Bangladesh has achieved remarkable progress in its healthcare sector in recent decades, marked by substantial reductions in maternal and child mortality rates, increased life expectancy, and improved immunization coverage.

The nation’s adept management of the Covid-19 crisis and successful vaccination campaign exemplify its dedication to public health and resilience. However, significant challenges persist in ensuring equitable access to quality and affordable healthcare services.

Limited healthcare coverage, especially in rural areas, remains a prominent obstacle. With only 2.5% of the population possessing health insurance, a majority remains vulnerable to the financial strains of healthcare expenditures.

To address these challenges, the government of Bangladesh has set an ambitious goal of achieving universal health coverage (UHC) by 2032.

How realistic is this ambition?

One of the main challenges for Bangladesh is the low level of public spending on health.

The general trend of the health expenditure as a proportion of GDP during 1997-2020 has been rising and averaged around 3%.

In contrast, government spending as a share of GDP has been falling and remained around less than one percent (<1%) throughout the period while falling more sharply in 2020 to 0.66% (BNHA 1997-2020).

This is contrary to the international trend for public expenditure on health to increase as a share of GDP as per capita income rises. This leads to inadequate infrastructure, human resources, equipment, and supplies in the public health sector.

We also have one of the highest out-of-pocket expenditures in the world. About 63% of the total health expenditure in Bangladesh is borne by the households themselves, which exposes them to financial risk and impoverishment.

There are also significant disparities in access to health services across regions, income groups, gender, and urban-rural areas.

The quality and responsiveness of health services are often compromised by factors such as lack of standards, accreditation, regulation, supervision, accountability, and feedback mechanisms.

There are also issues of corruption, absenteeism, negligence, and malpractice in the health sector.

And on top of all these, the health system in Bangladesh is also another challenge in itself. The health system in Bangladesh is characterized by fragmentation and lack of coordination among various actors and stakeholders. This results in duplication, inefficiency, wastage, and gaps in service delivery.

How can Bangladesh overcome these challenges? 

There is no simple or easy answer to this question, but I believe there are some key actions that can be taken to move in the right direction.

Increasing public spending on health and mobilizing more domestic resources for health, strengthening the stewardship and governance of the health system, ensuring accountability and transparency, improving the efficiency and effectiveness of health service delivery, ensuring quality and safety, etc are some of the ways we can face these challenges.

To achieve UHC, the Health Care Financing Strategy (HCFS) 2012–2032 proposes interventions to safeguard the healthcare expenses of the impoverished population.

One such initiative is the “Shasthyo Shurokhsha Karmasuchi (SSK).” Developed by the Health Economics Unit (HEU) under the Ministry of Health and Family Welfare (MoHFW), SSK aims to offer free healthcare services to households below the poverty line (BPL) and protect them from financial hardship in the event of a catastrophic illness. They are aiming to bring all the citizens under this scheme in near future to achieve UHC.

The public sector, multilateral organizations like WHO, academia, and research organizations and the media also have been actively involved to generate a common understanding of UHC among stakeholders and the general public.

Together, we must work towards consensus-building and clarity on the necessity of UHC, the steps needed to achieve it, and how all stakeholders can contribute.

Despite all these collective efforts from different sectors, in the pursuit of UHC in Bangladesh, various barriers are impeding progress across different levels.

These barriers have been categorized into three levels: a) larger policy-level barriers; b) implementation barriers; and c) demand-side barriers.

Complicating matters further, a lack of shared understanding of UHC serves as a cross-cutting barrier that affects all levels of advancement.

What are the key strategies we can follow to move forward?

1. First and foremost, we need to modify the financial system to accommodate flexibility for UHC, integrating demand-side financing and local-level planning.
2. Think about implementing a national single-payer system, explore innovative financing sources, and create oversight bodies to regulate health services and financing.
3. Enhance regulation and implementation protocols to ensure cost-effective, quality care, and establish codes of conduct for healthcare providers.
4. Engage civil society, non-governmental organizations, and the media to foster intersectoral collaboration for UHC.
5. Secure political dedication to UHC through engagement with political parties and inclusion in party manifestos.
6. Focus on primary healthcare, human resource management, and efficient service management.
7. Inform communities about UHC entitlements and enhance accountability.
8. Conduct further research and continue advocating for UHC based on best practices and multisectoral experiences.

As of now, it remains uncertain whether we can accomplish the goal of universal health coverage, and only time will reveal the outcome.

However, with political commitment, strategic vision, collaborative action, innovative thinking, and people’s participation, Bangladesh is making significant strides in the right direction.