[🇧🇩] Healthcare Industry in Bangladesh

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Rethinking Bangladesh's health sector reform after SWAp

The introduction of SWAp transformed Bangladesh’s health sector from a fragmented collection of donor-funded projects into a coordinated, government-led programme.

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Rethinking Bangladesh's health sector reform after SWAp

Rumana Huque

VISUAL: SALMAN SAKIB SHAHRYAR

After more than two and a half decades of being in operation, the Health, Population and Nutrition Sector Programme (HPNSP) was discontinued by the interim government last year. Operating under the health ministry since 1998, the HPNSP oversaw basic health, nutrition and family planning services across the country. The concern that follows this decision is only natural: does Bangladesh have a credible alternative to sustain the gains achieved through the programme over a quarter of a century, while addressing the problems in the health sector it could not resolve? To answer this question, it is worth revisiting why the first Health and Population Sector Programme (HPSP) was introduced, and what lessons its evolution offers for the future.

During the 1980s and 1990s, a number of low- and middle-income countries introduced health sector reforms as demographic change, shifting disease patterns, economic restructuring, and fiscal pressures exposed weaknesses in their public health systems. In Bangladesh, the health ministry was managing around 128 donor-funded standalone projects, each with separate objectives, procurement systems, reporting requirements, and financing arrangements. Resources were fragmented, duplication was common, and development priorities often reflected donor preferences rather than a coherent national strategy, limiting government ownership and long-term planning.

To address these challenges, the Bangladesh government adopted the first phase of HPNSP, the Health and Population Sector Programme (HPSP, 1998-2003) under the Sector-Wide Approach (SWAp). This phase was followed by the Health, Nutrition and Population Sector Programme (HNPSP, 2003-2011), the Health, Population and Nutrition Sector Development Programme (HPNSDP, 2011-2017), and the Fourth Health, Population and Nutrition Sector Programme (2017-2024). Under SWAp, planning began with a strategic investment plan, which translated national health priorities into long-term investments. This informed the multi-year Programme Implementation Plan (PIP), which was operationalised through operational plans (OPs) detailing activities, outputs and budgets. Allocations from the Annual Development Programme (ADP) were then drawn from the OPs. In 2006-07, the medium-term budgetary framework introduced three-year rolling expenditure ceilings, linking strategic planning with medium-term fiscal management while retaining the PIP-OP-ADP planning sequence.

The introduction of SWAp transformed Bangladesh’s health sector from a fragmented collection of donor-funded projects into a coordinated, government-led programme. It strengthened national ownership, improved coordination among development partners, reduced duplication, streamlined procurement and financial management, and introduced unified planning, monitoring and budgeting for the health sector. The approach also enhanced institutional capacity and contributed to improvements in maternal and child health, immunisation, and overall health system governance.

However, planning under SWAp was complex. Preparing each sector-specific programme required multiple planning documents, extensive consultations, and lengthy approvals involving ministries, planning agencies, and development partners. While these processes strengthened accountability, they reduced flexibility, making it often difficult to respond quickly to emerging health challenges. More importantly, integration remained incomplete: although sector planning became unified, the country continued to separate development and operating budgets, the latter remaining outside SWAp. As a result, infrastructure investments did not always get matched with adequate staffing, maintenance or operational resources. Planning became integrated on paper, but implementation remained fragmented. Donor harmonisation was also partial. While pooled financing reduced transaction costs, several bilateral agencies and UN organisations continued operating through parallel funding mechanisms with separate reporting and procurement systems, limiting full government ownership.

SWAp was also largely confined to the health ministry, despite the country’s increasingly pluralistic health system. Local governments, private providers and NGOs, despite being key contributors to service delivery, remained largely outside sector planning, limiting the programme’s ability to govern the health system as a whole. Although disease-specific programmes for maternal and child health, communicable and non-communicable disease (NCD) control, tuberculosis, family planning, immunisation, and nutrition achieved important gains, they often operated in silos. The number of OPs expanded from 22 under HPSP to 38 under HNPSP, before being reduced to 32 and 31 in the subsequent programmes, reflecting persistent programme fragmentation. Similar and sometimes overlapping OPs existed between the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP), particularly in areas such as maternal and child health and health information systems. As a result, patients with multiple health needs continued to navigate fragmented rather than integrated services.

Institutional fragmentation was reinforced by SWAp itself. Line directors managed development-funded OPs, while permanent directors remained responsible for routine functions under the operating budget. This created parallel management structures with separate reporting, planning and accountability systems, often blurring responsibilities and complicating coordination between development activities and routine service delivery.

Ironically, the end of SWAp has also exposed its value. The abrupt discontinuation of the health sector programme created uncertainty in planning, financing and procurement. Procurement of essential medicines, vaccines, contraceptives and medical supplies experienced delays as established financing and approval mechanisms were dismantled. Critical public health programmes, including immunisation, TB control, NCD control, family planning, maternal health and nutrition faced implementation challenges during the transition. Development partners accustomed to working within a common planning framework also had to adjust to new financing arrangements, creating coordination gaps.

This experience offers an important policy lesson. While institutional reform is necessary, abrupt institutional disruption carries real costs. The challenge now is to preserve what worked while addressing what did not. Future reforms should move beyond programme management towards institutional transformation. Planning should become genuinely inclusive by bringing together government and private healthcare providers, local government institutions, professional bodies, civil society, and patient representatives. Decision-making should also become more decentralised. Equally important is the reform of the financing process. Bangladesh can no longer sustain a system where development investments and operational expenditures are planned separately. Improved coordination between these financing streams would improve both efficiency and accountability while strengthening service delivery. Finally, success should be measured not by the number of projects completed or budgets spent, but by whether people receive timely, affordable and quality healthcare.

Bangladesh’s health challenges have changed profoundly since SWAp was introduced 28 years ago. Rapid urbanisation, ageing population, the growing burden of NCDs, climate-related health risks, and increasing public expectations demand a healthcare system that is more integrated, resilient and people-centred than the one designed in the late 1990s. SWAp solved many of yesterday’s problems by bringing order to a fragmented aid environment. The next generation of reforms must go further. In addition to a planning framework, the country needs stronger institutions capable of delivering high-quality healthcare regardless of who finances, manages or provides the service. That should define the future of health sector reform.

Dr Rumana Huque is professor in the Department of Economics at Dhaka University and executive director at ARK Foundation.​

 

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Hospital industry in Bangladesh: Reflections in healthcare management

The hospital sector has undergone profound transformation over the past two decades. When I began my professional journey in the hospital field in 2004, the healthcare landscape was significantly different from what it is today. At that time, hospitals were largely perceived as service-oriented...

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Hospital industry in Bangladesh: Reflections in healthcare management
Md Nawshad Pervez

Strong leadership, mutual respect, and continuous communication between clinical and administrative teams is key to good hospital management

The hospital sector has undergone profound transformation over the past two decades. When I began my professional journey in the hospital field in 2004, the healthcare landscape was significantly different from what it is today. At that time, hospitals were largely perceived as service-oriented institutions dedicated primarily to patient care. Organisational management, structured governance, and strategic business thinking were not always central considerations in many healthcare institutions.

However, over the past twenty-two years, the hospital sector, particularly in developing healthcare markets, has gradually evolved into a structured and competitive industry encompassing both public and private sectors.
This transition did not occur overnight. It has been shaped by a combination of factors including increased demand for healthcare services, rising patient awareness, technological advancement, and substantial private investment in healthcare infrastructure.

As urban populations expanded and healthcare expectations grew, hospitals were compelled to adapt. Institutions began to adopt more formal management structures, strategic planning processes, quality control mechanisms, and financial accountability systems. In essence, hospitals started to transition from purely service-oriented institutions into complex organizations that require professional management alongside clinical excellence.

One of the most challenging aspects of this transformation has been aligning healthcare professionals with the organisational framework required to run a modern hospital. Clinical professionals, particularly physicians, are trained primarily to focus on patient care and clinical outcomes. Their professional identity and ethical obligations revolve around healing and serving patients.

While this dedication forms the foundation of healthcare delivery, it sometimes creates tension when hospitals introduce administrative structures, operational procedures, and governance policies designed to improve efficiency and accountability.

Hospital administrators often face the difficult task of balancing clinical autonomy with organisational discipline. Physicians and nurses may perceive certain administrative procedures as unnecessary bureaucracy that interferes with patient care. On the other hand, hospital management must ensure compliance with regulatory standards, financial sustainability, quality assurance, and operational coordination. Reconciling these two perspectives requires strong leadership, mutual respect, and continuous communication between clinical and administrative teams.

Over the years, hospital management practices have gradually matured. Training programs in hospital administration, healthcare management, and quality assurance have become more common. Accreditation systems and regulatory frameworks have also played an important role in encouraging hospitals to adopt standardised practices. These developments have contributed to a more professional and structured approach to healthcare management.

Another important shift that has emerged in recent years relates to hospital marketing and brand positioning. Historically, hospitals relied largely on reputation and word-of-mouth referrals from satisfied patients. Marketing activities were minimal, and the concept of promoting healthcare services was often viewed with skepticism.

Without effective management structures, even the most skilled medical professionals may struggle to deliver consistent, high-quality care.
In contrast, the contemporary healthcare environment has become significantly more competitive. The rapid growth of private hospitals and diagnostic centers has intensified competition for patients. As a result, hospitals have increasingly adopted marketing strategies similar to those used in other service industries. Advertising campaigns, digital platforms, patient engagement initiatives, and brand positioning strategies have become common tools in hospital management.

One particularly notable trend is the increasing visibility of physicians in hospital marketing efforts. Many private hospitals prominently feature their renowned physicians and specialists in promotional materials, advertisements, and public communications. In many cases, these physicians effectively serve as ambassadors of the hospital brand, highlighting their expertise and professional reputation to attract patient trust.

This development raises important questions within the healthcare community. On one hand, featuring experienced physicians can help patients identify qualified specialists and feel more confident in choosing a hospital. In a healthcare environment where trust is essential, the reputation of respected physicians can strengthen the credibility of an institution.

On the other hand, some critics argue that excessive commercialisation of medical professionals may blur the boundaries between professional ethics and marketing practices.

The debate surrounding physician-centered advertising reflects a broader challenge within modern healthcare systems: balancing ethical medical practice with the realities of a competitive healthcare market. Hospitals must remain financially sustainable in order to invest in technology, infrastructure, and human resources. At the same time, healthcare institutions must uphold the ethical principles and professional values that form the foundation of medical practice.

From my personal observation over the past twenty-two years, the transformation of the hospital sector has been both inevitable and necessary. Healthcare delivery today involves far more than clinical treatment alone. Hospitals must manage complex systems that include medical technology, human resources, supply chains, regulatory compliance, patient safety programs, and financial sustainability.

Without effective management structures, even the most skilled medical professionals may struggle to deliver consistent, high-quality care.
Yet, as hospitals evolve into sophisticated organisations, it is essential that they do not lose sight of their fundamental mission. Healthcare institutions exist primarily to serve patients, alleviate suffering, and improve the wellbeing of communities. Efficiency, profitability, and competitiveness should support this mission, not overshadow it.

Looking ahead, the hospital industry will continue to evolve in response to new challenges and opportunities. Advances in digital health, telemedicine, artificial intelligence, and data-driven healthcare management will further reshape hospital operations. Patient expectations will continue to rise, and regulatory oversight is likely to become more rigorous. In this environment, hospitals will need leaders who understand both the clinical culture of healthcare and the managerial discipline required to sustain complex organisations.

Reflecting on more than two decades in the hospital sector, it is clear that the journey of healthcare institutions is far from complete. The sector stands at the intersection of medical science, organisational leadership, and social responsibility. Successfully navigating this intersection will determine how effectively hospitals can meet the healthcare needs of future generations.

Ultimately, the greatest challenge for modern hospitals will be maintaining the human essence of healthcare while adapting to the evolving realities of a rapidly developing healthcare industry. Balancing compassion with efficiency, ethics with competitiveness, and clinical autonomy with organizational governance will remain the defining task of hospital leadership in the years to come.

* Md Nawshad Pervez is DBA (Doctor of Business Administration), Group Executive Director, Human Resources, United Group​