Health budget is poor but capacity to utilise it is even poorer

The current fight with the Covid-19 has brought the vital but neglected poor health sector to the frontline to save the country.

With an allocation of less than 1% of the national GDP, and very few recruitments of nurses and technicians over the years, the health sector was never in a position to face a catastrophic event like the ongoing Covid-19 pandemic.

Even though, over the last ten years, the allocation in the sector has gone up in the national budget in terms of money, it has actually gone down in terms of percentage, below 5 percent, of the national budget over the same time span.

While Officials of the finance ministry agreed that budgetary allocation for the health sector in Bangladesh is relatively lower when compared to other countries, "But the health ministry fails to utilise whatever allocation it gets."

In Bangladesh, the budgetary allocation in the health sector is equivalent to a paltry 0.9 percent of the country's GDP. The government in its 7^th five-year plan has set a target to raise this allocation to 1.12 percent of the GDP.

The size of the national budget in 2010 was Tk1,32,170 crore. The health ministry was allocated Tk7,617 crore, which was 5.76 percent of the total budget for that year. In the current fiscal, the ministry has been allocated Tk25,732 crore, which is 4.92 percent of the Tk5,23,190 crore budget.

Meanwhile, finance ministry officials said a big portion of the budget allocation for the health sector is used in non-development sectors, including paying wages and the bulk of the allocation for development sectors is used in building infrastructures and purchases.

The allocation in the main budget for the health sector in the current financial year was Tk25,732 crore. Of this amount, Tk11,110.22 crore was included in the ADP, the rest was allocated for non-development or operational expenses. That means about 43 percent of the budget was earmarked for development and about 57 percent was allocated to operational expenses.

The health ministry and the health directorate have been slow in recruiting staffers, especially nurses and technicians, the finance ministry officials said. No technicians have been appointed to government health institutions after 2013.

Sources at the finance ministry and the health ministry say that in the nine months of the current financial year, two departments of the Health and Family Welfare Ministry could only spend a little less than 26 percent of the allocated budget.

In the revised ADP, the two departments, health services and health education and family welfare, were allocated a budget of Tk12,266.82 crore. In the current fiscal year, the two departments could spend Tk3,234.9 crore in the nine months until March.

However, the World Health Organisation recommends allocating 15 percent of a country's total budget and 5 percent of its gross domestic product (GDP) to its health sector.

According to the WHO information, Bangladesh is trailing behind all other South Asian countries in government expenditure per capita in the health sector. The per capita government expenditure in Bangladesh is $88. Pakistan is right ahead of Bangladesh with $129 while India spends $267. The Maldives spends about $2,000 and is in the top position among the South Asian countries. Sri Lanka spends $369 per capita for its people's health.

Fahmida Khatun, executive director of the Centre for Policy Dialogue, said Bangladesh needs to raise its health sector financing to 1.5-2 percent of the country's GDP. In India, budgetary allocation for the health sector is equivalent to 2 percent of the country's GDP.

Health Minister Zahid Maleque, however, thinks that the budgetary allocation for the health sector in Bangladesh is adequate. 

While talking to The Business Standard yesterday, the health minister claimed that the country's health sector did not have any noteworthy loose end. However, the healthcare sector is facing some new challenges due to the coronavirus, he said, adding that the government is taking necessary preparation so that it can face bigger challenges in future.

"The health sector in the country gets a bigger allocation than many other sectors. Because of the coronavirus situation, the allocation is going to be raised further this year. The prime minister has already issued a directive in this regard," the health minister added.

Minister Zahid Maleque also denied the allegations regarding the ministry's failure to make proper use of the budgetary allocation. He claimed the allocations are being properly utilised and projects are being implemented maintaining standard quality.

"If you look at the implementation of the government initiatives to face the coronavirus, you will find that we are capable of utilising allocations by maintaining quality," he said.

The health policy also recommended forming a national health council under the leadership of the prime minister. Although a 44-member council was formed in 2013, it has remained completely dysfunctional.

The health ministry had announced a 100-day programme in January this year. In that programme, the ministry revealed that among a total of 1,42,810 approved posts in the health division and its subsidiary institutions, some 31,745 were falling vacant.

The government recruited some 6,500 doctors in two phases and 5,000 nurses before the coronavirus outbreak. Therefore, more than 20,000 posts are still vacant.

The health minister said they are working to recruit some 5,000 medical technicians on a priority basis. 

Asked if the ministry has capacity to implement an increased allocation, Additional Secretary (development sub-division) to the health ministry Saidur Rahman told The Business Standard, "If the allocation is increased, it has to be raised in phases. Allocations need to be raised after scrutinising the capability of those who are involved in implementing the allocations."

In various cases, buildings and machineries are kept idle due to shortage of manpower, he pointed out, adding, "We are now finding out such hospitals where projects have been handed over, but the projects are not operating due to manpower shortage. We will take initiative to recruit officials in those institutions.

Commenting on some misconceptions of low budget allocation in the health sector, Mohammad Tareque, ex-finance secretary told The Business Standard, health sector financing in Bangladesh is not just one percent of the GDP. It will be above 3 percent if all other relevant aspects of healthcare are taken together in consideration which we often miss while talking about the health budget, he claimed.

"There is a popular demand for raising the health sector budget to 2 percent or 4 percent of the GDP. In most cases, these demands are a misunderstanding about what 'health' and the 'health sector' stand for," he continued, "Moreover, budget allocation to a particular ministry or division depends on the government's revenue earnings, borrowing capability, and also, it hinges upon the resource utilisation capacity of the respective ministry and/or division. The government always functions under budget constraints."

"When we talk about healthcare, we have to cover social wellbeing, mental wellbeing in addition to physical well-being. We will also have to cover preventive and promotive healthcare as well. The health sector involves a much broader area than what we see the health ministry covering," he explained.