This is the third month after Bangladesh discovered its first coronavirus cases and despite varied initiatives from government we actually are struggling to control this pandemic. The struggle has also increased by the weak health management system in Bangladesh. This is reminding us for a sustainable development we need massive improvement in our overall health system. In this situation Bangladesh Health Watch (BHW) has organized a webinar on 5 June titled `Bangladesh's health system and its commitment to achieving universal health coverage’. This session has been chaired by Mr. Md. Ashadul Islam, Senior Secretary, Health Services Division, MoHFW. The other distinguished speakers included Dr. Hossain Zillur Rahman, the Advisor of the former caretaker government also Chairman, BRAC and Executive Chairman, Power and Participation Research Centre (PPRC), Dr. Fahmida Khatun, Executive Director, Centre for Policy Dialogue (CPD), Robert Yates, Executive Director, Centre for Universal Health at Chatham House, UK, and Professor Dr. Mohammod Shahidullah, President of BMDC and Lead of National Technical Advisory Committee for Covid-19. The webinar was moderated by Dr. Ahmed Mushtaque Raza Chowdhury, Convener of BHW. Apart from Bangladesh Health Watch members, representative of Bangladesh government, member of the civil societies, NGOs, media, academics and development partners were present at the event.
The Convener welcomed every speakers and guests and said, `Throughout the world, including Bangladesh, as we struggle to combat the disease, the covid has drawn our attention once again to the weaknesses in our health system. These include weak management, lack of governance and poor budget in health sector. The covid crisis has set the ground for a new health system for Bangladesh. Though the government with the leadership of honorable Prime Minister Sheikh Hasina is committed to implementing universal health coverage in Bangladesh but, unfortunately this has remained unimplemented so far. This is expected that the learnings of the covid crisis will give the government enough impetus to implement universal health coverage for everyone so that no one is left behind and no one is denied quality healthcare for being unable to pay.’
Panelist Professor Dr Mohammod Shahidullah, who is the lead of national technical advisory committee for Covid-19 and President of BMDC presented his thoughts on this topic. He mentioned that, the poor planning of health sector is affecting us hugely during this pandemic.
``It (health sector) has grown mostly on ad hoc basis in a piecemeal manner, never in a holistic approach. And therefore the decisions at the policy which were taken, sometimes actually it was not planned in a way that how do the country should built on and what will be the health infrastructures’’.
The key challenges he highlighted are:
No holistic approach rather ad-hoc planning in health sector
No proper planning about how to deal and manage any emergency health situation, this pandemic was beyond imagination
Lack of testing considering the number, the quality and its robustness
No proper planning of detection, quarantine and isolation and also of hospitalization of covid positive patients. Improper management is also seen
Shortage of ICU care both in quantity and knowledge of management
Besides the numbers of doctors, nurses, cleaners their knowledge, skills, and trainings are also inadequate
Poor networking ability. Good networking means, ‘Once you are full, you know that there are other hospitals those can accommodate the patients’
Not only weak oxygen supplies even in most well established hospitals but also it is absent in some cases
Poor investigation facilities particularly in regional area, which has been exposed during covid crisis.
Poor allocation in health budget for long time.
Instead of piecemeal basis we need holistic approach
Reform the health sector immediately
contrary to follow the prescription of the donor of the international agencies, it is important to take decision based on our country context
Should focus on quality, equity, gender and sustainability
Develop disaster preparedness plan for health sector
Budget allocation in health sector should be increased. ``This Covid-19 has given us a kind of learning or opened up our eyes that spending money on the health sector is key to the development of whole country otherwise we cannot survive.’’
An open discussion was held after it and participants also shared their views on Post-pandemic challenges for Bangladesh, which are as follows:
Professor Shah Monir, Former Director General Health Services focused on:
Need to take all out approach involving public, private and NGO sectors with ensuring proper monitoring and quality assurance and coordination
For the development of effective public health system, the population health status monitoring is crucial
Health system in public sector should be decentralized, all levels of health services including division, district and upazila should give more delegations of authorities and financial autonomy. Which is important to ensure the universal health coverage for all
The government enacted an Ordinance to regulate private health care which is, Medical Practice and Private Clinics and Laboratories (Regulation) Ordinance, 1982. But now it is the time to do a lots of amendments to ensure improved and accountable health services.
Leadership of urban health system should be defined appropriately as this is the mandate of local government and local government does not have the capacity to run it properly.
Dr. A J Faisel, BHW Working Group Member and Government appointed one of the Divisional Advisor on Covid Operation, said that it is true that allocation of money in health sector is poor but on the other hand the absorption capacity of health sector is also poor.
Dr. Md. Maruf Haque Khan, Lecturer, DPHI, BSMMU, mentioned that to tackle Covid pandemic we should ensure proper planning and good coordination among the different ministries.
Implementing UHC in the post pandemic era: International Experience:
On this topic panelist Robert Yates, Executive Director, Centre for Universal Health at Chatham House, UK has given a brief presentation. In a few slides he presented his observations and opinions. From international examples and data he has given a brief views on UHC. He shared his potential thoughts for the Covid-19 crisis and its relation to accelerate the universal health reforms in Bangladesh.
Considering the covid crisis and UHC he mentioned:
Effective leadership is important to protect every people considering their health and financial ability.
Some leaders are taking Covid-19 very seriously and imposed very strict lockdown (Emmanuel Macron, President, and France) but, some are not. Like President Trump and as a result his popularity is going down. So every leaders should think about the dull areas and take proper initiatives to ensure full range of health services including preventive, curative and palliative care services as well.
All service should ensure in a way that no one face any financial hardship and that is the universal health coverage. People all over the world is crying out for this universal health coverage at this time.
After 2nd world war many countries like UK, Japan and France introduced universal health services. Which are acting as the backbone of their improved health system. After the financial crisis in Asia in late 90s the Prime Minister of Thailand Thaksin Shinawatra introduced universal health system in 2001. Now in Covid crisis Thailand is getting benefit of this positive decision of Thaksin. `` If we think of the Second World War when the UK obviously suffered tremendously, the population suffered tremendously and coming out to that we were bankrupt, our infrastructures were destroyed. But the incoming labor government in 1940s brought in a world first step providing the universal free health and education services as the backbone of its reforms. This is the picture of Aneurin Bevan, the architecture of the NHS literally on the day it was launched on the 5th of July 1948, we know that day and 70 years later when we have Olympic Games in London, you might remember in the opening ceremony we celebrated NHS as one of our nation’s great achievement. This is you know, absolute defining moment for UK coming out to the Second World War.’’
People also admire UHC very much which is proved in Indonesia as Joko Widodo came in power in 2014 with the promise of universal health system.
The key of UHC is to replace private pocket spending particularly for consulting and hospital services with public financing.
`This is Dr Gro Harlem Brundland, the former prime minister of Norway and former DG of WHO, at a high level meeting with Sheikh Hasina, spoke out last September, saying that, the only way you can reach UHC is through public financing’.
In Bangladesh public financing is low and Out Of Pocket (OOP) is high. But for UHC system it is important to increase public financing and countries which are good in UHC have relatively high spending of public financing. This is observing in China, Iran, and Indonesia and Thailand. By increasing public financing Bangladesh can be the UHC pioneer in South Asia.
Due to covid pandemic millions of Americans are losing their health insurance as they are losing their jobs and in this situation three quarters of Americans demanding universal health coverage. ``The big question is, will her Excellency Sheikh Hasina emerge from this crisis as Bangladeshi UHC health hero? And I think there is a tremendous opportunity.’’ Implications of the pandemic for national budget:
Dr Fahmida khatun, Executive Director of CPD discussed in brief on this issue. She focused on health budget and said, initiatives will be starting in the short term but will have to be implemented in medium to long term.
She mentioned Bangladesh has good policies, initiatives and achievements in health sector:
Bangladesh has some good achievements in health sector like, the life expectancy rate, which has reached to 72 years in 2017 compared to 65.2 years in 2005, infant mortality rate which was 50 in 2005, it has reduced to 24 per thousand life birth.
Bangladesh has approved its National Health Policy in 2011 which recognizes that health is a right to the citizens and aims to strengthen the primary and emergency care for all
Thorough HPNSDP program Bangladesh tried to develop its health population and nutrition sector which also aims to achieve health related goals mentioned in the SDG
Bangladesh has its Health Care Financing Strategy which aims to reduce the out of pocket expenditure to 32% by 2032 and increase health budget to 15% of total national budget
Besides good policies Bangladesh also has some good initiatives like the community clinics, which are the initiative to bring primary healthcare services to the door steps of people of the rural areas.
``we also know that expenditure or the budget is only one part of the situation of the health challenges because there is larger issue in the health sector.’’
Challenges in health sector, she mentioned:
Health expenditure in Bangladesh is negligible and it is 0.9% of GDP and less than 5% of total budget allocation. In Bangladesh the poor find it very hard to finance their health needs as OOP expenditure is very high.
Besides budget allocation quality of the expenditure is also challenging. Corruption, mismanagement and lack of good regulatory and accountability mechanisms are observed. Procurement and construction are often the sources of misappropriation of budget. And everyone in the society does not benefited from the expenditure equally.
The capacity to spend by health ministry and departments are really very poor. During the first nine month of this fiscal year, the health services department could spend only 26.7%. Health education and family welfare department could spend only 24.94%. Even if the finance ministry have the good intention to increase the health allocation, they cannot do because they have to rely on the record of the capacity of spending of the previous year
Health sector suffered from the shortage of doctors, nurses, midwives, and technicians. For example there is one registered doctor for 1581 persons.
Vacancy rates of doctors in rural areas, remote areas and hard to reach areas is very high.
Absenteeism at root level health centers is another common feature. Due to lack of the other facilities they are not interested to stay at remote areas.
In many public hospitals equipment is available but the position of technician is vacant.
Covid-19 highlighted that how neglected the health sector in Bangladesh. Limitations are observed in different facilities such as testing kits and hospital beds, number of doctors, intensive cares etc. Covid-19 crisis has testified that how ill prepared we have been to tackle health crisis.
The allocation for research and development in all areas including health sector is very much negligible.
Lack of real time data for any sector wide research including health is a problem. Due to proper data it often may give wrong signal.
The private health care sector is growing but mismanagement is also observed here. Due to lack of effective regulatory mechanism all the private health care services are not of good quality.
``So by development of health sector, if we mean good infrastructures, good buildings, good hospitals,, that is one part, but the quality of the health services that is more important, which is absent at the moment.’’ Key recommendations:
Need to ensure equitable public health care system.
Government needs to invest more to ensure affordable and accessible healthcare for all. This is also important to sustain the economic growth which have achieved during the last few decades.
Not only the investment but the management and coordination have also to be improved. It is important to reduce the waste and improve the governance in health sector.
Health services at remote areas cannot be developed in isolation. It has to be developed in conjunction with the development of other sectors. So, decentralization of development is important. This may help to motivate doctors to work in villages.
Besides recruitment and retention, training and development of the health workers are also very important.
The private health care services should come under the regulation of whole national public health care system.
Covid-19 has multiplied the need for massive health care facilities. ``So the improvement of the health sector should be looked holistically, not just in terms of allocation, not just in terms of management but overall sector has to be looked together with a broader lens.’’ Discussion and Question & Answer:
In this session also shared some of their views on the overall subject of the webinar. Which are as follows:
Professor Dr. Syed Abdul Hamid, Dhaka University and Member of Shoho-Jodha, put importance to develop a carrier path for doctors who are working as administrator at field level. Field level doctors are not even promoted in the higher position in DG health and also in ministry. Due to this practice doctors do not acquire adequate capacity to ask the budget and also spending effectively. He demanded the complete reform targeting to change this managerial capacity of doctors. And instead of piecemeal basis, he emphasized to have a master plan for all the changes.
Sayed Rubayet, Country Director, iPas, mentioned that health is not a political priority in Bangladesh. Over the course of 70 more years of time the health structure increase 20 to 50 times but even in district still we have the same numbers of health managers in there like two or three medical officers and Civil Surgeon and some junior staffs. And their capacity development is
always neglected. He recommended for a revolutionary change in the health system and increase investment in this sector. He also said that, after 1918 pandemic there was a baby boom happened worldwide. So it is important to take preparation to welcome the babies. Zahidul Quayyum, Co-Director Centre of Excellence for Urban Equity and Health (CUEH), BRAC James P Grant School of Public Health, BRAC University, also focused on the capacity development of Health Ministry and Directorate to absorb allocated budget effectively. Because as he mentioned, allocation of money and its proper management is important to move to UHC. He emphasized on political commitment for the development of health sector.
Professor Dr. Rumana Huque, Dhaka University and BHW Working Group Member, recommended:
Needs based allocation, district level planning, and decentralization, giving more autonomy at the district level for financial resource utilization and planning.
Training on procurement process, developing the operation plan, developing the program implementation plan, and how the results framework is linked to the budget and how the entire resource disbursement is linked to the indicators.
Focus on health technology assessment and do it regularly.
Create public health cadre system within the health sector, appoint at least one person at the district level as public health expert and lots of at the central level.
Create a long term plan to manage health services of elderly people as in next 20 years elderly people will be the major portion of our population. Advancing UHC in Bangladesh, session summing up:
Panelist Dr. Hossain Zillur Rahman, the Advisor of the former caretaker government also Chairman, BRAC and Executive Chairman, Power and Participation Research Centre (PPRC) addressed on this subject. He said it is urgent to improve our health sector. It cannot be a business of as usual type of discussion. He focused on urgency considering the development of health sector. He said, out of pocket expense is high not only for low public investment but also the nature of the expenditure. He placed an example that, `Right now in the pandemic, it’s not just the people are suffering from the infection but a 10 taka medicine is going for 700 taka, how is that possible?’ Other than increasing public financing to get rid of OOP burden he suggested:
Need to focus on efficiency in every steps of health sector
Create an effective system that protect people from paying money for unnecessary tests, examination, and ‘dalal’ fees
Cost efficiency is also crucial to reduce OOP.
He said, there is an imbalance and inconsistencies in item wise budget allocation like, in the development expenditure 4% is for man power but 2% for research. Due to the inconsistencies at district or Upazila level 250 beds or 500 beds hospital are sometimes operating by the capacity of 50 beds. This is also the reason that money is quickly disbursed for the concrete not for manpower.
He urged just not to expand the public finance to develop buildings rather than delivering health care. At district or upazila level new hospital only should be built after have the complete plan of human resource.
In Covid-19 pandemic he observed that the key weakness of health division is lack of coordination and proper management. ``I would actually not call it a weakness, I would call it a failure at same level; a communication failure of the type of message we should have gone out to the people. Communication is a critical part of public health and I think getting our capacity to deliver good effective usable communication is important and we have really mixed up our messages that we have given. For example even we have not use the word ‘lockdown’; we have used the word ‘general holiday with restrictions’.’’
This is his observation that, Bangladesh has a pluralistic healthcare system with government, NGO and private sector. But during covid it showed its weakness and as a result non-corona health care is largely dried out. Here strong governance is very important in private health care sector. `United hospital with its fire and then charging one of the victims with a huge cost is an extreme example of governance failure of the private health care system.’
He mentioned two important issues in health sector, one is corruption and another is lack of capacity of health ministry and department to absorb the allocation properly. `And here I would prefer to get angry rather than frustrated, we have to get angry.’ Reform is necessary but it is important to identify the exact area for proper reformation. Formation of health commission could be a way to lead the reformation. `We cannot just leave it to the health sector or to the some technical committee within the minister because they have not really stepped up to the job’.
To get reform in place he suggested to prioritize at least two agendas. Which are:
One is urban primary health care where some ground work has already been done. Urban primary healthcare which is both preventive but also can be the base for an effective referral system. Established effective urban primary healthcare system in the short run is important. Within the health discussion it should include the demand of big allocation for municipality health services.
Second one is health agenda should not taking only as the health agenda rather treating it as public health agenda. But in Bangladesh public health is the domain of local government. So here is a bureaucratic turf battle between health and local government ministry. Other agenda of public health like public hygiene, waste management should take into consideration for reform. Covid-19 opened up our eyes that how hand washing, social distancing are playing crucial role in containment of this virus. All these are public health issue. This public health sector is also ignored in Bangladesh. It is observed that allocation in the hygiene subsector is minimal, almost no existent. It is important to reverse those subsector allocation imbalances.
``the Covid-19 context, health cannot be left to be a sectoral agenda. It is the strategic agenda of today and tomorrow. Without health you will even not get the economic recovery that we are so desperately wanting. We have to accept the strategic nature of the health agenda and act accordingly.’’
Comments of Faruque Ahmed, BHW Advisory Board Member and Former Executive Director, BRAC International: He disagreed with the comments that health department has lack of capacity to absorb the allocation. He said from his experience during late 70s that for proper utilization of budget it needs dynamic leadership and political commitment. Three things he mentioned is important for health sector development, which are:
Political commitment.
More funding
Committed dynamic leadership in terms of human resource, accountable, system in place and supported by completely technical advisory group drawn from private sector and public sector to guide the government how to move on. `Perhaps this is the time to go with the health commission or something like that, so the urgency is very important here and now is the time.’ Closing remarks by Dr. Ahmed Mushtaque Raza Chowdhury, Convener, BHW:
He thanked all speakers for sharing their experience and views and thanked all participants for giving their time for this event. He hoped that this webinar leads to new areas of creating a kind of compelling case for universal health coverage and health sector reform.
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