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Health System in Bangladesh: Challenges and Opportunities

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DOI: 10.11648/j.ajhr.20140206.18

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American Journal of Health Research
2014; 2(6): 366-374
Published online November 20, 2014 (http://www.sciencepublishinggroup.com/j/ajhr)
doi: 10.11648/j.ajhr.20140206.18
ISSN: 2330-8788 (Print); ISSN: 2330-8796 (Online)

Health system in Bangladesh: Challenges and

opportunities
Anwar Islam1, *, Tuhin Biswas2
1
Adjunct Scientist and Consultant, Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research,
Bangladesh (ICDDR,B), Dhaka, Bangladesh; and Adjunct Professor, School of Health Policy and Management, York University, Toronto,
Canada
2
Research Officer, Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research, Bangladesh
(ICDDR,B), Dhaka, Bangladesh

Email address:
anwarhill@yahoo.com (A. Islam), aislam@yorku.ca (A. Islam), anwar.islam@icddrb.org (A. Islam)

To cite this article:

Anwar Islam, Tuhin Biswas. Health System in Bangladesh: Challenges and Opportunities. American Journal of Health Research.
Vol. 2, No. 6, 2014, pp. 366-374. doi: 10.11648/j.ajhr.20140206.18

Abstract: The health system of Bangladesh relies heavily on the government or the public sector for financing and setting
overall policies and service delivery mechanisms. Although the health system is faced with many intractable challenges, it
seems to receive little priority in terms of national resource allocation. According to the World Health Organization (WHO
2010) only about 3% of the Gross Domestic Product (GDP) is spent on health services. However, government expenditure on
health is only about 34% of the total health expenditure (THE), the rest (66%) being out-of-pocket (OOP) expenses. Inequity,
therefore, is a serious problem affecting the health care system. Based on a review of secondary data, the paper assesses the
current challenges and opportunities of the health system in Bangladesh. The findings suggest that although the health system
faces multifaceted challenges such as lack of public health facilities, scarcity of skilled workforce, inadequate financial
resource allocation and political instability; Bangladesh has demonstrated much progress in achieving the health-related
Millennium Development Goals (MDGs) especially MDG 4 and MDG 5. Although the country has a growing private sector
primarily providing tertiary level health care services, Bangladesh still does not have a comprehensive health policy to
strengthen the entire health system. Clearly, the most crucial challenge is the absence of a dynamic and proactive stewardship
able to design and enforce policies to further strengthen and enhance the overall health system. Such strong leadership could
bring about meaningful and effective health system reform, which will work more efficiently for the betterment of the health of
the people of Bangladesh, and would be built upon the values of equity and accountability.
Keywords: Health System, Determinants of Health, Societal Response

1. Introduction
The health system is the societal response to the the society” and the “improvement of the nutritional and the
determinants of health. Every society believes in a set of public health status of the people” [1]. In its early phase, the
determinants of health, not always following science or logic. health system in Bangladesh was primarily focused on
The fundamental premise of a health system is the value of providing curative services targeting maternal, child and
human life. The value that a society puts on human life newborn health. Since the 1990s, with the development of
largely determines the resources - human, material and modern science and technology and with the greater role of
financial - that it allocates for the health system. The United Nations agencies and non-government organizations,
effectiveness of a health system depends on the availability the health systems gradually shifted its emphasis equally on
and accessibility of services in a form which the people are health promotion and preventative services. The health
able to understand, accept and utilize. The Government of services also expanded its reach. Yet a large number of the
Bangladesh is constitutionally committed to “supply the people of Bangladesh, particularly in rural areas, remain with
basic medical requirements to all segments of the people in little access to health care facilities. Nevertheless, it must be
 American Journal of Health Research 2014; 2(6): 366-374 367

recognized that Bangladesh has a well-structured health 3. Country Context

system with three tiers of primary health care – Upazila
Health Complexes (UHC) at the sub-district level, Union Bangladesh is a poor and densely populated South Asian
Health and Family Welfare Centres (UHFWC) at the Union country. In 2013, it had a population of 156.6 million that is
(collection of few villages) level, and Community Clinics expected to increase to around 218 million by 2030 [7]. The
(CC) at the village level. These are backed by the District country is undergoing considerable social and economic
Hospitals providing secondary level care and the tertiary changes. Key demographic, economic and health indicators
hospitals of various kind in large urban centres. From a are summarized in Table 1. The country is experiencing a
purely structural point of view, the health system is based on high rate of urbanization. The population of the capital city
sound principles covering the entire spectrum of services and of Dhaka, for example, grew from 5.8 million in 1990 to 10.2
care – from health education and promotion to treatment, million by 2000 and is expected to increase to 16.8 million
care and rehabilitation. Moreover, the system is decentralized by 2015 [8]. The growing population in urban areas is often
covering all districts, sub-districts and rural towns and under-served in basic necessities like housing, security and
villages in the country. The Government, thereby, seeks to access to essential services, including health, sanitation and
create conditions whereby the people of Bangladesh have the potable water. Despite such rapid urbanization, Bangladesh is
opportunity to reach and maintain the highest attainable level still primarily a rural country, with more than 70 per cent of
of health. In short, Bangladesh has a good infrastructure for the population currently living in rural areas [8]. Nearly half
delivering primary health care services. However, due to of the population lives on less than US$1.25 per day [9]. The
inadequate logistics the full potential of this infrastructure population is relatively young, only 4 per cent being over 65
has never been realized. Clearly the health system in years of age or older. However, this is expected to change,
Bangladesh needs further strengthening in order to fully with the proportion over 65 years of age or older rising to 6.6
realize its potential. A good health system improves and per cent by 2025 [10]. Although there has been significant
sustains people’s lives tangibly every day. Health systems improvement in many health indicators in recent years, the
strengthening (HSS) is crucial for the successful scale up of Table 1. Major selected Socio-demographic indicators of Bangladesh
disease control interventions as well as promoting health
education [2-4]. Additional evidence also suggests that weak Subject Indicators Value
Total Population in million [18] 156.6
health systems are one of the main barriers in reaching the
Population Density (population/km2) [19] 1015
health-related Millennium Development Goals (MDGs)[4-5]. Crude death rate per 1000 population [19] 6
After independence Bangladesh has made tremendous Male [19] 66.6
Life
progress in health and development. In some cases, it has expectancy
Female [19] 68.8
made more impressive gains compared to most of its Persons per hospital bed [19] 1860
(years)
No. of doctors per 10,000 population [19] 7.7
neighbors in reducing poverty, malnutrition, illiteracy and
GNI per capita—US$ [20] $640
disease and deprivation. Despite these successes, the Economic
PPP GNI per capita—US$ [21] $1620
Bangladesh health system continues to suffer from indicators
Annual growth rate ( percent) [22] 6.3
innumerable challenges [6]. It is difficult to list and comment Sub-district hospitals [23] 413
on all these challenges. This paper is concentrated on an Secondary & tertiary hospitals [23] 117
Health
Medical Colleges [23] 17
analysis of a number of major challenges faced by the health Facilities/
Infectious Disease Control Centres [23] 5
system in Bangladesh. Hospitals
Chest Hospitals [23] 12
Community Clinics [23] 10,723
Physicians [24] 11,300
2. Methodology Health Nurses [24] 13483
Workforce in Medical technologists [24] 4,658
The paper is based on an extensive review of published
public Medical assistants [24] 3,694
and unpublished data/ information on health system in facilities Domiciliary staff [24] 23,285
Bangladesh. These include relevant annual as well as special Non-medical [24] 218
reports by the World Health Organization (WHO), the United Health Persons per hospital bed [25] 1,860
Nations Children’s Fund (UNICEF), United Nations Fund for services No. of doctors per 10,000 population [26] 7.7
GDP spent on healthcare [1] 3%
Population Activities (UNFPA), the World Bank (2012),
Health expenditure as a % government
Bangladesh Bureau of Statistics (2009, 2011), and the 7.4
budget [24]
Bangladesh Health Watch (2007, 2011) Reports by the Health Out-of-pocket expenditure for health [24] 65.9 %
Directorate General of Health Services as well as that of Financing Per capita total expenditure on health
23
other national and international agencies were also (U.S.$) [24]
Per cent coming from development
considered. Articles and research papers published in 8
aid/partners [24]
scientific journals were also reviewed. In short, the paper is a
review article based on secondary data. However the paper is Sources: (18) World Bank 2013, (19) Bangladesh Bureau of Statistics 2011,
(20) Trading Economics 2012a, (21) World Bank 2012a, (22) World Bank
exclusively based on reviews of English language articles
2011c, (23) Bangladesh Health watch Report 2011 (24) Director General of
and reports. Health Service 2010 (25) World Bank 2012 (26) Bangladesh Health Watch
2007.
368 Anwar Islam and Tuhin Biswas: Health System in Bangladesh: Challenges and Opportunities

government faces major issues concerning its capacity to national health policy nor a separate health sector plan
plan and implement a broad range of health and population outlining medium and long term goals. Five Year plans were
services [11]. A substantial proportion of the people, used to set medium and long term objectives for all the
especially the poor, experience a wide range of health sectors, including that of the health and family welfare sector.
problems linked to socio-economic disparities [12-14]. A comprehensive review of the Fourth Population and
Bangladesh has low per capita health expenditure as well as a Health Project led to concerns about the lack of progress in
low percentage of GDP spent on health. In 2009-10, the per reducing maternal mortality and morbidity, the low
capita national income and GDP were US$750 and US$684 utilization of Government health services, their cost-
respectively [15]. It is estimated that public sector health care effectiveness, as well as the sustainability and quality of such
financing accounts for only 34 percent of the total health care services. This review and its findings led to the further
expenditure, which is inadequate to meet the demands of the broadening of the public sector services and the formulation
population [16]. While table-1 indicates that the overall of the Health and Population Sector Program (HPSP). Under
proportion of development assistance going to the health HPSP (1998-2003), measures had been taken to restructure
sector is approximately 8 percent [17], the WHO country-by- the entire health system to make it more responsive to the
country comparisons of health development assistance health needs of the population. The goal of the program was
estimates that “nearly 16 percent of all health expenditures in to improve the health and family welfare status among the
Bangladesh are funded by international aid agencies”. most vulnerable segments of the population - women,
Regardless of the exact level, it does indicate the importance children and the poor through a client centered approach
of the contribution of development partners in setting geared towards greater utilization of health, population and
national health care priorities. family welfare services. As a consequence, resources were
allocated to those facilities and services (Upazila and below
3.1. Reforms of the Health Sector in Bangladesh level facilities) that were most needed and used by the
In the early years following independence in 1971, the vulnerable groups Since 2009 the newly elected government
health system in Bangladesh was focused primarily on the undertook a massive effort to establish Community Clinics at
requirements of rural areas. The First Five Year Plan (1973- the village level (1 Community Clinic for every 6,000
78) highlighted the importance of building a network of population) with a view to bring services to the doorsteps of
health facilities - a hospital in every district, in some cases the people at large. At the same time, since the second half of
supplemented by a Maternal and Child Welfare Centre the 1990s, issues such as pro-poor focus, community
(MCWC), and an Upazila Health Complex (UHC) in every participation and empowerment, accountability, public-
Upazila throughout the country. A number of vertical private partnership for service delivery and demand-side
programs like malaria and small pox eradication programs financing gained momentum. Consequently, the structure and
were initiated in 1976. After the formulation of the First Five the service delivery model of the publicly-funded health
Year Plan (1973-78), the Government of Bangladesh (GOB) system underwent profound changes.
revived the family planning program in an organized manner Table 2. Achievements of the Bangladesh health system
and a separate Directorate of Family Planning was
established within the Ministry of Health and Family Welfare. Infant mortality rate (IMR) 43 deaths per 1,000 live births
In 1975, an international consortium of bilateral development Child mortality rate 11deaths per 1,000 children
agencies, in coordination with the World Bank, started to Under-5 mortality 44 deaths per 1,000 live births.
Vaccination Coverage 87.5%
provide financial and technical assistance to the GOB for the
Under age 5 are stunted 41%
implementation of successive population and family planning
Severely stunted 15%
projects, each five to six years in duration. The initial project,
Overall wasting 16%
called the First Population Project (1975-80), provided
Children under age 5 are underweight 36%
support for re-establishing a physical infrastructure for Severely underweight 10%
family planning service delivery, which had been greatly Skilled attendance at deliveries 32%
damaged during the liberation war of 1971. The Second Maternal Mortality rate (MMR ) 194 per 100,000 live birth
Population and Family Health Project (1980-86) provided Antenatal Care Coverage (1 visits)
67.70%
funds for the further development of the national family from any Provider
planning program. The Third Population and Family Welfare Antenatal Care Coverage (4 visits)
25.50%
from any Provider
Project (1986-92) began to provide some support for the
Total fertility rate 2.30%
reduction of infant mortality along with support for family
planning services. The Fourth Population and Health Project Source: Simple Vital Registration System (SVRS) 2011.
(1992-98) provided further support for Maternal and Child
Health and disease control activities along with family 3.2. Achievements of the Bangladesh Health System
planning services. Primary Health Care (PHC) as the key
These restructuring efforts led to much improvement in the
ingredient of overall of health care was developed in the
overall health and social development as reflected in some of
Second Five Year Plan of the country (1980-1985). However,
the key socio-economic and demographic indicators (Table-
at that point Bangladesh neither had a comprehensive
 American Journal of Health Research 2014; 2(6): 366-374 369

2). It can be proudly said that Bangladesh has surpassed care health facilities. The medical college hospitals are
many neighboring countries in South Asia as well as so many located in the regional urban hubs covering several districts,
other developing countries in terms of progress in achieving and provide specialty care in a wide range of disciplines.
the health-related Millennium Development Goals (MDGs) These hospitals provide tertiary care services. Tertiary
as well as in improving the overall health status of its people. hospitals also include national level super specialty hospitals
Over the last four decades, the average life expectancy of or centres which provide high end medical care services,
Bangladeshis increased from 44 years to 66 year today. specialized in only one particular area of healthcare. Over the
Moreover, the gender disparity in average life expectancy last few decades, Bangladesh has experienced a rapid
that it had in the 1970s (females had a considerably lower expansion of the secondary and tertiary care networks all
average life expectancy than males) slowly disappeared as over the country (Table 2). Of 64 districts, 59 have a hospital
women’s health status improved. Bangladesh has already met with secondary level health care. However, these hospitals
the MDG target of reducing under-five mortality rate. Data have limited specialists, diagnostic and laboratory services.
provided by the Sample Vital Registration System (SVRS) In addition, there are nine general hospitals with 100-250 bed
2011 show that the under-five mortality rate was 44 per capacity each. The types, number and size (bed counts) of
1,000 live births in 2011 as compared to 146 in 1991. The public sector hospitals and their service packages are
MDG target of reducing the infant mortality rate is also on presented in Table-3. When compared with other developing
track. countries, it becomes clear that Bangladesh does not have
According to the country’s first MDG Progress Report, the adequate number of hospital beds to serve its large
maternal mortality ratio in 1990 was 574 per 100,000 live population [9]. For example, while Bangladesh has only 0.4
births. However, according to Bangladesh Maternal Mortality bed per 1,000 population, Ghana has 0.9 bed per 1,000
Survey (BMMS), maternal mortality declined from 322 in population. Similarly Kenya at the same level of economic
2001 to 194 in 2010, a 40 percent decline in nine years. The development as Bangladesh has 35 percent higher number of
average rate of decline from the base year has been about 3.3 hospital beds than Bangladesh.
percent per year, compared with the average annual rate of
reduction of 3.0 percent required for achieving the MDG by 3.5. Compromised Access
2015. The proportion of deliveries by medically trained A wide variety of inpatient care services is available in
providers has doubled from about 16 percent in 2004 to public hospitals. On the other hand, the three tiered PHC
about 32 percent in 2011, mostly due to improvement in system (sub-district, union and village level) established to
institutional delivery mechanism. Much of these serve the population at large. However, access to this
improvements may be attributed to the country’s tremendous network of health care facilities is often seriously
success in achieving almost universal immunization coverage. compromised. It should be noted that while basic health care
While less than 5% of children were immunized at the time service is supposed to be free in public hospitals and other
of independence, currently almost 100% of Bangladeshi facilities, patients end up bearing the costs of medicine and
children receive immunization thanks to the success of the laboratory tests, as well as some additional unseen costs.
Extended Program of Immunization (EPI) that penetrated the These costs seriously restrict the access of the poor and the
entire country. Bangladesh was successful in taming many disadvantaged to most publicly-funded health care services.
communicable diseases too. Table 2 presents some of these Moreover, in many public hospitals the available ambulances
successes of the Bangladesh health system. are either inoperative or being used by the physicians and
3.3. Challenge for the Health System in Bangladesh other staff. Patients are deprived of use of ambulance
services. In short, there is a gap between principle and
Despite these successes, the Bangladesh health system practice in public health facilities seriously compromising
continues to suffer from many drawbacks Some of the major the accessibility of the poor. The fact that almost 66% of
drawbacks of the health system include health care costs are out-of-pocket expenses borne by
individuals and families also serious restricts the access of
3.4. Limited Public Facilities the poor to the health system undermining the principle of
A total of 536 public hospitals with 37,387 beds provide equity so enshrined in the country’s constitution.
inpatient care services in Bangladesh for a population of 160 3.6. Lack of Essential Commodities
million. There are 413 Upazila (sub-district) Health
Complexes which have limited inpatient care services (Table Availability of drugs, medical supplies and family
2). Most UHCs has 20 beds primarily to cater to emergency planning commodities is almost a constant problem in many
needs of pregnant women. District hospitals are usually public health facilities throughout the length and breadth of
termed secondary care hospitals since unlike the medical Bangladesh. While part of the problem lies with lack of
college hospitals these have fewer specialty care facilities. effective supply chain management, lack of funds (or timely
Apart from these, there are different types of special care release of available funds) to pay for supplies is also a
centres such as, infectious disease hospitals, tuberculosis serious problem. Shortage of logistics in most public health
hospitals, and leprosy hospitals which fall under secondary care centers, especially at the Uazila Health Complexes and
370 Anwar Islam and Tuhin Biswas: Health System in Bangladesh: Challenges and Opportunities

district hospitals is a common phenomenon. It is widely 3.8. Lack of Devolution

known that almost 65% of the ambulances in these facilities
are non-functional at any point of time either because of lack Although decentralized, the health system never went
of maintenance or fuel money. In many public health through a process of devolution. In other words, power and
facilities x-ray machines to incubators to various lab decision-making remain concentrated in the MHFW in
equipment are in need of either urgent repair or of Dhaka with the UHCs simply carrying out plans and
replacement. Often essential drugs and family planning programs decided by the Ministry. Plans and programs,
commodities meant for free distribution to patients and users therefore, often do not reflect local realities. Moreover, lack
are pilfered and sold to the private sector vendors. of decision-making power at the local level often prevents
the local health professionals from effectively responding to
3.7. Unavailability of Health Workforce unique local level emergencies or crisis.

Unlike many service sectors, inpatient healthcare demands 3.9. Lack of Local Level Planning
highly qualified labor force (health workforce) including
physicians, dentists, nurses, midwives and medical It flows from the earlier one – lack of devolution. It seems
technologists. Bangladesh has a chronic shortage of that Upazila Health and Family Planning officials are always
appropriately trained human resources of health including asked to develop a plan of action to be implemented during
physicians, nurses and midwives. Such a shortage must be the coming year based on local epidemiological and
considered to be a strong limiting factor for population health demographic situation. Although these local area plans are
[27]. Bangladesh government has sanctioned 20,234 routinely submitted to the Ministry, they seldom receive any
positions for physicians of which 11,300 are currently filled attention while developing overall health sector plans. It is
up, which means a total vacancy of 44.2%. In total 13,483 apparent that they remain largely an exercise in futility.
nurses are currently working in the public health facilities, 3.10. Misuse or Misappropriation of Resources
while the total number of positions sanctioned are 17,183.
The distribution of vacant positions of different levels of It is a common complaint from clients that medicines or
nurses shows that around 96 percent positions of senior nurse drugs that are supposed to be available free of charge (or
are vacant. Corresponding vacancies for junior (class II) and with minimal fee) often “disappear” from the UHCs and find
aide nurse (class III) are 67.6 and 19.5 percent respectively. It their way to the local market to be sold at a hefty price. X-ray
means that vacant positions are higher among the nurses with films remain routinely unavailable at the UHC forcing a
higher qualifications. Table 3 presents information on patient in need of one to buy it from the local market. It is
sanctioned and vacant positions in public hospitals of reported that because of either misuse or inappropriate use
different types of medical personnel. The highest vacancy of almost 65% of the ambulances given to the Upazila Health
medical staff is observed in Barisal (64.9%), followed by Complexes are “inoperable” or non-functional at any given
Khulna (58.2%), Rajshahi (55.3%), Sylhet (54.7%), point of time [29]. Clearly the patients suffer for the
Chittagong (50.7%) and Dhaka (25.4%) [28]. In other words, inefficiency of the health system.
there is almost a direct relationship between distance from
the capital Dhaka and the number of vacant health personnel 3.11. Lack of Community Empowerment at the Local Level
positions – the greater the distance the greater the percentage Because of government regulations, community
of vacant positions. These shortages are clearly undermining management committees are often established at the Upazila
the quality of the health care system. level to oversee the UHCs. However, these committees
Table 3. Shortage of Health service providers in public facilities in
seldom truly represent their communities or are empowered
Bangladesh. to demand accountability from the health officials. Devoid of
meaningful community participation in the planning and
Types of medical care and staff Sanctioned Vacant
provision of health care services at the local level, the UHCs
Allopathic Medicine
Physicians 20,234 8,934 continue to be dominated by the bureaucrats. Bureaucratic
Senior nurse 161 155 efforts in forming local committees hardly recognize that
Junior nurse 463 313 community is a heterogeneous entity and that men, women,
Aide nurse 16,559 3,232 rich and poor, Muslims and non-Muslims, all are needed to
Medical technologists 6,150 1,492
represent a community. A committee formed of so-called
Medical assistants 5,411 1,717
Domiciliary staff 26,416 3,131 community leaders (often representing the rich and the
Non-medical 466 248 powerful) does not necessarily represent a community in the
Alternative medicine real sense of the term. Bangladesh health system at the local
Unani 66 46 level fails to understand this reality while talking about
Ayurvedic 66 44
community participation.
Homeopathic 66 50
Compounders 64 16
Herbal garden assistants 467 42

Source: Directorate General of Health Services(DGHS), 2010.

 American Journal of Health Research 2014; 2(6): 366-374 371

3.12. Lack of Public Health and Management Expertise at 3.14. Growing and Continuing Inequity within the Health
the District and Upazila Levels System

Civil surgeons are responsible to oversee the district health Poor and the disadvantaged groups still have significantly
system while Upazila Health and Family Planning Officers less access to health care services than the rich and the
(UHFPOs) are the heads of the Upazila Health Complexes. privileged. For example, only 8% of pregnant women from
Civil surgeons are physicians and so are most of the the poorest income quintile deliver their babies at any health
UHFPOs. In many cases these physicians have very little centre or clinic compared to 53% pregnant women from the
knowledge or expertise on public health or in management. richest income quintile. There is serious disparity in terms of
Although they are good physicians, they often lack expertise antenatal and post-natal care too. While only 31% pregnant
in management. Consequently, the health system at the women from the poorest income quintile ever seek antenatal
district and sub-district levels suffers from paucity of care, the rate is as high as 82% among the richest income
knowledge on public health and of management expertise. quintile. The corresponding figures for post-natal care are 7%
More catastrophic is the almost total absence of ethics and 51% for the poorest and richest income quintile mothers
guiding the behavior of health professionals. Although the respectively. Most importantly, poor continues to die at a
government has prescribed office hours for all employees at younger age than their rich compatriots. The infant mortality
the district hospitals, UHCs and community clinics, rate varies from a low of 43 per 1,000 live births among the
physicians in these health care institutions often have their richest income quintile to over 85 per 1,000 live births
own “office hours” quite different from that of the official among the poorest income quintile [30] The MOHFW could
one. Inconvenience to the patients seldom gets any attention. hardly take any effective measures over the years to carefully
Patients are often neglected or even abused by the health care assess the social determinants of such inequities and to come
workers; their dignity and privacy seldom respected. Ethics up with effective corrective measures. The problems faced by
and morality have disappeared so much that patients are the health system are well known and yet the leadership at
often diverted or enticed to private clinics or to a physician’s the top seldom demonstrates the eagerness and/or the ability
home so that he/she can be charged a fee. A “normal” to tackle them. A health system consists of six interrelated
delivery could be delayed beyond the office hours so that a and interdependent building blocks – efficient and effective
fee can be exacted. Or a “normal” delivery could be health service delivery; appropriately skilled, adequate
transformed into a “cesarean” one to earn some extra bucks. number and properly distributed health workforce; a well-
Morality and ethics that used to guide physicians and other functioning health information system; equitable access to
health care professionals seem to have disappeared from essential medical products and technologies; adequate
Bangladesh. Hippocratic Oath that guided physician-patient financing; and leadership and good governance. It is doubtful
relationships for centuries does no longer get covered in whether the steward of the Bangladesh health system truly
Bangladesh’s medical education. appreciates and comprehends the inter-relatedness of all
these building blocks and the need to addressing them
3.13. Inadequate Financial Resources simultaneously in order to overcome the drawbacks of the
In Bangladesh, about 3.4% of GDP is spent on health, out overall health system. The steward must realize that without
of which the government contribution is about 1.1%. In term such a comprehensive approach it would be futile to put
of dollar, the total health expenditure in the country is about more resources or to build more infrastructures (like
US$ 12 per capita per annum, of which the public health community clinics) and expect good results. The important
expenditure is only around US$ 4 only. More than two-thirds question is whether the planners and policy makers have the
of the total expenditure on health is privately financed, time and the inclination to have a critical look at all these
through out-of-pocket payments. Of the remaining one-third interdependent elements of the health system with a view to
(public financing), about 60% is financed by the Government make their efforts part of an integrated comprehensive
out of tax revenues, development outlays, and the remaining approach.
40% through international development assistance. Health 3.15. Political Instability and Lack of Commitment
care expenditure of the MOHFW at different levels shows
that 27% of the primary level health care allocation is going As a developing country Bangladesh is faced with political
to the richest quintile and 21% to the poorest quintile. instability and unrest that often turn into violence. Such
Health financing is mainly tax-based, along with the political unrest (often coupled with street violence and
financing from development partners. But the poorer people destruction of public and private property) has significant
spend more on health through out-of-pocket payment, which adverse impact on the economy. Health system is the indirect
often leads to their impoverishment. Health insurance is victim of such political turmoil. During hartal (total
almost non-existent in Bangladesh. Although some NGOs shutdown of public and private transportation and of day-to-
have piloted health insurance schemes in recent years, it will day economic activities) doctors and nurses (as well as others)
presumably take a longer period of time to gain wider public are afraid to go to work due to lack of safety and security.
acceptance. Patients also face similar problems and can hardly seek
needed health care services during such political disturbances.
372 Anwar Islam and Tuhin Biswas: Health System in Bangladesh: Challenges and Opportunities

In other words, political instability and violence paralyses the private sector. In addition, the health workforce is skewed
health care system. towards doctors with a ratio of doctors to nurses of 1:0.4, and
Moreover, political parties in Bangladesh seem to have that of doctors to technologists of 1:0.24, in stark contrast to the
little commitment to shun violence or to honor their pre- WHO recommended ratio of 1:3.5.
election “promises”. Every government has promised to Statistics on private sector appointment of medical staff
ensure health for all and enshrined it in the constitution. are not available. However, the physicians in public sector
Nevertheless, the promise remains unfulfilled even after forty often provide services in private hospitals. Moreover,
years of the independence of Bangladesh On the other hand, Bangladesh has only 0.4 hospital bed per 1,000 population
intolerable corruption within and outside the health sector compared to that of 0.9 bed per 1,000 population in Ghana
seems to have further deprived the country of its resources (WHO, 2011). Likewise, although at a similar economic
and denied it of decent human development. It is a country level as Bangladesh, Kenya has 35 percent higher number of
where the rich and powerful (including political big shots) hospital beds per 1,000 populations.
routinely fly to Singapore, Thailand or India to avail health Another problem plaguing the health system is the sorry
care services. There is hardly any commitment to improve state of infrastructural facilities. It should be noted that the
the health system at home so that people at large could government has a policy of establishing 1 Community Clinic
benefit. Clearly the health system requires a strong and for every 6,000 population covering rural Bangladesh.
efficient steward to come out of these drawbacks and deficits. However, it is yet to be fully implemented. In most cases,
It is unfortunate that the health system in Bangladesh does community clinics consist of two rooms with drinking water
not seem to have an effective steward. and lavatory facilities, and a covered waiting room.
Unfortunately it remote areas of Bangladesh community
3.16. Weak Health Information System clinics usually do not have even such meagre infrastructural
Reliable and up-to-date health-related information is facilities.
essential for developing an efficient health system. Thus So far as human resources for health is concerned, it is not
WHO has emphasized on it as one of the building blocks of even clear if the sanctioned positions are sufficient to provide
any health system (WHO, 2008). Only collecting raw data is healthcare services to all citizens covering their needs. It is
not enough; those data must be managed, analyzed and more important to look at the distribution of health care
disseminated systematically to the appropriate authority to expenditure of Bangladesh. In Bangladesh, the major sources
facilitate decision-making and to take prompt actions. Over of healthcare funding include: households, government,
the years, many nation-wide as well as smaller scale surveys, NGOs and development partners. Insurance makes up a
surveillances and research studies have been conducted in the small share of the total source of health care financing in
health sector of Bangladesh; but it still do not follow a Bangladesh (BNHA 2003). The continued absence of social
standardized procedure to collect and manage health-related insurance and a minuscule private insurance market are
data from all health facilities at a regular interval. By compelling the house-holds, particularly the rural poor, to
following such unified and standardized health information bear a large proportion of the national health expenditure
system, Bangladesh can improve the efficiency of all other through direct or out of pocket (OOP) payments. Household
components of its health system. OOP expenditures constitute by far the largest component of
the Total Health Expenditure (THE) - its share was around
69% in 2001 (BNHA 2003). The share of out-of-pocket
4. Discussion expenditure in the total health expenditure increased from
The challenges faced by the health system are multifarious 57% in 1997 to 64% in 2007 .It should be noted here that
and varied. Bangladesh has a severe shortage of physicians, while basic health care service is supposed to be free in
nurses, midwives, and health technicians of various kinds. The public hospitals, patients end up bearing the costs of
deficit will keep on rising as the population increases. medicine and laboratory tests, as well as some additional
Inadequate number of appropriately trained human resources for unseen costs .Moreover, 5,122 registered diagnostic centres
health in Bangladesh is a strong limiting factor for population are currently operating in Bangladesh (along with many
health [31]. In terms of health technicians of various kinds (from unregistered ones). Apart from these, there are a large
laboratory technicians to physiotherapists) the deficit is almost number of private clinics and hospitals in different districts
half a million. Midwives and community health workers are also and cities that are not registered. Private for profit
in short supply. The gap between what the government has clinics/hospitals, geared toward maximizing profit, usually
assessed (sanctioned) as requirement for providing healthcare target middle- to high income segments of the society.
services and the positions vacant clearly shows that Bangladesh According to Health Bulletin 2013 there are 2,983 registered
has to make much greater efforts in ensuring accessibility to private hospitals and clinics in the country with about 45,485
essential health care services. Moreover, the human health beds. Only a few among these have free beds for the poor.
resources are heavily concentrated in urban centers, depriving The health system information technology (IT) is primarily
rural areas of much needed human resources for health. focused on family planning, safe motherhood, child health,
According to Bangladesh Health Watch report (BNHA 2011) and immunization. Unfortunately the health information
62% of medical doctors in Bangladesh are working in the system does not cover chronic non-communicable diseases
 American Journal of Health Research 2014; 2(6): 366-374 373

(NCDs) – the fastest growing disease burden and threat to the [8] World Bank. 2007. Improving living conditions for the urban
health and wellbeing of the people of Bangladesh. poor. Bangladesh Development Series, paper no. 17. Dhaka
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be ignored. The heavy burden of OOP makes it extremely pocketbook of Bangladesh 2010. Dhaka: BBS.
difficult for the poor to access needed health care services.
[10] The World Bank (2011). World Development Report 2011.
Needless to say, not only the poor but also some in the
middle class citizens dread being afflicted with a serious [11] Vaughan, J.P., E. Karim and K. Buse. 2000. Health care
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5. Conclusion
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once again the issue of equity in health systems, and the
[15] Financial System Management Unit. 2011.Bangladesh
importance of a multisectoral comprehensive approache to economic review. Dhaka: Finance Division, Ministry of
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desperately needs a dynamic leadership that is prepared to
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