27yrs, billions spent: Health now set for shift from sector-wise umbrella approach

After spending billions on infrastructure and services over 27 years, the performance of the multi-lender-funded Health, Nutrition, and Population Sector Programme (HNPSP) has come under scrutiny. The way the health sector umbrella programme was being implemented has caused overlapping and wastage of resources, prompting the Planning Commission to call for a review of the approach to make its 5th phase more effective, ministry officials said.

They say the health ministry is developing a two-year exit plan to shift from the sector-wise budgeting approach to the regular revenue budget. This transition will ensure smooth implementation of routine expenditures like salaries, medicines, patient nutrition, utilities, and maintenance, aligning with the Planning Commission's recommendations to streamline financial management and enhance healthcare efficiency.

Professor Dr Md Sayedur Rahman, special assistant at the health and family welfare ministry, told The Business Standard that the transition from the sector programme is under active consideration. The goal is to integrate medical and healthcare services, streamlining the system under a unified framework.

"We aim to consolidate the fragmented components, ensuring a more cohesive and efficient healthcare system," he explained.

He also acknowledged the challenge of transitioning, noting that the health system has long relied on the sector programme. With guidance from domestic and international experts, the ministry is working to ensure a smooth shift and build a health system suited to Bangladesh's needs.

The health ministry had proposed Tk1.06 lakh crore for spending in 38 operational plans under the 5th HNPSP from 2025-2029 to be implemented on sector-wise approach being practiced since the beginning in 1998.

The planning commission, after a series of evaluation meetings since July, concluded that most of the plans fall within the core responsibilities of the health ministry and should be implemented under the revenue budget instead of project-based approach.

The commission's project evaluation committee revealed how sector-wise approach rendered many hospital buildings and expensive medical equipment unused due to complications arising out of revenue and non-revenue budget expenditures.

"Say, sophisticated medical instruments have been procured under one operational plan, but no technicians have been recruited to operate those. One is development expenditure, the other is revenue, which needs to be coordinated," a senior planning official said, explaining why the key health services should come under the ministry's revenue budget to ensure desired benefits.

Before 1998, the health and family welfare ministry ran its development activities through separate projects. In 1998, 126 projects were consolidated into the HNPSP under the first five-year programme, followed by the 2nd, 3rd, and 4th sector programmes. 

The proposed 5th HNPSP includes 38 operational plans – 23 for the Health Services Division and 15 for the Health Education and Family Welfare Division. It aims to improve healthcare access, reduce maternal mortality, and strengthen family planning.

The plan covers a wide range of services, including primary healthcare, disease control, hospital management, maternal and child care, medical education, immunisation, family planning, and public awareness. It also includes infrastructure development, human resource management, and monitoring and evaluation.

Success in communicable disease control

Bangladesh has made significant progress under the sector programme in eliminating cholera, malaria, tuberculosis, kala-azar, and rabies, with WHO recognising Bangladesh as the first country to eliminate kala-azar in 2023.

Malaria cases dropped from 57,480 infections and 45 deaths in 2014 to 16,567 infections and six deaths in 2023. Experts suggest integrating these diseases into the regular health programme to prevent resurgence. 

The Planning Commission recommended treating the 5th HPNSP as a sector action plan and incorporating it into the project proposal for an exit plan. In response, the health ministry sent a letter on 6 February to agencies, requesting urgent matters be included in operational plans up to June 2026 and restructured plans be submitted by 28 February. The proposed changes will be submitted to the Planning Commission for final approval.

Dr. Halimur Rashid, line director of the Communicable Disease Control Programme at DGHS, told TBS that they have been instructed to run an operational plan from July 2024 to June 2026. With seven months already passed, only one year and four months remain, so they must submit the plan accordingly.

"We aim to finalise the exit plan within this month. All operational plans must be submitted separately by then," he added.

A health ministry official, speaking anonymously, said, "The Planning Commission's directive requires an exit plan based on the latest sector program. A committee is working on the plan to fulfil the PEC's recommendations. We've asked everyone to submit their exit plans. The exit may take two to three years, depending on what emergency tasks need to be excluded from the operational plan. A meeting may be held this month for further discussion."

Budget of four sector programmes

The 1st to 4th sector programmes were implemented with costs of Tk6,117.13 crore, Tk16,456.46 crore, Tk19,571.06 crore, and Tk49,374.74 crore, respectively. Development partner funding decreased from 38% in the 1st programme to 16% in the 4th, while government funding increased from 62% to 84% over the same period.

What experts say

Health Economist Professor Dr Syed Abdul Hamid told TBS that the operational plan is no longer needed. While urgent services like community clinic salaries, medicines, and vaccines should still be funded, other activities should be reconsidered. "After 25 years, the operational plan hasn't shown much benefit," he said.

He added that malaria and kala-azar control will continue as part of the regular programme, funded through the revenue budget for continuity. He also emphasised that the operational plan's five-year gaps and associated costs, such as directors, are unnecessary. Instead, the focus should shift to strengthening health sector departments. Despite challenges, he sees the exit decision as a positive step.

Speaking to TBS, Dr Abu Jamil Foisal, a public health expert, said the government's short-term plan is a good approach.