Healthcare reform proposals sound promising. But what about financing?

The Health Sector Reform Commission has laid out an ambitious set of proposals aimed at making healthcare more accessible and financially manageable for the public. On paper, the positives in this report clearly outweigh the negatives.

But even as the commission's recommendations read like a dream blueprint, experts are already questioning whether they can be translated into real-world outcomes — particularly because of concerns over financing.

One of the bolder recommendations is financial: allocating 5% of the country's GDP and 15% of the national budget to the health sector — a significant increase from current levels. Crucially, the commission also proposes that the poorest 20% of the population receive all healthcare services for free, with private hospitals required to provide free treatment to 10% of their patients from low-income backgrounds.

Among the other major highlights is a push to clean up physician-pharmaceutical relations. The commission has called for a total ban on drug samples and gift-giving as a means of influence. There is also a strong push to make life-saving medications more affordable: VAT and taxes on cancer and diabetes drugs should be lifted entirely, the report suggests.

The list of essential medicines is another area the commission wants to overhaul. It recommends expanding this list and updating it every two years to keep up with changing health needs. These medicines should be available for free at the primary level and at subsidised prices elsewhere.

Prescriptions are also under the microscope. The commission recommends that doctors start by prescribing 25% of medicines using generic names, gradually increasing that to 100% within five years. The state-owned Essential Drugs Company Limited (EDL) is set for modernisation, while strategic procurement from the private sector will be ramped up to ensure quality medicines across the board.

To cut down on the number of patients heading abroad for treatment, the commission suggests recruiting more healthcare workers, expanding the essential drug list, and building new hospitals across the country.

However, experts like Dr Shafiun Nahin Shimul, a professor of the Institute of Health Economics at Dhaka University, are particularly concerned about whether there is enough money to back up the commission's ambitions.

"In my initial conversations with people involved with the commission, I noticed a huge gap — the ground reality is far more complicated than what they imply. I'm still not convinced the necessary funding to implement these reforms will be available," he said.

His concerns are not unfounded. The proposed allocation for health in the upcoming Annual Development Programme (ADP) has been slashed significantly. Tk5,616 crore has been proposed for 14 ongoing projects — down from Tk11,153 crore in the current fiscal year's original ADP. Even compared to the revised ADP, the proposed figure is lower by Tk57 crore.

Meanwhile, 27 new projects have been proposed but remain unapproved. Overall, the health sector's share of the national budget has dipped from 5.33% in FY24 to 5.20% in FY25. As a share of GDP, it has declined slightly from 0.75% to 0.74% — continuing a two-decade trend of health receiving less than 1% of GDP.

Per capita health spending has barely improved, rising by just Tk186 — from Tk2,227 in 2023 to Tk2,413 in 2024. Projects like the Urban Primary Health Care Services Delivery Project have also seen drastic cuts, with its budget falling from Tk439 crore to just Tk180 crore.

What's more, the lion's share of the health budget still goes toward non-development or operational expenditures, leaving little for infrastructure or innovation.

Compared globally, Bangladesh's health spending remains worryingly low. India spends around 1.9% of its GDP through government sources and about 3.3% in total, while Indonesia allocates approximately 1.4% and Vietnam about 2.0% in government health spending.

Developed countries invest substantially more — Germany, for instance, spent 12.8% of its GDP on healthcare in 2022. The global average for total health expenditure stands at around 9.2%, placing Bangladesh among the lowest health spenders in the world.

More often than not, the practice of budget cuts in the healthcare sector are defended by pointing to underutilisation of previous allocations.

But Dr Shafiun dismissed the argument as a "fallacy." He said, "Yes, technically some funds go unused, but that's because the way we allocate them is flawed."

Budgets are often raised slightly across the board — without evaluating which sectors actually need more funding. As a result, low-performing areas keep getting money, while critical services like cancer care, kidney treatment, mental health, and preventive services remain starved.

"The real issue isn't just underutilisation — it's misallocation," he argued, adding that even where funds are available, bureaucratic red tape holds back spending.

"District health officials have no real autonomy. Everything needs central approval. So even when money is there, it's often not spent because the system isn't functional."

Reducing budgets because they weren't fully spent, he warned, is both "short-sighted and dangerous"— especially in a country where millions still lack access to essential healthcare.

Another sceptic of the commission's design is Dr Mohammed Belal Hossain, a healthcare researcher and professor at the Department of Population Sciences, Dhaka University.

He points out a fundamental flaw in the commission's composition. "It's mostly dominated by doctors and biomedical experts, who tend to focus on curing over prevention. But public health is largely about prevention — it's rooted in behavioural change, and that can't be ignored," he said.

When asked about the implementation challenges surrounding the Healthcare Reform Commission's recommendations, Dr Syed Akhtar Mahmood, a former lead private sector specialist at the World Bank Group, underscored the need for rigorous project design and robust monitoring mechanisms.

He emphasised that projects must be well-designed, with clearly stated objectives that are reflected in measurable indicators, and with activities logically linked to those objectives.

"It's not just about launching initiatives — we need to ensure that the government can track whether projects are actually achieving the intended results. And if not, corrective actions must be taken," he said.

Dr Mahmood also highlighted the importance of creating beneficiary feedback loops. This, he noted, would allow the government to understand whether the expected benefits are truly reaching the intended recipients.

"Finally," he added, "projects should be evaluated based on outcomes — not on how much was spent. So to summarise, increasing the budget is not enough. How well it is spent is crucial."

Meanwhile, Shaikh Masudul Alam, project director of Bangladesh Health Watch emphasised the need for a phased action plan.

"The commission has made many recommendations. But without clearly prioritising which are immediate, short-term, or long-term, we risk losing focus. The operational plan from last year has already been extended. If we don't move quickly, we will fall further behind."