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Universal Health Coverage: Bangladesh Perspective
Abbas Bhuiya, Deputy Executive Director, icddr,b Universal Health Coverage (UHC) is a top priority for Bangladesh. Under UHC people are expected to have access to needed quality health care services without any financial hardship. Although Bangladesh has been moving ahead in extending health care services to its citizens, there is still disparities in accessing services by various social groups. Financial barrier is still a very important barrier in accessing health care. As we know that annual per capita health expenditure is $ 27. Of this, 64% comes from individual pocket which is one of the highest and has a serious impoverishing effect on household economy. We are having an epidemiological shift in disease burden where infectious diseases are taking a back seat and chronic diseases are coming up. And our health system is not ready for this shift and healthcare is likely to be more costly. Unless we take an approach for UHC, it will pose to be a serious challenge for the people and the nation.
I am delighted that the Government of Bangladesh has taken the spirit of UHC very seriously. The government has already drafted a roadmap towards UHC. Our Honorable Prime Minister has put UHC as a post-MDG goal for the country.
However, it is unrealistic to think that we will achieve UHC within a short time. If we want to achieve it within a reasonable period, we have to work on policy, system, strategy, and health service delivery level. We also have to focus on developing an appropriate health care financing model. As mentioned earlier, the government has a roadmap but it needs a lot of support from NGOs, academics, researchers and advocacy organizations. Today's meeting is one step towards achieving that.
Dr. Mohammad Touhidul Islam, Senior Programme Manager, Health Nutrition & Population Programme, BRAC, Keynote Speaker Bangladesh has made substantial progress over the two decades. However, still 64% of health expenditure comes out of pocket which is very alarming. As a result, thousands of poor households are being pushed into poverty which we call catastrophic expenditure. Bangladesh is experiencing the highest (15%) catastrophic expenditure whereas India is experiencing around 10-12% and Thailand is experiencing lower than 2%. The question is how was it possible? Thailand started some pre-payment scheme in early 70's and incorporated UHC in 2002.
UHC is right to health that means every person everywhere should have access to quality healthcare without suffering financial hardship. It offers a range of essential services of good quality. It says about reducing the out of pocket expenditure through the cost sharing or prepayment mechanism.
So far there are a lot of challenges for achieving UHC. First one is mobilizing the resources for health. It does not mean that a country has to have more wealth. Actually it is the process of mobilizing resources. Cuba and Rwanda are very good examples for this. Second challenge is reducing the out of pocket expenditure. Third, reducing inefficient and inequitable use of resources. Other challenges are improving the responsiveness, equity, quality of healthcare services, use of IT for achieving UHC and so on. WHO report proposes three interrelated health financing strategic options: 1. Raising sufficient fund for health 2. Reducing heavy reliance on direct out of pocket money 3. Reducing and eliminating inefficient and inequitable use of resources.
UHC lifts people out of poverty because direct out of pocket expenditure deters people from going for the health services and the high out of pocket money leads to catastrophic expenditure.
What are the requirements for achieving UHC? To ensure efficient and effective health care UHC must be accompanied with the political commitment and political commitment must be reflected on the health budget and public administration. Quality of the health care, transparency and accountability in the health sector are also much needed requirements.
Is Bangladesh ready for UHC? At the strategy level, Bangladesh has adopted the health care financing strategy 2012-2032. It also worked on health workforce strategy 2013-2033 and communication strategy for UHC 2014-2016. At the action level the government has increased the manpower for hospitals and health centres to provide better health care services. The government has already established and revitalized 13,000 community health clinics. In the question of whether the commitment is reflecting in the budget we see that share of budget for health ministry is decreasing. So we should look into the issue of increasing budget for health sector.
Ahmed Mushtaque Raza Chowdhury, Vice Chairperson & Interim Executive Director, BRAC On December 12, the world celebrated the first UHC day. Over the last two years there have been a lot of works in mobilizing for UHC worldwide. More than 500 organizations have lined up from 100 countries to celebrate this day and work for UHC which is a big show of solidarity for the cause. In Bangladesh we started talking about UHC from 2009-10 and have achieved some success. But we have to do a lot more We are committed to the world's effort to reach UHC. We cannot miss the bus. UHC is needed for health, for human rights and for poverty alleviation.
Hossain Zillur Rahman, Executive Chairman, PPRC The issue of UHC and the issue of health in general have become significantly more important. We have to find out the way forward to achieving UHC within the context of the country. Our challenge is to fill up the knowledge gap to build cross-sectoral coalition because it is not the only job of the health specialists. As an economist, I am concerned that 4 million are at risk of falling into poverty due to out of pocket expenditure. The issue is not reducible to one dimension alone like health finance. It has to address issues from a holistic perspective. Our key challenge is to convince the policy makers as we saw from the presentation that the budgetary share of health sector is going down. Our arguments and proposals have to have the cutting edge that will bring the policy on the board.
Manzur Kadir Ahmed,Coordinator, Gonoshasthaya Kendra (GK) We should set priorities that whom we will cover first, what facilities we have to expand more and who are the most vulnerable groups and so on. The government should set up working committees for each priority areas. Now, if we look at the changing patterns of mortal diseases we have to change our service delivery system. For example, community clinics are good for various primary ailment but not for chronic diseases like coronary diseases, diabetes and so on.
Another important area is effective management of manpower so that we can avoid misuse and duplication of human resources for health. In addition, priority should be given to functioning the existing government health facilities.
Atiqun Nabi, Executive Director, INAFI
When we are asking money for piloting we have to go to
NGO Affairs Bureau. They have a list of charitable and non charitable works. They do not approve the project of micro-insurance, pre-payment methods. This is a major constraint. There is no clear indication how health insurance will come into the business of insurance. There is another issue of coordinating the financing institutions and service providing institutions.
Md. Humayun Kabir, Former Senior Secretary, Ministry of Health and Family Welfare, Government of Bangladesh
I am not sure whether we need health insurance for ensuring UHC at this stage as health insurance needs strong institutions and supportive infrastructures. Otherwise private providers may benefit and public institutions would remain ineffective. We need to ensure that public funds are used efficiently and to their fullest extent. In the post-MDG era, donor support for the health sector might decrease. There is a need for government to increase spending in the health sector.. Increased budget should not be spent for paying salaries only, but also for running core health programmes. Health equity fund can be a good idea as included in the National Health Financing Strategy.
Dr. Veronica Vargas, Senior Economist (Health), Health, Nutrition & Population Global Practice, World Bank
We are conducting a study how the government can free up resources, increase efficiency and identify areas where savings can be made in the health sector. We will present this study to the health ministry. It will help them bargain with the finance ministry. I am here to learn from you and take your suggestion so that we can incorporate those recommendations in our study.
Kelvin Hui, Principal Advisor, GIZ
UHC is not only about access. It is also about quality of health service. The challenges and the landscape keep changing. Locally we always hear about the negative perception of pooling money through health insurance. Government collecting taxes and providing health services is actually also a method of pooling money. Some countries like UK, Norway and Malaysia have done remarkably through this type of pooling system but it requires very strong governance. There are countries which pools money differently, through a system of social health insurances and give patients the choice of accessing either private or public facilities which has also done very well in achieving UHC.
At the end of the day, what is necessary is that we learn from examples of various countries and pick the most suitable for Bangladesh. From the German Development Cooperation perspective what we want to do is to facilitate this learning. We need to consider coverage, quality of health care, out of pocket expenses and stimulate debate amongst civil society and policy makers so to find the best solution. We need to consider how the future health system of Bangladesh should look like.
Dr. Sukumar Sarkar, Senior Technical & Policy Advisor, USAID
From USAID we see UHC as a goal as well as a process of incremental policies and programme decisions. UHC is mainly for resource poor setting. Here comes the question of prioritization. Do we need to prioritize in terms of
population segment? UHC has not yet defined any definite approach, strategy, target, objective and all those things. Even, what are the services we should provide under UHC? That is something we need to think about. Our demography is changing. More and more population is getting into the aged group. There is a need for services of non-communicable diseases. So we need to define a strategy for UHC in Bangladesh.
Another issue is domestic resource mobilization. Donors' funds are shrinking. So we have to think about how we can mobilize our own resources to sustain what we have achieved. Leveraging private resources and pulling it into health programme can be one of the alternatives. In India they have already started such programmes. In the health ministry there is no such cell that can look after pulling private resources for the health sector and leveraging private sectors' support public health programmes.
Shishir Moral, Special Correspondent, Prothom Alo Lancet proposed five ways to reach UHC and the government has also formulated policies to reach the same goal. Now we should have a dialogue on these two approaches. There are some differences between these two policies. We should look into this issue.
Dr. A. M. Zakir Hussain, Former Director Primary Health Care & Disease Control, Directorate of Health Services and former Regional Advisor, South East Regional Office of WHO
What do we need healthcare care? We need it basically for diagnosis and treatment of diseases and for prevention of diseases. Private health insurance system will never include preventive care. That's why we talk about universal health coverage. Universal health coverage, i.e. UHC, is there, but actually it is not there, in Bangladesh. Government tries to cover everyone with all types of health care but it fails to do so.
Social health insurance, is a UHC, which is a mandatory process, where somebody is paying for somebody else, in addition to his or her own, although he/she doesn't need services all the time. So the question is who will pay how much, to whom and for what. The payment system is itself complex, different payment approaches have different degrees of efficiency and complexity, based on the type and magnitude of coverage. Who will ensure this? Patients cannot, because they are not health literate. So some agency, for example, government itself employs some agency that is very well versed with health system. They buy the services for the people.
UHC has another advantage. We have failed to regulate health care quality and coverage in Bangladesh. UHC shops and pays for quality and coverage.
The other issue we need to understand is the size of pooling of fund. The bigger the fund, the bigger is risk spreading and hence equity, which means the fewer the purchasing agencies, the more is the efficiency, but the less will be the competitive edge of buying services. UHC needs 5 to 15% of the total budget for administering it. How much are we ready to expend?
Dr. Kaosar Afsana, Director, Health Nutrition & Population Programme, BRAC
In our country, people are already spending a huge amount of money from their pockets for healthcare. But,
they are not getting quality healthcare, and many are getting poorer due to high health care cost. In this context, Universal Health Coverage is an essential next step in evolution in health sector for improved access to health care and making impact on health. I really appreciate the government's move towards UHC which has been reflected in the Health Care Financing Strategy2012-32. However, it needs major reforms and legislative changes, strong political will and government efforts to achieve it.
Aligned with the government's endeavor, BRAC is implementing "BRAC Health Security Programme" at a small scale using alternative health financing strategy and testing out various pre-payment models for different income groups. We want to learn whether quality health services can be ensured and financial catastrophic consequences can be protected. The whole purpose is to develop an alternate model for the National Health System. Until and unless we generate evidence and model, we will not be able to develop a favorable health system for UHC.
Professor Dr. Rashid-E-Mahbub, President, HRMNC First we need proper management of our existing resources. If we can do that effectively we can go a long way to reaching UHC.
Dr. Jahangir A.M. Khan Health Economist, icddr,b Social health insurance and tax based system have redistributive mechanism. Rich people usually have good health; they pay more and get less service while poor people suffer from poor health. They pay less and get more services.
Second point is how private health providers are involved in the UHC. If the public sector buys services from private sector it will create competition among private health providers and will, ultimately, reduce cost of health care. Government will also be able to monitor private health providers through this system.
Dr. Fariha Haseen, Assistant Professor, BSMMU We have to listen to the young people's voice on UHC. They can explore new and innovative ideas to reach people using new technologies. General people's opinion is important. Huge numbers of low income group people are moving from rural to urban area. We should also address UHC issue of internal migrants especially in major urban cities because it is closely related with urban health care. We need more evidence based research.
Professor Liaquat Ali, Vice-chancellor, Bangladesh University of Health Sciences (BUHS)
First of all the philosophical position of the state has to be well defined: is health just a commodity like all other commodities in an open market economy or is it a right which needs to be implemented by proper regulation both for public and private sector?
There are big scopes of domestic resource generation. Diabetic Association of Bangladesh now has yearly budget of $50 million and almost the whole budget is mobilized from domestic sources. Cross-financing between rich to poor and centre to periphery can be an effective alternative.
We are probably concentrating too much on the financing issue. Actually we see more success and sustainability in this sector where there is more democratic governance and accountability. So we need to emphasize more on the governance aspects.
Dr. Ashraf Uddin, Executive Director, Delta Life Insurance Company Limited
In UHC programmes, users have to participate in the financing programme. Insurance companies can effectively facilitate their participation.
Dr. Mohammad Iqbal, Deputy Project Coordinator, icddr,b
In our country 30% people still live under poverty line. They cannot pay for health care. This is a huge number. So we need a lot of resources for ensuring health care for this section of our population. Without proper commitment to the poor people we cannot achieve this.
Hossain Ishrath Adib, Head of Programmes, WaterAid Bangladesh
We need to define short term, medium term and long term goals for achieving UHC. From a platform of informed civil society we should push the agenda of: 1) ensuring functionality of the existing system with acceptable quality and 2) instituting accountability of the private providers rather than making efforts to curtail their profit-seeking behavior. We have to create incentives for the healthcare providers and bring them into competition for providing better services.
Malabika Sarker, Professor, JPGSPH, BRAC University We have not provided focus on informal health providers. One research conducted in Rangpur shows, 72-75% people go to informal health providers. We have to engage them in our UHC programmes.
Dr. Syed Masud Ahmed, Director, Centre of Excellence for Universal health Coverage, JPGSPH, BRAC University
Dr. Ahmed emphasized the need for reaching at a common consensus regarding what UHC means in the context of Bangladesh induding its components and priorities. This is necessary for a common understanding on UHC for relevant stakeholders. Whether we are doing optimal use of existing resources is an important question. First we have to ensure that we do not waste resources...we can go a long way using our existing resources effectively. Regarding pre-payment and health insurance mechanisms, he reminded the underlying prindple of "from each according to his ability to each according to his need" so that the pool can be made bigger.
Hossain Zillur Rahman, Executive Chairman, PPRC In Bangladesh, as a first entry point we have talked about the systemic functionality in a bigger way. We need to focus on two overriding realities in the way forward. One is resource constraint. And the other is poor governance environment. Bangladesh has excelled in finding solution to poor resource environment. We achieved the primary health agenda despite our poor health structure. But the Non Communicable Diseases (NCD) agenda cannot move forward without the development of our health structure. Therefore quality of the services and accountability of the system have become core issues. Now for round two, we need action plan, sequendng targets, redudng financial risk and so on. In our country there is a core system weakness. Knowledge gap is another important issue. Typically at the ground level, government has made big investment for buying a microbus but does not have the system for small investment to repair puncture. We think of health equity fund as a national thing. Is that a right way to approach the issue? Should we have a community based equity fund for an Upazila as an entry point? Our audience is the uninterested policy makers. Our challenge is to make them deeply interested in the agenda. If we can understand the challenges well we will succeed to do that.