Reforming healthcare in Bangladesh: What to prioritise?

Representational Photo: TBS

The July uprising has sparked new hope for positive changes in Bangladesh. However, health sector reforms have received less attention, especially from key stakeholders. 

Here, I will address some key issues that need to be prioritised for effective health sector reform in Bangladesh.

Declare health as a constitutional right

Health is the foundation of all other human rights. It is, therefore, important to declare health and medical care as a fundamental right of citizens in the Constitution and enforce this constitutional right through law. 

Health is not explicitly mentioned as a fundamental human right in the 1972 Constitution of Bangladesh. The Constitution recognises medical care as a basic necessity of life and asserts that it is the state's responsibility to secure "the provision of the basic necessities of life, including food, clothing, shelter, education, and medical care". 

Additionally, article 18.1 states that "raising of the level of nutrition and improvement of public health" shall be regarded as primary duties of the state. However, there is no other mention of the protection of health and medical care rights in the Constitution. 

Many countries, including Cuba and Iran, have included healthcare rights in their constitutions. They have done this to ensure that every citizen has access to medical care and public health services, recognising health as a fundamental human right. This constitutional inclusion has led to better healthcare by making governments legally responsible for providing and maintaining healthcare services. 

Decolonising health by reforming colonial bureaucracy

Our health system is deeply rooted in the British colonial system. We need to decolonise health through a massive reform in colonial healthcare systems. I believe that the way our health system was shaped during the British colonial period is a big reason why many people today distrust doctors and are disappointed in Western medicine. 

If we make an effort to move away from those colonial influences, it will help improve the trust between patients and doctors. This change can also make hospitals and healthcare centers more welcoming for everyone. Modern medical education, shaped largely by colonial values, ethics, and practices, often fails to address the cultural and emotional needs of our patients. 

While doctors trained in allopathic medicine are highly skilled, they often lack bedside manners and spend less time with patients. Decolonising the health system and medical education would help create doctors who are not only professional but also empathetic and understanding. 

In my opinion, the intention of doctors to take control of the health ministry does not reflect the people's interests. Instead, it prioritises their personal gains, such as promotions, upgrades, and consolidating power within their own community. 

In the long run, entrusting healthcare systems solely to doctors without relevant training would not be beneficial. A potential solution could be to restructure the healthcare bureaucracy. 

Minimum wage and independent salary structure

There is a common belief that doctors earn a lot by taking advantage of patients, but how many actually do? Only a small number of senior doctors. Most healthcare professionals, including doctors and nurses, are underpaid given their skills and hard work.

Recently, the interim government announced an increase in the stipend for postgraduate trainee doctors to Tk35,000 starting in July 2025. While this is a step forward, it falls short of meeting the rising cost of living and the demands of their job. 

The situation is even worse for nurses and other healthcare workers. Without fair wages, how can we expect them to provide high-quality healthcare services? 

It is crucial to reform the current wage structure and introduce a universal minimum wage that allows doctors, nurses, and healthcare professionals to live healthy and dignified lives.

Increase allocation of the health budget

Bangladesh only spends 0.7% of its GDP on healthcare, which is the second lowest in the world.

The World Health Organization (WHO) recommends that health budgets should constitute 5% of a nation's GDP. While this may not be feasible for Bangladesh, we can adopt the African Union's recommendation of allocating 15% of the government budget to health. 

This funding should focus on updating medical education, offering advanced training for healthcare workers at home and abroad, using modern technology in diagnostics, creating key positions in government hospitals, and investing in healthcare research.

The country is facing a shortage of positions for doctors and teachers in public medical colleges and healthcare facilities. Over 6,000 qualified doctors are waiting for promotions due to a lack of posts, and more than 40% of teaching positions in medical colleges are vacant, affecting the quality of education.

To address this, the government should allocate a special budget to create more positions, considering factors like population density and public health needs. Healthcare research should also receive proper funding to drive innovation and support evidence-based medicine, with a focus on areas like artificial intelligence, personalized medicine, precision nutrition, and pandemic preparedness.

Additionally, essential health services should be nationalised, such as treatments for chronic diseases, care for newborns and pregnant mothers, and support for vulnerable groups like mothers and workers. 

A health allowance or voucher scheme for laborers, farmers, and migrant workers should be introduced. Increasing the health budget will help make these initiatives a reality and improve healthcare access for all citizens. The commission should recommend appropriate funding and spending priorities to strengthen the healthcare system.

The need for comprehensive primary healthcare

Prevention is better than cure, and this principle must guide the ongoing reforms in our healthcare system. 

Primary healthcare should be at the forefront of these reforms, emphasising disease prevention and the development of robust infrastructure and advanced technology. To ensure access to quality care in both urban and rural areas, primary healthcare delivery systems must be strengthened. 

A key step would be integrating urban healthcare centers currently managed by the Ministry of Local Government, Rural Development, and Cooperatives into the National Health Service (NHS) framework. 

Non-governmental organizations (NGOs) and the private sector played an important role in improving many of the primary healthcare indicators in the country. A collaborative partnership between the public and private sectors is needed to strengthen primary healthcare services throughout the country. 

The focus must remain on promoting preventive care and ensuring access to essential health services, particularly for children, adolescent girls, women of reproductive age, and marginalised communities.

Preventive healthcare should begin early, ideally in schools. Adding health education to school curriculums can promote lifelong habits of physical activity and healthy living. Schools and madrasas should also provide nutritious meals to improve student nutrition. This approach will enhance health outcomes and reduce the risk of malnutrition and nutrition-related diseases like obesity, diabetes, and hypertension. In Bangladesh, 14% of adults are diabetic, and 29% have hypertension. 

To address the rising rates of these conditions, policies should limit the consumption of processed foods, sugary drinks, and excess salt, supported by public awareness campaigns and regulations. The commission should make specific recommendations on these issues.

Regulation of the private sector and pharmaceutical industries

During the fascist regime, several medical colleges were established based on political considerations. Businessmen and political leaders were granted licenses to open medical colleges without meeting the necessary standards. 

Many of these institutions lack adequate staff and proper infrastructure and fail to deliver quality medical education. This issue also affects many newly established public medical colleges. It is crucial to assess the performance of all public and private medical colleges in the country. 

Substandard and unnecessary medical colleges and hospitals should be shut down immediately. Additionally, stronger regulations are needed for the private healthcare sector, including clinics, diagnostic centers, and pharmaceutical industries. The private sector should focus on patient care rather than just making immediate profits.

In my opinion, integrating the Directorate General of Drug Administration (DGDA) into the proposed National Health System (NHS) is vital, as medicines are a cornerstone of healthcare. 

The government should use the growing pharmaceutical industry to provide essential and costly medicines free of charge to patients. It must also ensure medicine quality, eliminate substandard companies, regulate the prices of life-saving drugs, and address antimicrobial resistance (AMR). AMR, caused by the overuse and misuse of antibiotics, worsens health outcomes and increases healthcare costs. To tackle AMR, strict laws against selling antibiotics without a prescription should be enforced.

Sketch: TBS

Shah Mohammad Fahim is a physician and Associate Scientist at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). He is currently pursuing his PhD at Cornell University, NY, USA. Fahim is the author of the book "Kolpo Daktar" and has published 65 scientific articles in peer-reviewed international journals including The American Journal of Clinical Nutrition, The American Journal of Tropical Medicine and Hygiene, The Journal of Infectious Diseases, PLoS Neglected Tropical Diseases, Public Health Nutrition, and The New England Journal of Medicine.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard.