Why Bangladesh should reconsider the push toward PPP in Healthcare

Healthcare is a fundamental right, and a welfare-oriented state has a duty to ensure equitable access for all citizens.

Yet Bangladesh's growing emphasis on Public–Private Partnerships (PPP) in the health sector has raised serious concerns. While PPP is often promoted as an innovative response to rising healthcare demands, the reality is more complex. Rapid moves toward privatisation risk undermining universal health coverage, increasing financial pressure on citizens and weakening the government's ability to provide fair, transparent and affordable public services. Before adopting PPP as a national strategy, Bangladesh must rigorously assess its implications at home and abroad.

According to National Health Accounts, nearly 69% of total health expenditure in Bangladesh comes directly from people's pockets—evidence of severe gaps in financial protection. In such a context, expanding private sector involvement through PPP may deepen the crisis. The fact that 62% of patients rely on private providers is less an indicator of trust than a sign of chronic underinvestment in public facilities. The rise of more than 15,233 private health establishments as of 2024 reflects necessity, not choice. Greater PPP reliance risks shifting even more essential services into the hands of profit-driven actors, away from public oversight.

Proponents argue that private operators can improve use of idle government infrastructure or equipment. But once private entities manage public assets, the state loses authority over pricing, quality and accessibility. PPPs often create long-term dependence, where essential services are operated with limited transparency or accountability. If the objective is better utilisation of public resources, the government should strengthen its own capacity instead of outsourcing critical functions to partners whose primary accountability is to profit, not the public.

Global examples cited in favour of PPP provide more caution than inspiration. The UK's Private Finance Initiative, long held up as a model, is now widely criticised for saddling hospitals with decades of debt. India's PPP outcomes vary significantly by state, with documented cases of corruption, inflated costs and persistent quality gaps. Even Thailand—frequently presented as a success story—built its universal healthcare system on strong state investment and tight regulation, not privatisation. Bangladesh does not have comparable regulatory strength. Borrowing these models without replicating their governance frameworks could lead to unintended harm.

Incorporating private providers into public insurance programmes such as the Shasthyo Surakkha Karmasuchi (SSK) also presents risks. Without strict price controls and rigorous monitoring—both of which remain weak in Bangladesh—PPP-based arrangements may inflate costs and undermine accountability. Poorly structured contracts often guarantee financial returns to private operators even when service quality falls short, limiting the government's leverage and eroding public trust.

Effective PPPs require strong regulatory institutions, but Bangladesh's health governance remains constrained by limited staffing, outdated monitoring systems and uneven enforcement. Expanding PPP without strengthening regulation risks creating oversight gaps. Even proposals for an independent Healthcare Regulatory Commission raise concerns, as institutional integrity must be ensured before—not after—private sector expansion.

Calls to reduce reliance on imported medical equipment through PPP also warrant scrutiny. Building medical device manufacturing requires major investment, strict quality standards and long-term national planning. Without robust regulation, PPP arrangements may lead to monopolies and inflated prices. Similarly, foreign joint-venture medical colleges risk commercialising education and limiting access for poorer students.

Advocates often argue that PPP will enhance private sector capacity through loans, training and accreditation. While capacity building is necessary, prioritising private sector expansion over public sector investment risks widening inequality. International certifications may improve perception, but they do not guarantee affordability or ethical practice. As long as private healthcare is market-driven, expanding its authority will not automatically translate into equitable care.

The long-term consequences of aggressive PPP adoption extend far beyond financial risks. A system shaped increasingly by private interests becomes fragmented and exclusionary. Urban-centred PPP projects may draw resources away from rural and marginalised communities. The aspiration of universal healthcare becomes harder to achieve when pricing and service quality are determined by market forces rather than public policy.

Bangladesh aims to build a more inclusive health system by 2030. Achieving this requires strong public investment, efficient management and sustained commitment to strengthening public hospitals—not handing responsibility over to private entities. Projections that PPP will expand the country's health market to USD 23 billion by 2033 reflect economic ambition, not a public health vision. A national health system must be built around people's needs, not market size.

In the current context, expanding PPP risks reducing affordability, widening inequality and diluting state responsibility. Before embracing PPP as a central strategy, Bangladesh must confront a fundamental question: should healthcare be treated as a public right or a commercial opportunity? The answer will shape the future of millions who depend on a strong, accountable and public-centred health system.