What is universal health coverage? In simple terms, UHC means every person has access to good quality health services whenever they need them. More importantly, UHC absorbs the risks of financial hardship for everyone. A big benefit of UHC is that it prevents health care costs pushing people into poverty. Every country has already committed to achieving UHC three times at the United Nations in the past decade. In September 2019, Sheikh Hasina, Bangladesh’s prime minister, restated her commitment to bringing UHC to the country.

There are important reasons for countries moving towards UHC. Orienting a country’s health system towards UHC can bring substantial societal benefits. Those worthy of mention are improved quality of life, enhanced economic returns, better social cohesion and political benefits. Meanwhile, the health care system and the population become more resilient to future crises.

Opportunity in crisis

Interestingly, transitions towards UHC often occur quite suddenly. UHC transitions commonly take place after periods of crisis, when the status quo is disrupted and there is a political pressure for change. UHC policies were introduced in Thailand after a financial crisis, in Brazil after political upheaval and in China after the impact of SARS and subsequent political unrest.

Like other countries, Bangladesh has been afflicted by multiple crises since the 2010s. These include the covid-19 pandemic outbreak since 2020 and energy/food price rise-induced hyperinflation owing to the conflict in Ukraine since 2022, as well as the climate emergency at large. The question is for Bangladesh: is there an opportunity to catalyse UHC reforms out of these crises?

Looking forward from 2022, Bangladesh is in advantageous yet challenging situation. It is among the countries that have shown strong recovery from covid-19-induced setbacks. Meanwhile, it is also facing graduation out of United Nations-enlisted least developed country (LDC) status. At such a watershed moment, a smart policy choice for ripple impact would be to invest in the health sector. This would reap benefits of human capital growth, economic productivity and a healthier population.

Why Bangladesh needs UHC

Bangladesh has historically seen modest health expenditure. Even with its limited spending, the country performed well on the health-related Millennium Development Goals of the United Nations, which ended in 2015. This means that health spending was efficient. The government focused on primary health and family planning services at household and community level. It also deployed low-cost intervention strategies like vaccination and oral rehydration therapy campaigns, which have drastically improved population health.

…Bangladesh remains among the lowest public spenders on health.

However, seven years since the beginning of the Sustainable Development Goal (SDG) era from 2016, Bangladesh remains among the lowest public spenders on health. When public spending is low, the burden of financing health care falls on households. This pushes millions of people into poverty through catastrophic payments, diminishing their productivity and wellbeing. In Bangladesh, the biggest reasons for out-of-pocket (OOP) payments are the purchase of drugs and consultations. According to 2015 government-published data, drugs and consultations make up 64% of OOP expenditure.[1]

Bangladesh, like many other lower-middle-income countries, is at a crossroad when it comes to health care – especially in terms of financing primary health care. With changing disease burdens, rapid urbanisation and the impending graduation from LDC status, the country urgently needs to invest in people’s health, wellbeing and economic productivity. As it stands in 2022, the level of public spending and service delivery for health care, including primary care, is not sufficient. However, stepping up an income level will give Bangladesh the opportunity to change this, especially in the context of its ambitious Vision 2041 plan, 2041 being the year it wants to be an advanced economy.

Achievements and commitments

Bangladesh has demonstrated strong commitment towards a primary health care-oriented health system. In prioritising rural primary health care, the country spearheaded an impressive expansion of primary health care facilities through the revitalisation of its grassroots-level ‘community clinics’ from 2009 onwards. By 2020, 13,861 such clinics were providing services in rural areas.

Bangladesh has committed to increasing health care spending to 2% of GDP by 2024–2025. It is currently developing its next policy document, the Health Sector Development Programme. It has also published the Health Financing Strategy 2012–2032, which identifies the challenges of inadequate health financing and the inefficient use of existing resources.

External shocks, such as the covid-19 pandemic, have affected the fiscal space for health. Despite the challenges the pandemic has posed, Bangladesh has performed well in tackling covid-19. Following its quick response to the first cases, the early drive for vaccines and effective campaign management, Bangladesh has managed to vaccinate more than 70% of the population against covid-19.

Bangladesh’s government adopted an across-the-board fiscal strategy to protect essential health services as part of its covid-19 response. It reallocated under-spent health budgets while utilising new funding from development partners. Meanwhile, it also increased the budget of the go-to government body, the Ministry of Health and Family Welfare.

Outside of the health sector, Bangladesh expanded social assistance to provide additional coverage for marginalised groups. Its central bank also adopted microcredit measures to support the most vulnerable—namely, low-income groups, farmers and small businesses.

The opportunity for UHC in Bangladesh

According to the World Bank’s Bangladesh Development Update report of 2022, Bangladesh’s economy has shown strong resilience since the covid-19 pandemic. The country’s GDP growth has remained strong despite inflationary pressures. The main contributing factors have been the rebound of the manufacturing and services sectors. The country’s graduating from LDC status in 2026 will bring both opportunities and challenges.

As part of its early-phase development journey, Bangladesh has enjoyed access to the World Trade Organization-designated Trade Related Aspects of Intellectual Property Rights (TRIPS) waiver, which will expire in 2033. This is likely to have negatively affected the country’s thriving pharmaceutical sector. Around 20% of drugs manufactured in Bangladesh are generic versions of patented drugs developed with TRIPS flexibilities.

Around 20% of drugs manufactured in Bangladesh are generic versions of patented drugs developed with TRIPS flexibilities.

One 2020 analysis by researchers at Boston University finds that, after graduation, poverty will increase for households with members with diabetes.[2] Already, households with non-communicable diseases (NCDs) bear the brunt of the burden of out-of-pocket health care spending. Households with an NCD burden are 85% more likely to have to sell assets or engage in informal sector borrowing to finance their treatment.

The opportunities of Bangladesh’s LDC graduation—such as increased foreign direct investment flows—are very clear. Meanwhile, the risks—such as the rising financial burden of health care on households—are also well anticipated. To benefit from the opportunities of the LDC graduation, Bangladesh needs to ramp up public investment in its human capital by channelling more of its ever-rising revenues to universal health and education services. This will prepare the country for the changing health needs of its ageing population.

In implementing this strategy, Bangladesh could leverage its advantages—namely, strong GDP growth, its centralised system of government, a highly developed domestic pharmaceutical industry and comparatively good geographical access to services. Combined with the political commitment from its prime minister and increased public financing, this gives Bangladesh tremendous advantages over its neighbours in the region, where progress towards universal health coverage (UHC) has been slow.

Resource mobilisation

As an immediate first step, the Bangladesh government could allocate an additional 1% of GDP to the health budget. Experiences from other countries indicates that kickstarting successful national UHC reforms typically requires around an additional 1% of GDP in public financing. Thailand used this share in 2002 to launch its famous UHC reforms; China used the same share in the aftermath of the SARS epidemic in 2004.

These funds could be sourced an all-of-the-above strategy. To begin with, reallocations within the national budget represent a quick move. Then could come linking rising health spending to judicious tax increases. Finally, we could see the smart introduction of new or reformed taxes to maximise revenues from tobacco and other harmful substances, or reducing wasteful government subsidies, such as fossil fuel subsidies. Iran and Indonesia have funded reforms this way.

In terms of best-buy priority areas for investments, Bangladesh could consider rapidly increasing expenditure on human resources for health. It can also expand access to medicines in the essential benefit package, offering free medicines to all.

Reshaping human resources

Ensuring enough human resources to deliver services is a challenge in any country, especially given the vibrant global market for qualified health workers. Recent evidence suggests Bangladesh has a density of doctors, nurses and midwives of 9.9 per 10,000 population, which is far below international standards of 44.5.[3]

Strategies to improve human resources for the health sector could include broadening the recruitment pool and non-traditional entry points for the workforce. Additionally, developing retention strategies and increasing salary levels in the public sector would densify the supply of health workers.

Expanding the medicine package

When it comes to increasing access to essential medicines, Bangladesh has the advantage of being able to leverage its domestic pharmaceutical industry. At present, because of the low availability of medicines in the public sector, most Bangladeshis access medicines in the largely unregulated private sector. This is particularly true for medicines to treat non-communicable diseases (NCDs). These medicines are the least affordable and they tend to be the least available from the government’s health system.

In Bangladesh, medicines for hypertension, diabetes and cholesterol issues are the most expensive. Households have to bear a catastrophic financial burden because of them. Expanding the availability of free medicines in the essential services package is a key step towards easing this burden. Moreover, increasing the number of facilities and dispensaries in both rural and urban areas will increase the availability of medicines in the public sector.

In Bangladesh, medicines for hypertension, diabetes and cholesterol issues are the most expensive.

Increasing access to and availability of free medicines will have multiple benefits. It will expand the appropriate consumption of quality medicines, reduce the need to pay for medicines in the private sector and therefore dramatically reduce the financial burden of health costs on families. Such a strategy could prove popular with the electorate because it would not only improve health indicators but also increase household disposable income.

The can-be South Asian UHC champion

Bangladesh has an opportunity to seize. It could become a regional leader in universal health coverage (UHC) and create one of the biggest publicly financed, truly universal health care systems in the world after China and Brazil. With its current socioeconomic profile, strong recovery from the covid-19 pandemic and political commitment, Bangladesh has the chance to surpass its neighbours and take a giant leap towards UHC. Such an investment in human capital would enable Bangladesh to reap the benefits from its demographic dividend. It would also stimulate economic growth, propelling it up the league table of middle-income economies.

 

[1] 2015 is the latest year of data available from Bangladesh’s Ministry of Health and Family Welfare, which is charged with the health policy of the country.

[2] The analysis was carried out by Deen Islam, Warren A. Kaplan, Veronika J. Wirtz and Kevin P. Gallagher by using insulin prices.

[3] Nuruzzaman, M., Zapata, T., McIsaac, M. et al. ‘Informing Investment in Health Workforce in Bangladesh: A Health Labour Market Analysis’. Human Resources for Health.

 

Photo ©️ Mahmud Hossain Opu

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Mushtaque Chowdhury is Professor at the Mailman School of Public Health, Columbia University, New York, USA. He is an academic. He is also the convener of Bangladesh Health Watch and a member of the steering committee of Asia Pacific Action Alliance on Human Resources for Health. He was Founding Dean of James P. Grant School of Public Health at BRAC University. He was a MacArthur/Bell Fellow at Harvard University and a coordinator of the United Nations Millennium Task Force on Child Health and Maternal Health. He has received the Medical Award of Excellence from Ronald McDonald House Charities. He pursued his doctoral studies at the University of London.
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Nina van der Mark is Research Associate of the Centre for Universal Health at Chatham House. She is an international development professional. She is a co-chair of the Chatham House Equity, Diversity and Inclusion Working Group. She specialises in health financing, sexual and reproductive rights, youth participation and maternal/child health. She completed her graduate studies at the London School of Economics, UK.
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Robert Yates is Executive Director of the Centre for Universal Health at Chatham House. He is a health economist. He is also Honorary Associate Professor at the London School of Hygiene and Tropical Medicine. He has been a senior health economist with the UK’s Department for International Development and the World Health Organization. His areas of expertise include the political economy of universal health care (UHC), health finance and national UHC programmes. He pursued his graduate studies in health management at the University of Leeds, UK.