Sonia Akhter is a mother who lives with her middle-class family in Gopalganj. She came to Dhaka with her measles-afflicted daughter Ramjana on June 22 for treatment at the advice of the doctor there. She at first went to Dhaka Medical College Hospital with Ramjana where she was told to go to Mohakhali DNCC dedicated covid hospital for treatment of her daughter. From Mohakhali Hospital she was directed to Suhrawardy hospital. As there was no bed available she was told to go to MR Khan Child Hospital at Mirpur. She went there and found no seat was available there, too. Finally, after waiting for some time she managed to have a seat for Ramjana at Bangladesh Child Hospital and Institute. Sonia Akhter informed the reporter of Bengali daily Amader Somoy that the travel in ambulance to carry her daughter from one hospital to another in Dhaka had already cost her Tk 16,000- Tk 17000 and she was at a loss as to how the cost of Ramjana’s treatment at the hospital will be borne by her.
At the same hospital is Poli Akhter’s seven months old baby, Nusrat Jahan who contracted measles on May 18. After her birth she underwent treatment at a clinic in Dhaka which had cost her about taka four lakhs. Unable to bear further expenses she transferred her baby daughter to National Child Hospital after a long wait.
Fakrul Islam, father of Faria, another measles patient at National Child Hospital, had already sold six decimals of land in his village in Bogra for Tk 150,000 only. After exhausting that amount he has now mortgaged 30 decimal of land and received Tk 40,000. Even that amount will not be enough for the treatment of his daughter, he apprehends. ( Amader Somoy, 22 June).
The above are some of the instances of how treatment of simple diseases like measles and dengue cost so much that family’s face acute financial crisis leading to sell of properties or to incur debt. Costs of more serious nature like cancer render middle-class families pauper almost overnight. The poor families with no land or savings face an even bleaker future when anyone in the family fall ill.
According to recent World Bank/ WHO data, about 80 per cent of the total health expenditures in Bangladesh is directly paid by households, meaning that for every Tk 100 spent on health care, roughly Tk 80 is borne by the patients or their families. Earlier studies and official health accounts found the figure to be around 65 per cent which was already one of the highest rates in the region.
It has been estimated that for a middle-class family of four expenses like (a) routine doctor visits and medicines; @ Tk 10,000- Tk 30,000; (b) diagnostic costs @ Tk 5,000 – Tk 20,000; (c) one hospitalisation @ Tk 30,000 – Tk 300,000; and ( d) chronic disease @ Tk 50,000 - Tk 500,000 may claim more than six months income of the family. A single serious illness, on the other hand, in the family may force borrowing or sale of assets, the study has found. Research studies have repeatedly found that health shocks are a major cause of financial distress in Bangladesh and largely contribute to worsening of poverty situation among families hovering just over the poverty line.
When the financial condition of middle-class families is so precarious in the face of medical expenses the plight and helplessness of poor families can easily be imagined. In fact, most poor families in Bangladesh do not have any meaningful access to modern medical treatment except visit to government-run hospitals and having free prescription. According to National Household Income and Expenditure Survey (HIES) in 2016 researchers found that around 4.5 per cent of the population (about 8.6 million people) were pushed below the poverty line because of healthcare expenses. A study by BRAC Institute of Governance and Development found that health expenses were the largest driver of financial hardship of the poor.
Until the proposed allocation in the national budget this year health sector stagnated around 3-4 per cent of the total budget expenditures. The proposed budget for 2026-2027 has doubled the allocation to health sector comprising Tk 278.26 billion for operating spending (salaries, allowances) and Tk 350.26 billion for development spending (infrastructures, machinery, equipments etc). A major study of Bangladesh health financing shows over 50 per cent of health budget is spent on salaries, drugs and hospital operations which includes ‘free healthcare’. The true share of ‘free health service’ being embedded in: (a) salaries and allowances, (b) hospital maintenance, (c) procurement of medicines and (d) operating costs. So, it is difficult to measure separately how much is actually spent on ‘free health service’.
From health accounts and policy studies it has been found that government fund covers only about 22-30 per cent of total national health expenditures, leaving 65-70 per cent for out-of-pockets expenditures by households. This implies that the state subsidy for health care (mostly ‘free service’) is roughly one-quarter to one- third of total health spending, even though much of it is not labelled ‘free’. What is more significant than this fact is the findings by researchers that ‘free health service’ is not fully free. Studies consistently show that in government-run health facilities (hospitals, clinics) consultation may be free or cost a nominal amount of Tk 20-50 but patients pay heavily for medicines ( 60-70 per cent), diagnostic tests and ‘informal’ payment in some cases. So, ‘free healthcare’ in Bangladesh is mostly free consultation in subsidised hospital access.
It is apparent from the above discussion that health care facilities costs middle class so much that in normal years it claims 50-70 per cent of their income and in cases of serious illness of any member of the family the expenses may push them into indebtedness and financial hardship. As regards the poor, the health care system is even direr, making it so expensive as to be inaccessible. As pointed out earlier, the ‘free health service’ does not go beyond subsidised consultation.
It is in this prevailing context that the declaration in the budget proposal for next fiscal about introduction of universal health care and making it accessible to the rural and marginalised group appears as of great interest. Though ‘health care for all’ became a slogan years ago, precious little has been done to make it even incrementally a reality. This is not to ignore the many obstacles, financial, institutional and moral (corruption-free), that stand in the way of implementing the programme.
Even developed countries continue to grapple with this challenge of universality of health service coverage. Two models have emerged from the practice of the developed countries: (a) the privatised model; and (b) the nationalised model. Under the former health services and medical treatment have to be covered by insurance policy bought by individuals for him/herself and for their dependent minors. Since the scope and coverage of illnesses depend on premium paid, those in the lower income bracket cannot afford to have comprehensive insurance coverage. In America, where this model developed and is continuing, the federal and state governments supplement insurance coverage with financial contributions (medic aid, Medicare etc) for people in the lower income bracket. Even with this supplementary measure the privatised health service has not covered the lower income groups and the unemployed adequately.
The second model can be seen in the healthcare system of the United Kingdom (UK) where the National Health Service (NHS) has remained a cornerstone of the whittled down welfare state. The NHS is based on three key principles: (a) it is tax-funded and most of the funding comes from general taxation (and some National Insurance contributions); (b) It is free at the point of care. Patients do not have to pay when receiving health care; and (c) NHS provides universal coverage, covering all legal residents of the UK.
Private healthcare exists in the UK and the relatively well off use private insurance to avoid waiting times. Under the NHS the standardised system works as follows:
Most patients first see a General Practitioner (GP) who diagnoses common illnesses and prescribes medicines for the same. In case of complicated illness he/she refers to specialist consultants or refers directly to hospitals for treatment. Emergency treatments are made by hospitals without referral by GP. Prescription medicines are free in Scotland, Wales and Northern Ireland. But in England medicines are partly paid by patients. Part payment for dental care and optical services is made by patients all over the UK.
In selecting a model for universal health care the NHS model appears to be preferable. But the main implementing problem will be financial as our tax revenue is not yet adequate to fully fund a free and universal health care system. If this problem leads to a semi-privatised ( through insurance ) model then the coverage will not be universal as the poor will not be able to buy insurance while the middle-class will have to settle for a less than comprehensive insurance because of income constraint.
Choosing a model for universal health care for Bangladesh should involve an in-depth study of all the health service models. It should combine relevant parts from the existing models keeping our present income groups, their ability to pay insurance in part (lower income group) or full (the upper income bracket). Such an eclectic model (public-private) will require a sliding scale of government contribution based on the income of the individuals. The worst choice will be to opt for a system of health care that is predominantly privatised. In that model Sonia from Gopalganj, Poly from Dhaka and Fakrul Islam from Bogra will find themselves bypassed by a market-based health care system. They and the people under them in the income ladder are the majority of Bangladeshis. It would be a misnomer to call a system of healthcare ‘universal’ if it bypasses them.
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