[🇧🇩] Healthcare Industry in Bangladesh

[Saif]

Dhaka hospitals need urgent support

They are struggling to provide necessary care to patients

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Dhaka hospitals need urgent support
They are struggling to provide optimal care to patients

VISUAL: STAR

The updates coming from several government hospitals in Dhaka in the aftermath of recent violent clashes are quite concerning. These hospitals, treating people injured during the unrest centring the quota reform movement, are struggling to provide optimal care due to the sheer number of incoming patients, as per a report in this daily. Clearly, these and other public hospitals in major cities need proper support from the authorities.

According to our report, the hospitals in Dhaka, especially the Dhaka Medical College Hospital (DMCH), have been stretched thin since July 18, when violent attacks spread out across the city. People were injured with shotgun bullets or pellets as police and Border Guard Bangladesh (BGB) troops shot at protesters and alleged infiltrators. At the DMCH, some 1,071 people wounded by sharp weapons, bullets and/or pellets sought treatment between July 15 and 22. Most of these victims—ranging from teenagers to middle-aged individuals—said they were merely bystanders or commuters and not associated with the protests or clashes. All the patients currently admitted at the DMCH were injured critically and had to undergo surgery. Overwhelmed by the surge, the hospital had to prematurely discharge those who had come in before the start of the violence to make room. The situation is similar at Shaheed Suhrawardy Medical College Hospital (SSMCH), NITOR, and the National Institute of Ophthalmology.

Healthcare services in general have been facing a massive disruption due to the ongoing situation. Due to the nationwide internet shutdown, which came into effect on July 18 night, private medical colleges, hospitals and diagnostic centres have been unable to provide services, according to another report in this daily. All online healthcare services have been out of reach as well. These facilities and services cater to a significantly large number of people in Bangladesh.

Given the unprecedented levels of violence, deaths and destruction seen over the past week, it is understandable that hospitals would get overwhelmed to some extent. However, as we have said numerous times before, an emergency service sector like healthcare must always have contingency plans anticipating all kinds of crisis. We urge the government to urgently mobilise all resources needed for the DMCH and other hospitals so that they can provide the best possible treatment to patients. The medical professionals who worked tirelessly in such a high-stress situation deserve some compensations as well.

The limited restoration of internet services is a positive turn of events; this means private healthcare facilities and online services can get back to doing their job. We expect the authorities to extend the necessary logistical and technical support to all healthcare service providers so they can help people without disruption.​

 

[Saif]

Health sector needs attention on an urgent basis

The interim government must focus on purging partisan influences from the public healthcare sector.

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Health sector needs attention on an urgent basis
The interim government must focus on purging partisan influences from the public healthcare sector

VISUAL: STAR

A Prothom Alo report on the politicisation of the public health sector portrays a grim picture of how far the rot has spread. The report details how partisanship has pervaded the sector—from medical academia to healthcare services to projects under the health ministry—ensuring absolute dominance of the erstwhile ruling party. But Awami League was not the only one to have spread its tentacles; BNP also did the same while in power, and it seems the party is trying to do it again after the fall of the former.

Reportedly, after forming government in 2009, Awami League and its affiliates placed loyal officials in various health-related institutions. One example is the Bangabandhu Sheikh Mujib Medical University (BSMMU), where five consecutive vice-chancellors appointed since 2009 have either been a member of pro-AL Swadhinata Chikitsak Parishad (Swachip) or directly involved with AL politics. The same goes for pro-VCs, proctors and others in top positions. Political recruitments were also seen at 37 other public medical colleges. Elsewhere, at the 495 upazila health complexes, only officials loyal to AL were appointed as upazila health officers. Thus, loyalists were favoured in leadership positions at every level of the public healthcare sector—from the grassroots to the top—whether they were qualified or not. In the process, AL deprived anyone with suspected links to BNP and even deserving nonpartisan candidates.

During BNP's rule in 2001-2006, it was the pro-BNP Doctors Association of Bangladesh (DAB) that dominated public-sector recruitments, choosing party loyalists in important positions, and thus depriving those even remotely affiliated with AL and its politics. During the times of both regimes, those who were not affiliated with either party or their politics have suffered, and the lack of competent leadership eventually plunged the sector into an unprecedented crisis.

In the aftermath of Sheikh Hasina's fall, it seems BNP is focused on repeating the same cycle. As many as 173 doctors who were recruited in BNP's time, and deprived of promotions throughout the AL rule, were all promoted in one day—on August 8. The Prothom Alo report suggests that the spate of promotions is still going on. Frustrated DAB members are cornering relevant authorities, staging protests in various medical institutions, and in some cases even vandalising public hospitals.

We understand the frustration of pro-BNP doctors and medical professionals, but their attempt to forcefully claim what they think they deserve cannot be acceptable. Political partisanship is one of the root causes behind the ailing public health sector, and it's time to do away with it. Otherwise, much-needed reforms in the sector will continue to elude us. To restore discipline in this vital sector, we urge the interim government to be strict and judicious about all appointments and promotions. Only those who are qualified and deserving should get preference.​

 

[Saif]

We must be bold with health sector reforms

While we have made significant achievements, complacency cannot be allowed

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We must be bold with health sector reforms
While we have made significant achievements, complacency cannot be allowed

VISUAL: SHAIKH SULTANA JAHAN BADHON

The health sector holds an important place in a nation's development. The past few decades have witnessed some remarkable strides in Bangladesh's health sector. However, this has largely stalled since 2010. Between 1990 and 2010, Bangladesh reduced its maternal mortality ratio from 600 per 100,000 live births to 194, an astonishing achievement. After almost a decade, however, there has been little improvement. Such stagnation was similarly observed in several other indicators of a nation's development.

It is said that we harvested the "low-hanging fruits" well. Bangladesh is committed to reducing the maternal mortality ratio to 70 by 2030, but given the current situation, this seems like an unachievable target. To attain progress, we need to focus on the more difficult, "high-hanging fruits." Civil society activists and health experts repeatedly highlighted this challenge to the previous government, but sadly, serious efforts were not made. Instead, a sense of complacency prevailed. The result was that any idea suggesting reform faced resistance.

The anti-discrimination movement has inspired the nation and sparked hope among the masses. It has given us a chance to rethink our future. In the health sector, we now have an opportunity for comprehensive reform. If we want to move forward in line with the times, we must be ready to tackle some difficult tasks.

We know, for instance, that good governance is a major issue for development in Bangladesh. Poor governance leads to many problems, and the health sector is no exception. The absence of doctors in health centres is a perennial issue. The corruption that surfaced during the Covid pandemic is still fresh in our memory. We know these issues arise due to the lack of accountability and poor management. The private healthcare sector has become a behemoth without any control whatsoever, harbouring severe inequalities. In 1982, an ordinance was passed giving special priority to the private sector, but it has not been updated since. There is no clear regulatory provisions to control them, leading them to get away with unethical and illegal practices. Despite the presence of the Bangladesh Medical and Dental Council which was established decades ago to monitor the professional behaviour of doctors, many still engage in unethical practices without facing any consequences.

One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.

Another significant drawback in our healthcare system is poor investment. Currently, the government's spendings on healthcare is one of the lowest globally: only 0.7 percent of the GDP. With such meagre investment, it is impossible to imagine modern healthcare. We have seen to our dismay that two of the important pillars of human development, health and education, were among the lowest priorities for the previous government. Our neighbour Sri Lanka, which is far ahead of us in most indicators, spends nearly four times more on health than we do in Bangladesh. Even the small funding that the health sector gets is not fully utilised, with the utilisation rates remaining below 80 percent. One of the main reasons for this is the lack of adequate capacity in the ministry of health, whose inefficiency in drafting a proper budget, planning, and utilising funds is very well-known. The lack of vision is yet another reason. A "poverty of vision" seems to have gripped the ministry. If we want to emerge as a prosperous nation, our health planners must have a clear vision befitting the health system of a developing country, and our budgets should be framed accordingly.

One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.

In addition, another significant issue plaguing Bangladesh's healthcare system is its human resources. Doctors, nurses, and midwives are in severely short supply. To address this crisis, the previous governments licensed new institutions in both the public and private sectors which contributed in alleviating the crisis to some extent. However, there is no effective mechanism in place to ensure the quality of these institutions. Similarly, we need to focus on research. Recently, Bangladesh Health Watch published an extensive research-based book documenting Bangladesh's first 50 years, which shows how Bangladesh has surpassed its neighbours in various health indicators. One of the findings revealed that in recent years, Pakistan has been able to overtake Bangladesh in health research.

The previous government had expressed its commitment to achieve Universal Health Coverage (UHC). Unfortunately, it never felt the need to explain in detail how this would be done or where the additional funds would come from.

The recent uprising is a massive achievement, with tremendous sacrifices made by students and common citizens. We know that every crisis also presents an opportunity. After World War II, the European countries built their health systems on the ruins of war, ensuring free healthcare for all citizens. In the 1990s, after a horrific genocide, Rwanda launched its UHC programme. As I see it, the student revolution has similarly given us a golden opportunity to overhaul our broken health system. Experts have agreed on what needs to be done. This can be broadly divided into five actions: i) establish a high-powered permanent national health commission to create and monitor a roadmap for implementing UHC nationwide; ii) establish a national health security office to ensure accountability in the health system by separating the ministry of health's roles as a "purchaser" and "provider"; iii) ensure good governance and proper management; iv) increase healthcare investment to two percent of GDP, with increased priority for primary healthcare; and v) enhance the quality, efficiency, and oversight of institutions involved in professional health education and research.

I believe that if we follow this path, we will confidently move towards achieving our national goals. While we have made significant achievements, complacency cannot be allowed and must be kept at bay. To bring about a real and lasting change, there is no alternative to reform. This is something the student leaders have repeatedly emphasised. The interim government must take a bold stance and move towards reforms in the health sector that lead to the public being served.

Ahmed Mushtaque Raza Chowdhury is convener at Bangladesh Health Watch, and professor of population and family health at Columbia University, New York.​

 

[Saif]

Healthcare in tatters: Health workers must go to the distressed

When it is not possible for the distressed people to come to the Upazila Health Complexes for treatment, then the health workers themselves have to reach out to them. More medical teams should be sent to the affected areas on an urgent basis. Sending only the medical teams won’t do, they should...

en.prothomalo.com

Healthcare in tatters: Health workers must go to the distressed
Editorial Desk
Published: 01 Sep 2024, 19: 02

Healthcare experts had warned already that various water-borne diseases will spread out in the flood affected areas as soon as the water recedes. Especially there looms the risk of a diarrhoea outbreak in these areas due to the lack of pure drinking water. And that’s exactly what happened in reality.

The healthcare system we have here is the one where the patients are required to go to the hospitals, clinics and physicians. The physicians or the health workers do not go to the patients. This might be acceptable under normal circumstances.

But that seems no longer a possibility for many during natural calamities like floods and cyclones. Though the water has receded in many areas the road communication could not be restored yet. In Bangladesh, Upazila Health Complexes are the main support for reaching out health care at the grass root level.

However the problem is that these establishments lack in the necessary manpower, infrastructure, equipment and medicines. The condition of the community clinics that were established to reach out healthcare to remote areas during the Awami League government’s regime is also of the sort that even if they do have the wish to provide healthcare they lack the capability. Besides, not all the villages have clinics either. And, the villages where there is a clinic are visited by the people seeking health care from the surrounding villages.

The communication system in some districts of the eastern region has been completely destroyed by to severe floods that continued for several days this time. There is not even a way to go to the next house let alone the next village. As reported in Prothom Alo, people in the flood affected areas started suffering from diarrhoea, skin diseases, fever, cold and cough as soon as the flood water receded. Plus, sores and skin rashes are being noticed on the hands and feet of many.

Since the flood situation continued for nine days, the elderly and the children are suffering more from fever, cold and diarrhoea in Feni, Noakhali, Lakshmipur and Cumilla districts. Residents of the affected areas complain that many of the community clinics are closed due to waterlogging. The ministry of disaster management and relief has stated that a total of 619 medical teams are working in 11 districts to provide medical services to people in the flood-affected areas.

Then where are these many medical teams are working? Are their activities limited only to the side of the roads and the highways?

Civil surgeon in Feni, Md Shihab Uddin has also admitted that the number of diarrhoea cases is very high in the flood affected areas. The number of patients has increased in all hospitals of the upazilas as well as of the districts. For the time being there is not that much shortage of saline and ORS for diarrhoea.

According to the office of the civil surgeon in Lakshmipur, as many as 40 community clinics and three sub-health complexes on the union level have been submerged underwater. Strong efforts are being made to provide good treatment to the people affected by the flood at various places including the shelters.

The in-charges of all the hospitals and clinics are providing records of how many patients they have received. However, they are saying anything on how many patients they reached out to. When it is not possible for the distressed people to come to the Upazila Health Complexes for treatment, then the health workers themselves have to reach out to them. If there are some issues with boats in this case, those have to be solved as well. Plus, arrangements have to made quickly so that the closed down community clinics can be reopened as soon as the water recedes.

More medical teams should be sent to the affected areas on an urgent basis. Sending only the medical teams won’t do, they should also have the necessary medicines and medical supplies. There should not be even a single day of delay, especially in the areas where there has been a diarrhoea outbreak already.​

 

[Saif]

Bold, pragmatic measures can revitalise Bangladesh’s health sector

Investment in the health sector must unquestionably be enhanced with the objective of major overhauling.

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Bold, pragmatic measures can revitalise Bangladesh’s health sector

FILE VISUAL: SHAIKH SULTANA JAHAN BADHON

Bangladesh, with a population of over 17 crore, is the eighth most populous country in the world. With the annual population growth rate of around one percent, it is likely to stabilise at around 240-250 million, posing considerable challenges for Bangladesh given its small land area and other resource constraints.

From high fertility (TFR of over six) until the mid-1980s, fertility declined to 3.3 during 1994-2000, and further to 2.3 by 2011. However, it has stalled at that level since then. The family planning programme achieved commendable success until 2011, with the contraceptive prevalence rate (CPR) rising from around four percent in the 1960s to 61.2 percent in 2011, but it has remained almost unchanged (64 percent in 2022, according to Bangladesh Demographic and Health Survey) since then. This is on account of several factors, including, but not limited to: i) decline in the relative share of longer-acting and permanent methods (LAPM), from 32 percent of modern method use in 1994 to only 14 percent in 2022; relying on temporary methods rather than accepting LAPM by women who have completed their family size poses a major problem for the efficiency of the programme; ii) Relatively high unmet need for contraception (10 percent); if users of traditional methods (nine percent) are considered, the total unmet need for modern methods was 19 percent in 2022; iii) relatively high discontinuation, implying huge system loss for the programme (around half of the users stop using a method within 12 months of starting its use; and iv) erratic interruptions in supplies of contraceptives.

Since independence, Bangladesh has achieved considerable success in most health indicators, though there are inequities based on the socioeconomic status of the population. The infant mortality rate (IMR) declined from 144 deaths per 1,000 live births in 1971 to 25 in 2022, though it is higher than in Sri Lanka, Nepal, Maldives and Bhutan. The under-five mortality rate declined from 223 to 31, but it is higher than in Sri Lanka and Maldives. The maternal mortality ratio (MMR) declined from 574 deaths per 100,000 live births in 1990 to 176 in 2017, but it is higher than the average MMR in South Asia (157 in 2017), and also higher than in India, Sri Lanka, Bhutan and Maldives. Over the past five decades, there has been a rise in life expectancy from 45 years to around 74 years, but it is lower than in Sri Lanka and Maldives.

Between 1990 and 2019, the total number of people with non-communicable diseases (NCDs) increased from 9.55 crore to 14.5 crore. Deaths due to NCDs increased, with 14 of the top 20 leading causes of death in 2019 due to such diseases, with stroke at the lead. If this trend continues, management of the increased burden of NCDs will be a considerable challenge for the country's healthcare system. Cost-effective, multisectoral efforts are needed to prevent and control NCDs, promote healthy lifestyle, and prevent premature mortality and disabilities. There has been a substantial decline in deaths due to communicable diseases—malaria, dengue, AIDS, tuberculosis and diarrhoea—though they still remain significant causes of illness and premature deaths. Bangladesh is also a high-risk country for emerging communicable diseases as a result of its high population density and poverty.

Although there has been considerable decline in child and maternal malnutrition, it continues to be a serious public health problem in the country. Also, there are sharp differences in child malnutrition based on mothers' education and household income.

Women of reproductive ages are vulnerable to chronic energy deficiency and malnutrition, the major risk factors for adverse birth outcomes. The double burden of malnutrition is becoming more prevalent among Bangladeshi women. Those with uneducated husbands, those with little or no education, and those belonging to less well-off households, especially from rural areas, are more likely to be underweight than women in other groups, while overweight is higher among the educated and those belonging to relatively well-off households. High rates of maternal malnutrition and low birth weight (LBW) can lead to a high burden of NCDs in adult life. The prevalence of LBW in Bangladesh is around 16 percent, similar to that in India and Pakistan, but higher than in Nepal and Sri Lanka. LBW is inversely associated with mothers' education, household income, and occupation.

In addition to problems specific to population, health and nutrition, there are several constraints that cut across all three of these sub-sectors. Quite importantly, there is an apparent lack of political commitment, affecting the overall healthcare sector. This is clearly evident from i) low investment in the health sector (less than one percent of GDP), the lowest in South Asia; ii) high out-of-pocket (OOP) expenses—about 70 percent—the ever-rising cost of healthcare making quality healthcare services virtually out of reach, especially among the poor; iii) both the health and population policies of 2012 not updated for 12 years; iv) human resource problems—inadequate staffing, lack of trained staff, absenteeism at different levels, one of the worst nurse-physician ratios in the world; v) lack of coordination among various actors and stakeholders, resulting in duplication, inefficiency, wastage, and gaps in service delivery; vi) bifurcation of the Ministry of Health and Family Welfare into two divisions, thereby further hampering coordinated service delivery from the Directorate General of Family Planning (DGFP) and Directorate General of Health Services (DGHS); vii) lack of effective coordination between the health ministry and the Ministry of Local Government, Rural Development and Cooperatives, thereby adversely affecting urban healthcare delivery services; viii) lack of effective monitoring and supervision; and ix) lack of transparency and accountability at different levels of the programme.

Bold and pragmatic reform measures should be undertaken to revitalise the entire health sector to overcome the constraints identified above in order to improve access, quality, and sustainability of healthcare services to people, with special consideration given to the poor and the needy. Investment in the health sector must unquestionably be enhanced to around two percent of GDP, together with enhanced spending capacity of the programme with the objective of major overhauling of the sector, wherever needed, such as in human resource-related issues, procurement, and helping reduce OOP. Likewise, allocation to the education sector should be enhanced to raise not only enrolments but also—and more importantly—to improve quality of education at different levels, with special consideration given to female education. The latter will help reduce child marriage and raise child-bearing age as well as female employment.

The outdated health and population policies should be updated, taking into consideration both demographic and epidemiological changes as well as socioeconomic changes that have occurred during this period. Pragmatic mechanisms should be put in place to ensure effective monitoring and supervision, meaningful coordination among all actors and stakeholders in the programme, including between the health and local government ministries, and address issues related to the lack of accountability and transparency at different levels of the programme. To give further impetus to political commitment, a high-level body—a national health council—should be formed under the leadership of the head of the government, to review progress and constraints, and provide oversight to programme activities, at least biannually. The council should include concerned stakeholders, including high-level professionals from relevant disciplines.

Barkat-e-Khuda, PhD, is a former professor and chairman of the Department of Economics at Dhaka University.​

 

[Saif]

WB points out myriad issues in healthcare

The World Bank has committed to giving Bangladesh $400 million for implementing the next five-year plan for the health sector, which is estimated to cost around $9 billion.

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WB points out myriad issues in healthcare
Commits $400m to Dhaka for the next five-year plan

The World Bank has committed to giving Bangladesh $400 million for implementing the next five-year plan for the health sector, which is estimated to cost around $9 billion.

The government expects $2.3 billion of it to come from multilateral and bilateral partners, including the World Bank (WB), the Asian Development Bank (ADB), and the Japan International Cooperation Agency (JICA).

According to finance ministry officials, negotiations with the WB were completed on Monday, and the first round of talks with the ADB and JICA also concluded.

Officials of the Economic Relations Division of the finance ministry said they would soon finalise each development partner's contribution to the plan. The government would foot the rest of the bill.

The plan, titled "Health, Nutrition, and Population Sector Development Programme (HNPSDP)", is renewed every five years. The current plan is set to expire in June next year.

Experts said the existing budget for health is insufficient and that the sector has struggled to effectively use the funds allocated to it.

In recent review of the health sector, the WB said, "Bangladesh's Health, Nutrition, and Population (HNP) sector faces numerous challenges, including maintaining immunisation coverage, improving child nutrition, enhancing the quality and reach of services, reducing socio-economic and regional disparities, addressing emerging health challenges, and strengthening financial management in the health sector."

Syed Abdul Hamid, health economics professor at Dhaka University, said the current health system is ineffective, preventing people from truly benefiting from it.

"The main issue is that the sector lacks sufficient funding. We are unable to even fully utilise the limited funds. The money is often inefficiently spent," he told The Daily Star, adding that corruption was a major issue too.

The World Bank has identified several challenges, including the slow pace of poverty reduction amid widening inequality, as well as malnutrition.

It noted that even though the maternal mortality ratio has declined to 143 per 1,00,000 live births, it is still more than double the global Sustainable Development Goal target of 70.

It observed that malnutrition threatens health outcomes and human capital. Nearly one in five women in Bangladesh is undernourished, one in three women aged 15-49 is anaemic, and one in six babies is born with a low birth weight, it said.

Improving the quality of antenatal care by including measures like multiple micronutrient supplementation could help prevent these poor outcomes, stated the WB.

Action is urgently needed as Bangladesh is also vulnerable to climate change, which threatens to exacerbate malnutrition and increase the risk of climate-sensitive non-communicable diseases, it said.

"Underlying these trends is a low-quality health system," the WB said, adding that maternal health services suffer from poor quality, with issues like inadequate midwife support during childbirth, overuse of cesarean sections, and ineffective referral systems for timely care of complications.

The WB further mentioned that "primary healthcare facility performance is about 60 percent", contributing to a high rate of preventable complications, increased reliance on more expensive and climate-intensive services, and a high out-of-pocket payment rate of 68.5 percent.

Prof Syed Abdul Hamid held the sector's inefficient management accountable for these issues and suggested that recruitment for managerial positions needs to be overhauled, with rigorous training provided for both managers and supporting staff.

He advocated for block allocations for public hospitals to address emergency crises and recommended involving the private sector for repairs of machinery.

Hamid also called for streamlining the medicine supply chain, strengthening Essential Drug Company Ltd., increasing dedicated drug storage capacity, overhauling the rural healthcare sector by consolidating health and family planning services under a single framework, and establishing primary healthcare services in urban areas.

To reduce out-of-pocket expenses, he suggested lowering medicine consumption, regulating pharmacies, and controlling drug prices.​

 

[Saif]

Bangladeshis spend $4b annually for healthcare abroad

DCCI Senior Vice President Malik Talha Ismail Bari says in a seminar on outbound healthcare tourism

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Bangladeshis spend $4b annually for healthcare abroad
DCCI Senior Vice President Malik Talha Ismail Bari says in a seminar on outbound healthcare tourism

Bangladeshis spend around $4 billion abroad every year for healthcare, according to Malik Talha Ismail Bari, senior vice president of the Dhaka Chamber of Commerce and Industry (DCCI).

This is due to a lack of specialised treatment, trust on doctors and advanced technology within the country alongside costs being comparatively lower abroad, he said.

Bari, also a director of United Hospital, was delivering a keynote paper through a presentation at a seminar, styled "Reversing the Outbound Healthcare Tourism", at the DCCI today.

There are 5,461 private hospitals and clinics in Bangladesh, of which 1,810 are within Dhaka division, he said.

People in rural areas are deprived of quality and adequate healthcare services while pressure is created for an influx of patients at healthcare facilities in Dhaka.

Limited infrastructure, a lack of skilled workforce, quality and safety concerns, low doctor-patient ratio and long waiting periods are some of the bottlenecks to access advanced healthcare in Bangladesh, he added.

Bari informed that Bangladesh allocated Tk 30,125 crore, or 3.78 percent of its national budget, for public healthcare in fiscal year 2024-25.

Pre-capita health expenditure, or annual government spending for healthcare per person, is $110 in Bangladesh whereas $401 in South Asia, he said.

Patients sometimes go abroad for healthcare services due to a lack of facilities, trust and comfort and reversing this trend requires formulation of a proper plan and identifying the bottlenecks, said National Professor AK Azad Khan.

"Since medical science is an ever-changing process, we need to have a proper curriculum to adopt the best technological advancements," said Khan, also president of the Diabetic Association of Bangladesh.

He also stressed on the standardisation of laboratories, adequate budgetary allocation, facilitating more research and strengthening the Bangladesh Medical and Dental Council (BM&DC), which is the regulatory authority for medical and dental education in Bangladesh.

Trust is a crucial factor when considering this sector's development, said Rezaul Karim Kazal, professor of the obstetrics and gynaecology department at Bangabandhu Sheikh Mujib Medical University.

Quality hospitals should be established in rural areas for wider coverage alongside customised services for all types of patients, he added.

Only doctors should be appointed through Bangladesh Civil Service for the public health administration to be run efficiently, said Syed Abdul Hamid, professor at the Institute of Health Economics of the University of Dhaka.

Moreover, a "health service commission" should be formed similar to the Bangladesh Judicial Service Commission, which assess the suitability of persons for entry-level appointments as assistant judges or judicial magistrates, he added.

Liaquat Hossain, registrar of the BM&DC, suggested that the national policy for registering foreign doctors to practice in Bangladesh could be simplified.

Of the 1,34,000 doctors in Bangladesh, only 33,000 are in public service, said Abul Bashar Md Jamal, a former professor of surgery at Dhaka Medical College Hospital.

However, over 10,000 foreign students are studying in different public and private medical colleges here, he added.

Members of middle-income households are increasingly seeking healthcare services abroad, mainly for a lack of confidence and satisfaction, said DCCI President Ashraf Ahmed.

Only a few types of advanced treatments, such as robotic surgery, are available locally, he said.

The trend can be reversed by outperforming regional competition, ensuring customer satisfaction and enhancing quality of medical services, reliability and branding initiatives, he added.

"We need to be more open to foreign doctors, nurses, medical technologists and other specialists," opined Ahmed.​

 

[Saif]

Accessibility of healthcare in Bangladesh

What should be the government’s main role in health service delivery?

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Accessibility of healthcare in Bangladesh

While the public health infrastructure in rural areas is considerable, this infrastructure needs an upgrade for maintaining quality PHC services. FILE PHOTO: STAR

Health is a fundamental human right and all citizens, regardless of their socio-economic status, have the right to enjoy optimal health. This article emphasises on the issue of equity in health systems. It underlines the importance of a comprehensive multisectoral approach to improve the health system. Though Bangladesh has an adequate health infrastructure, a cause for concern is the uncontrolled growth in the private health sector. The challenge is to regulate the mushrooming private sector from exploitative cost of treatment. The aim is to ensure that the disadvantaged and vulnerable population have better access to basic healthcare without the current back-breaking cost.

The government needs strengthen the Primary Health Care (PHC) system in partnership with the NGO sector. The NGOs lead the way in community-based initiatives and outreach at the grassroots. Utilising the private sector is also a priority but needs coordination and regulation. At the macroeconomic level, initiatives need to be undertaken that nudge the Bangladesh Ministry of Health and Family Welfare (MOHFW) towards reform and the adoption of new evidence-based practices that strengthen the health information system.

While the public health infrastructure in rural areas is considerable, this infrastructure needs an upgrade for maintaining quality PHC services. The quality of services remains a major issue, areas that need urgent attention is lack of investment in facilities. There is also an imbalance between availability and placement of human resources in the healthcare system. Frequent staffing mismatch in relation to demand-supply affect efficiency. The regulatory process to implement policies and laws is slow and often delayed in operation.

As Bangladesh becomes increasingly urban, the government's role in establishing a PHC infrastructure to deliver services in urban areas appears to be lackadaisical at best. Most commentators want to see the government considerably strengthen and fulfil its governance role in overseeing and monitoring aspects of health services. The government also needs to coordinate critical strategic developments, especially around the financing of this sector.

This begs the question, what should be the government's main role in health service delivery? Both the NGO and private sectors could be given specific tasks that are quantifiable to assess progress. They can develop guidelines and operational plans to help the ministry, donors, NGOs and the private sector work in a more coordinated manner.

Meanwhile, health experts in Bangladesh have felt a dire need for greater inter-ministry and intra-ministry coordination and collaboration. This is especially true between the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP), and between the MOHFW and the Ministry of Local Government, Rural Development and Cooperatives (LGRD). With the latter being responsible for urban health, there is a need to decentralise the urban health system whereby city corporations can take primary responsibility for the health of urban people.

Some sector experts recommend a full-scale reform of the MOHFW with a modern structure and practices that make it fit to guide and govern the development of a modern PHC system in Bangladesh. Any serious changes within this ministry can only be brought about by decisions at the highest level of government. The latter, however, is mainly interested in wielding political power, rather than pushing bureaucratic reform and healthcare for the poorest.

The health system in Bangladesh needs dynamic leadership that is prepared to design and enforce evidence-based policies and programmes. The stewardship of the health system must have a strategic vision and determination to improve and strengthen both the public and private health sectors of the country. Equity must be the overarching guiding principle underpinning the health system.

A starting point for reform would be to ensure that a wider range of health personnel are included in health planning: women and men with an understanding and experience of PHC needs at community, union and upazila levels. People with requisite qualifications and expertise should be hired. Increasing representation of women in management and decision-making within the MOHFW should also be a priority, along with serious efforts to institutionalise gender equality. This would help improve understanding, thinking and practices across operational units and departments.

Similarly, there is a need to expand and develop the non-doctor health cadres to meet the basic needs of PHC. Such paramedics and non-medical professionals need training, and support for acting as the first-line service providers. They also need support for clear career paths and further personal growth. Nurses and medical technicians are two key professionals that require investment and augmentation by way of better training.

The current referral system at the primary care level also needs to be strengthened through capacity building. The current dynamic climate around healthcare in Bangladesh offers opportunities to explore the possibilities for more equitable financing mechanisms, especially for the poorest. A more inclusive and equitable health system will never be achieved if out-of-pocket expenditure on health is as high as 67 percent, as is now. This is pushing an estimated five million people into deeper poverty each year.

To facilitate strategic communication, policy advocacy to push the universal primary healthcare approach is needed. This can be achieved through regular engagement and convening with the senior leadership at all levels to support government efforts in formulation of Human Resources for Health (HRH) action plan. This will go a long way in implementation of the HRH strategy and action plan to bolster HRH production, mobilisation, deployment, and retention of human resources. The goal is to improve HRH competencies to deliver high quality health services.

If the expertise of personnel in the MOHFW, such as those at the Health Economics Unit of the DGHS, can be harnessed with field workers having exposure and understanding of ground realities, as well as innovators from the NGO and private sectors, the vision of an efficient healthcare system in Bangladesh can become a reality. For that to materialise, a strong leadership with necessary political will is essential.

Dr Md Khurshid Alam Hyder is public health specialist.​