this mindset needs to change. We must set a standard for service across all public and private hospitals. Healthcare must be equitable, and experts should be entrusted with responsibilities.

Those living below the poverty line will receive a government-issued health card, which will allow them to access free services at both public and private hospitals. The government will cover all expenses.

Those with expertise in healthcare must be given the responsibility to work on health policy. One of the main reasons for the poor quality of services in government hospitals is that, despite the increasing number of patients, the number of doctors, nurses, and necessary equipment is not being expanded. Each year, the number of hospital beds is increased for political reasons, with officials proudly announcing that they have added more beds to hospitals.

In Bangladesh, healthcare services and medical care are often used interchangeably, and we must move away from this practice. The entire healthcare system should focus on promotive, preventive, curative, rehabilitative, and palliative care. These concepts are not well understood by the public.

People are accustomed to the idea that when they fall ill, a doctor will prescribe an injection or medication, and they will get better. We need to move beyond this limited approach.

Dr Nahitun Naher, Assistant director, Centre of Excellence for Health Systems and Universal Health Coverage

The World Health Report states that a minimum of 5% of GDP should be allocated for government health expenditure, as supported by an international communiqué. However, in Bangladesh, only 0.74% is being spent.

The World Health Organisation recommends that 15% of the national budget should be allocated to health. In Bangladesh, the allocation is just 5%. Moreover, even the allocated budget for this sector is not fully implemented. The private sector remains unregulated.

Dr Dibalok Singha, Executive director, Dushtha Shasthya Kendra (DSK)

The government must demonstrate a commitment to improving the health sector.  With around 400 million people living in extreme poverty in the country, we can learn from successful examples of universal health coverage in Rwanda, Vietnam, Brazil, and Thailand, tailoring those lessons to our own needs.

Currently, Bangladesh allocates only 0.74% of its GDP for health, which should be increased by an additional 1%. It is essential to prioritise what the government will implement in the short, medium, and long term for the health sector.

Our tax-to-GDP ratio is among the lowest in the world. We need to increase our tax collection rate, as this would allow the government to allocate more funds to the health sector. To achieve this, more taxes must be collected from the wealthy, as is done in developed countries. This would increase government revenue.

The discussion highlighted the lack of investment in the health sector, poor governance, a shortage of skilled human resources, subpar service quality, and the absence of a focus on preventive healthcare. Therefore, the current government needs to implement short-term, medium-term, and long-term plans with a priority-based approach to rapidly improve the health sector.

Dr Md Aminul Hasan, Former director, DGHS ‍Consultant, Ministry of Health and Family Welfare

Our healthcare system is not functioning properly. Since 2017, urban health has been managed by the local government ministry, and it is no longer under the Ministry of Health. As a result, urban healthcare services are on the brink of collapse. When implementing universal health coverage, we need to focus on how to coordinate this effectively.

The main obstacle to implementing universal healthcare is the fragmentation of healthcare services at the policy level. We need to figure out how to bring everything together. 

The responsibilities of the Directorate General of Health Services have been divided, but now we need to consolidate everything under one umbrella, which requires a regulatory framework. Without the government's will, this issue cannot be resolved. Based on the experience of the last 30 years, these are the key challenges. Once these are addressed, the implementation of universal healthcare will be possible.

Dr Mahbub Elahi Khan Chowdhury, Scientist, Health Systems and Population Studies Division, icddr,b

If we had received healthcare services at minimal costs, the health expenses from people's pockets would not have increased so much. Our research shows that there is a considerable resource shortage. There is a lack of trained personnel in government service centres, a shortage of equipment, and a lack of coordination. As a result, the quality of service is poor.

Central-level authorities do not listen to local concerns. Therefore, inter-institutional coordination is necessary. Due to numerous issues in public health, the number of private healthcare providers is increasing, but they are not regulated.

Healthcare has become highly centralised in Dhaka. This needs to be decentralised to the divisional level. Additionally, there should be a separate pay structure to increase benefits for physicians and medical doctors, so they are motivated to provide services in all areas.

Dr Subrata Paul, Focal point, UHC and National Health Accounts, Health Economics Unit

Our health sector policies have lagged behind, and we are currently focusing on Noncommunicable Diseases (NCDs). However, globally, the focus has shifted from NCDs to the Dual Burden of Disease. The weaknesses of our health sector became evident during the COVID-19 pandemic.

The Shasthyo Shurokhsha Karmasuchi (SSK) was initially launched as a pilot programme. Worldwide, there is a shift away from the health insurance model, with more emphasis being placed on public funding. Rwanda and Ethiopia are the only two countries where community-based health initiatives have been successful, but even they are now shifting away from this model. Sri Lanka does not have national health insurance, yet their public health services are quite advanced. Therefore, considering all these experiences, our government must take action.

SSK began in 2015 in three upazilas of Tangail. It was later expanded to all upazilas of the district. However, due to financial constraints, the programme has been suspended since July. Based on years of experience, we have advised the government to scale up this programme nationwide through the National Health Authority. This requires strong political commitment.

Dr Mohib Ullah Khondoker, Director, Gonoshasthaya Kendra

To improve the quality of healthcare services, the government must have a strong political will. This is a political matter. They must be willing to allocate resources and focus on the sector.

I do not expect the current government to bring significant change to the health sector. In the ministry's meetings, health is the 139th agenda item. They have many other priorities. The government cannot undertake major reforms in health as it is not a priority for them. No government has ever considered the health sector a priority in Bangladesh. There needs to be policy integration in the country. While policies may exist, real implementation requires the government's commitment.

The government must provide free services to the poor. It would not be advisable to privatise and commercialise the health sector.

Dr Sohana Shafique, Assistant scientist, Universal Health Coverage, International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b)

Instead of "care", we prefer to use the term "coverage". We have collected data from 40,000 households in urban areas. Those living below the poverty line in urban areas are facing significant challenges. Working women are particularly struggling, especially when they fall ill. When they require services at government hospitals, they are unable to access them due to being at work.

Reforms are necessary for universal healthcare. Our public health leaders must understand the specific challenges in their areas. Based on this understanding, they should engage the community.

Beyond direct healthcare services, we also need to focus on community involvement. We must create leaders from within the community and establish a monitoring system. For example, construction workers should be ensured proper safety equipment while working.

Our research has shown that the poor in rural areas are becoming even poorer while trying to meet medical expenses. They are facing even greater hardships.

Professor Rashed E Mahbub, Former president, Bangladesh Medical Association (BMA)

Health is a political issue. The progress made in the health sector in Bangladesh has not been achieved during democratic times. In fact, progress has been hindered during democratic regimes. We keep talking, but where are the people to implement these ideas? 

During the previous government, we made many recommendations regarding the health sector. However, it was found that many of these recommendations were not even looked at by the Ministry of Health. The current government has set up a health reform commission, but it has yet to be notified. The health sector does not truly receive the attention it deserves, even though it should be a top priority for the government.

Universal health coverage is essential. No one can disagree with this. It is unacceptable that those without money cannot access medical care. The current government could, at the very least, implement universal primary healthcare across the country based on the experiences of the Shasthyo Shurokhsha Karmasuchi (SSK) programme. This would be a step forward.

At the secondary and tertiary levels of healthcare, we see that those with power can access treatment for free, while the poor and marginalised suffer. Public healthcare should be a form of protection for all.

Professor Liakat Ali, Former vice chancellor, Bangladesh University of Health Sciences

Primary healthcare coverage is the key to achieving universal health coverage. It should be funded by the government.

The issue with implementing this through Public-Private Partnerships (PPP) is that once healthcare is handed over to the private sector, it becomes difficult to bring it back under government control.

We still take pride in the National Drug Policy introduced in 1982. The goal was to reduce the number of prescribed medications and ensure that the public received quality medicines. However, this is no longer being followed.

Prescriptions often include multiple medications, and there is no auditing of prescriptions. As a result, the drug industry benefits, and unhealthy practices are emerging in this sector. While the government has received praise for this drug policy internationally, the public, who were supposed to benefit, is now paying high prices for medicines. Currently, 64% of what people spend on healthcare goes toward purchasing medicines.

The government must ensure free primary healthcare services for the public, and this should be legally binding. If people do not receive these services, they should have the right to seek redress in court.

Professor Zahidul Quayyum, Professor and co-director, Centre of Excellence for Urban Equity and Health (CUEH), BRAC James P Grant School of Public Health

Services must be provided according to local needs. The budget allocated for the health sector must be utilised properly.

We can learn from the experiences of India and Thailand, where they have successfully implemented universal healthcare.

The return on investment in health is higher than that of large infrastructure projects like bridges and roads. If health expenditure is properly increased, the population will become more productive.

Dr Mushtaque Raza Chowdhury, Convenor, Bangladesh Health Watch

The interim government should provide free medications to reduce out-of-pocket expenses.

Any mass movement can yield positive results. We hope this interim government will remain in office for another year and a half, during which they can achieve significant developments in the health sector – such as establishing a Health Security Office, forming a Permanent Health Commission, and implementing the Shasthyo Shurokhsha Karmasuchi (SSK) in every thana (police stations), along with the necessary policy revisions.

A referral system in healthcare is a structured process that guides patients from primary care providers to specialised services or higher levels of care when needed.

Thailand has made healthcare services free for its citizens. This was a political commitment by the Thai government to provide free medical care to the people. Former Thai prime minister Thaksin Shinawatra initiated this programme, and it is still maintained by the country's political parties.

Every December, a discussion on the health sector takes place in Thailand's capital, with civil society organisations participating. These discussions focus on the development of the sector, and the recommendations made are fully funded by the Thai government for implementation.

Thailand's health institutions, including those focused on research, make significant contributions. However, while Bangladesh also has institutions, they are not able to contribute effectively to policy-making in the same way. During the COVID-19 pandemic, we saw that these institutes failed to offer concrete solutions for controlling the virus. Therefore, we need to modernise our health sector institutions.

Thailand's experience can serve as a model for achieving Universal Health Coverage (UHC).

Last year, the Bangladesh government organised a conference on the health sector. We were hopeful that during this time, the government would announce that they would implement universal healthcare services. Instead, we heard the government leader say, "We are committed to universal health coverage, but the funds must come from foreign donors." This left us disappointed. While our economy is improving, we are still seeking health sector funding from foreign donors.

The current government must establish a Permanent Health Commission to oversee the continuous development of the health sector. This commission would monitor areas where reforms are needed and drive progress in the sector.