Health indicators Bangladesh Maldives Sri Lanka India Nepal Pakistan Myanmar
Total fertility rate
(TFR) per woman 2.2 1.7 2.3 2.6 2.7 3.3 2 Maternal Mortality Ratio (MMR) per 100,000 live birth, 2010 240 60 35 200 170 260 200 Life expectancy at birth (years) 70 77 75 65 68 67 65 Under-five mortality rate per 1,000 live births
46 11 12 61 48 72 62
Source: (56)
HEALTH SERVICE DELIVERY
Health services in Bangladesh are delivered through a mix of public-private institutions and Non-government Organizations (NGOs). The public sector provides both curative and preventive care and is considered to be the key source of care for the majority of the population. The private sector, on the other hand, mostly provides curative care while NGOs provide preventive and basic primary level care (60).
ORGANIZATIONAL STRUCTURE AND GOVERNANCE OF HEALTH SERVICE DELIVERY
Public health services in Bangladesh are provided through a four -tier system of extensive facilities which are setup at union (lowest level administrative and local government unit), Upazila (sub-district), district and regional level (60, 61). A total of 4,400 Union Health and Family Welfare Centres (UHFWC) are located at the union level to deliver primary healthcare (PHC) and each of these UHFWCs cover a population of around 30,000. At the ward level (9 wards make up a union), community clinics serve 6,000 people each. Upazila level facilities include 417 Upazila Health Complexes (UHCs) with 31-50 bed capacity. Both in-patient and out-patient care, PHC, family planning services and some referral services
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are provided through these settings. The Union Health and Family Welfare Centres and the Upazila Health Complexes are the key facilities to provide healthcare to the rural population of the country. At the district level there are 59 District Hospitals and some general hospitals with bed capacities ranging from 50 to 350. Primary and tertiary level care for in-patient and out-patient services are provided through these hospitals. At the regional level 13 Medical College Hospitals are responsible for delivering tertiary level care with bed capacities ranging from 250-1,700. In addition, specialized laboratory facilities are also provided for treating complicated cases (60, 62). Complementing these four- level facilities are the six postgraduate institutions providing both in-patient and out-patient specialized care at the national level. The private sector, on the other hand, is diverse, ranging from modern facility-based services to indigenous medical practitioners, village doctors/drug sellers and other non-qualified practitioners (63).
All of these health sector institutions belonging to the public and private sector are managed and controlled centrally under the policy guidelines of the government (64) (65). The Ministry of Health and Family Welfare (MoHFW) is the highest authority, headed by a Cabinet Minister, responsible for policy formulation, planning, implementation and decision-making regarding the health sector activities of Bangladesh. The secretary is the administrative head of MoHFW (64). The MoHFW operates through four implementation wings: Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP), Directorate of Nursing Services (DNS) and Directorate General of Drug Administration (DGDA). The DGHS provides technical support to the ministry and is responsible for implementation of the health programmes/services. The DGFP oversees the operations of district-level Maternal and Child Welfare Centres (MCWCs) and union-level health centres. At the most peripheral areas both wings work to provide healthcare at the domiciliary level (60). The DGDA supervises and implements drug regulations in the country and the DNS contributes in policy making related to nursing, health and family planning (65).
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COST OF HEALTHCARE
The constitution of Bangladesh entitles its citizens to primary healthcare free of charge. In the rural areas the Upazila Health Complexes (UHC) and facilities below this level are meant to provide both curative and preventive healthcare free of charge. Similarly in the urban context the government dispensaries are to provide curative and preventive healthcare free of charge to the urban population. Fees like registration fees for in-patient and out-patient services are fixed and fees for services including surgery, ambulance, radiological tests, etc are variable (42). Although there is provision of free of charge primary healthcare at the public facilities of the rural and urban areas, services most often involve unofficial payments (23, 66). First and foremost is the expense for medicine. Other unofficial payments include bribes to receive better care (including good behaviour towards patients), and to secure drug and other supplies for the patient. Studies have found these unofficial payments to be higher than the official payments in most instances (44, 66, 67). Unfortunately it has been observed that patients of lower socioeconomic status bear a higher percentage of these illegal payments compared to the better-off patients (67). The private health facilities including the NGOs, on the other hand, provide healthcare on a fee-for-service basis. However, most of the NGOs have safety net programmes where they provide healthcare at free of cost or at a minimal charge to patients with limited ability to pay, particularly patients of lower socioeconomic status. In addition the NGOs are running a few micro health insurance schemes in parts of the country to provide healthcare (26).
HEALTHCARE FINANCING
In Bangladesh per capita expenditure on health is very low at US$ 27 which constitute 3.8% of its GDP(68). The major financing agents in Bangladesh health systems are households, the government, NGOs and foreign Development Partners (DP) (69). Households are the largest source of financing and about 64% of the total national health expenditure is financed privately through out-of- pocket (OOPs) payments (69). This share is far too high compared to the global
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level where OOPs account for about 32% of total health expenditure (17). Government with a share of 26% is the second largest financing source for healthcare in Bangladesh (69). Development partners contribute a sizable amount of their assistance for health through government and the NGOs. While funds provided to the government from development partners is combined in the government expenditure statistics, direct assistance to the NGOs for health related activities varied from 5% to 9% of total health expenditure during the period 1997-2007 (69). Public expenditures and funds from development partners are primarily used to finance the public provider system whereas the OOPs are mostly used to finance pharmaceutical products and diagnostic tests.
HEALTH FINANCING VIA HEALTH INSURANCE
Private health insurance, even though it exists in Bangladesh, is accessible for a limited number of the population engaged in formal sector employment. A large segment of the population is involved in informal employment, which is largely characterized by the absence of any collective arrangements to pay for healthcare. Community financing mechanisms, used in some parts of the world to serve the informal sector, are nearly non-existent in Bangladesh except for a few attempts by NGOs on a limited scale and contribute less than 1% of the total health expenditure (62, 70). Analysing the shares of the various financing agents for the country it has been observed that the role of insurance companies as a financing agent is very limited. Health care spending by insurance companies, which are mostly private sector firms, was Taka 314 million in 2007, or less than 0.2% of total health expenditure (69, 70). However, about one-third of private health insurance expenditures are for health insurance administration, and almost all the rest is used to pay for services at private hospitals. Figure 2 illustrates the flow of funds to the health system of Bangladesh from sources of financing to the entities that manage health funds to the providers of services.
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