We must be bold with health sector reforms
The health sector holds an important place in a nation's development. The past few decades have witnessed some remarkable strides in Bangladesh's health sector. However, this has largely stalled since 2010. Between 1990 and 2010, Bangladesh reduced its maternal mortality ratio from 600 per 100,000 live births to 194, an astonishing achievement. After almost a decade, however, there has been little improvement. Such stagnation was similarly observed in several other indicators of a nation's development.
It is said that we harvested the "low-hanging fruits" well. Bangladesh is committed to reducing the maternal mortality ratio to 70 by 2030, but given the current situation, this seems like an unachievable target. To attain progress, we need to focus on the more difficult, "high-hanging fruits." Civil society activists and health experts repeatedly highlighted this challenge to the previous government, but sadly, serious efforts were not made. Instead, a sense of complacency prevailed. The result was that any idea suggesting reform faced resistance.
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The anti-discrimination movement has inspired the nation and sparked hope among the masses. It has given us a chance to rethink our future. In the health sector, we now have an opportunity for comprehensive reform. If we want to move forward in line with the times, we must be ready to tackle some difficult tasks.
We know, for instance, that good governance is a major issue for development in Bangladesh. Poor governance leads to many problems, and the health sector is no exception. The absence of doctors in health centres is a perennial issue. The corruption that surfaced during the Covid pandemic is still fresh in our memory. We know these issues arise due to the lack of accountability and poor management. The private healthcare sector has become a behemoth without any control whatsoever, harbouring severe inequalities. In 1982, an ordinance was passed giving special priority to the private sector, but it has not been updated since. There is no clear regulatory provisions to control them, leading them to get away with unethical and illegal practices. Despite the presence of the Bangladesh Medical and Dental Council which was established decades ago to monitor the professional behaviour of doctors, many still engage in unethical practices without facing any consequences.
One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.
Another significant drawback in our healthcare system is poor investment. Currently, the government's spendings on healthcare is one of the lowest globally: only 0.7 percent of the GDP. With such meagre investment, it is impossible to imagine modern healthcare. We have seen to our dismay that two of the important pillars of human development, health and education, were among the lowest priorities for the previous government. Our neighbour Sri Lanka, which is far ahead of us in most indicators, spends nearly four times more on health than we do in Bangladesh. Even the small funding that the health sector gets is not fully utilised, with the utilisation rates remaining below 80 percent. One of the main reasons for this is the lack of adequate capacity in the ministry of health, whose inefficiency in drafting a proper budget, planning, and utilising funds is very well-known. The lack of vision is yet another reason. A "poverty of vision" seems to have gripped the ministry. If we want to emerge as a prosperous nation, our health planners must have a clear vision befitting the health system of a developing country, and our budgets should be framed accordingly.
One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.
In addition, another significant issue plaguing Bangladesh's healthcare system is its human resources. Doctors, nurses, and midwives are in severely short supply. To address this crisis, the previous governments licensed new institutions in both the public and private sectors which contributed in alleviating the crisis to some extent. However, there is no effective mechanism in place to ensure the quality of these institutions. Similarly, we need to focus on research. Recently, Bangladesh Health Watch published an extensive research-based book documenting Bangladesh's first 50 years, which shows how Bangladesh has surpassed its neighbours in various health indicators. One of the findings revealed that in recent years, Pakistan has been able to overtake Bangladesh in health research.
The previous government had expressed its commitment to achieve Universal Health Coverage (UHC). Unfortunately, it never felt the need to explain in detail how this would be done or where the additional funds would come from.
The recent uprising is a massive achievement, with tremendous sacrifices made by students and common citizens. We know that every crisis also presents an opportunity. After World War II, the European countries built their health systems on the ruins of war, ensuring free healthcare for all citizens. In the 1990s, after a horrific genocide, Rwanda launched its UHC programme. As I see it, the student revolution has similarly given us a golden opportunity to overhaul our broken health system. Experts have agreed on what needs to be done. This can be broadly divided into five actions: i) establish a high-powered permanent national health commission to create and monitor a roadmap for implementing UHC nationwide; ii) establish a national health security office to ensure accountability in the health system by separating the ministry of health's roles as a "purchaser" and "provider"; iii) ensure good governance and proper management; iv) increase healthcare investment to two percent of GDP, with increased priority for primary healthcare; and v) enhance the quality, efficiency, and oversight of institutions involved in professional health education and research.
I believe that if we follow this path, we will confidently move towards achieving our national goals. While we have made significant achievements, complacency cannot be allowed and must be kept at bay. To bring about a real and lasting change, there is no alternative to reform. This is something the student leaders have repeatedly emphasised. The interim government must take a bold stance and move towards reforms in the health sector that lead to the public being served.
Ahmed Mushtaque Raza Chowdhury is convener at Bangladesh Health Watch, and professor of population and family health at Columbia University, New York.
Views expressed in this article are the author's own.
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