51 years of independence: State of our public health

We have reached 51 years of the declaration of our independence with great pride. Throughout the decades we have achieved a lot of our rights which we had fought for. From rights to speech to living independently in all spheres of life, reducing social inequality and advancing human rights for creating a society with equity was the vision of our independence. Among many of our expectations, quality and equality in health service is a crucial one. 

Our healthcare situation has significantly improved over the past 50 years. We have achieved growth in average lifespan from less than 50 to above 70 years, thanks to increasing access to healthcare, increasing the number of hospitals and community clinics in the rural areas, reducing mortality rate, dropping child and maternal mortality, success in fighting tuberculosis, malaria, and diarrhea, smallpox, polio, rubeola and many more. 

A report by Institute of Epidemiology, Disease Control and Research (IEDCR) in 2019 found that after liberation our child mortality rate dropped from 221 deaths per 1000 live-births in 1972 to 38 deaths per 1000 live-births in recent years. It has also shown impressive improvements in population health status by achieving United Nations Millennium Development Goal (MDG) 4 by reducing child deaths before the 2015 target. 

Though the death rate is declining, Bangladesh still is far behind in ending preventable deaths of newborns and under-five children to achieve the Sustainable Development Goal (SDG) 3.2. Despite decreasing of emerging infectious diseases, other non-communicable diseases like cancer,  lower respiratory infections, chronic obstructive pulmonary disease, ischemic heart disease, stroke, preterm birth complications, tuberculosis, neonatal encephalopathy, diabetes, and cirrhosis have been the major causes of death in Bangladesh, according to the Center for Disease Control (CDC).

Our healthcare system has indeed been significantly improved over the five decades, yet, quality and equality in healthcare is yet to be achieved which is another goal in SDG 2030. Health inequalities due to socioeconomic inequalities in our country have been revealed several ways, several times and the population of Bangladesh experiences discernable differences in health and longevity due to socioeconomic status differences. 

It has affected people of poorer socioeconomic backgrounds, living in deprived locations both in the rural and urban areas, minority ethnic groups, and vulnerable groups of the society suffering the full force of unequal distribution of healthcare. In the past two years, the coronavirus pandemic has also confirmed the prevailing health inequalities in our country, even though Covid-19 has impacted every person, group, and community. But the impact has been different on different social classes. 

For communities who experience vulnerability and marginalization, the challenges have been aggravated even further by the pandemic. According to a report of Leave No One Behind (LNOB) Network, people belonging to ethnic minority and sex workers faced discrimination at public hospitals during the peak period of the pandemic.

Our country is also critically suffering from both a shortage of health workers and disproportionate distribution of hospitals and health service institutions. Here, we get only six doctors and four nurses per 10,000 patients, an extremely low ratio. In the early years of independence, the healthcare system in Bangladesh concentrated largely on the health service requirements of rural areas. The first Five-Year-Plan (1973- 78) emphasised on building a network of health facilities establishing a hospital in every district, accompanied by a Maternal and Child Welfare Centre (MCWC), and an Upazila Health Complex (UHC) in every Upazila. 

51 years later, 70 percent of our population still resides in rural areas and the rest in the  cities. Yet, the healthcare sector is heavily concentrated in Dhaka. The rural people are deprived of quality health, as defined by the World Health Organisation (WHO). The treatment and medicine facilities in the government hospitals and community hospitals are also mostly in the peripheral areas. 

As a result, people are rushing to metropolitan areas for treatment and the hospitals are struggling to accommodate the patients and provide services. According to the quality healthcare ranking by WHO, Bangladesh ranked 88th, which is better than any of the SAARC countries, and even better than India, which is ranked at 112. Bangladeshi patients still spend two billion dollars a year in India for medical treatment.

The health financing system in Bangladesh is quite underfunded in the proportion of the need of an increasing population and demand and modernization. In terms of healthcare financing policies, Bangladesh follows a combination of general revenue taxation, the donation from development partner countries, and comprehensively depends on the 'out of pocket-payment' (OOP) system. The funding for mental health is even less effective, with the mental health expenses being only 0.44 percent of the total health budget. The same is true for adolescent healthcare, which is yet to be introduced in the national healthcare budget.

Although public health care expenditure in Bangladesh has significant focus on benefiting poorer people, it is not distributed fairly in accordance with the needs of the citizens of all classes. Since poorer people tend to suffer more from health problems, they have a greater need for healthcare. Additionally, we see that lower socioeconomic status is associated with higher mortality compared to others of high socioeconomic status. 

The socio-economic class differences in getting treatment have increased over the past decades after independence. There is substantial evidence regarding racial/ethnic and socioeconomic inequalities in health-related behaviours, health status. The economic growth in our country is also not fully inclusive to all classes and income groups of people, which has an impact on the health status as well. In the absence of socially inclusive support packages and protection, the rapid economic growth has made the marginalized groups permanently poor. 

The healthcare system in the country still lacks availability, equality and reliability. It has also been proven to lack affordability, particularly in the wake of Covid-19. The pandemic exposed many gaps in our healthcare system, including poor governance and monitoring system, corruption, inadequate healthcare facilities, and poor public health communications. 

The health sector, nevertheless, has a huge potential for growth but for this to happen, measures should be taken through policy to overcome the obstacles and loopholes. The immediate need, however, is to improve the quality of healthcare in Bangladesh for all classes of citizens. 

The Government of Bangladesh has a plan to introduce a public health card system along with a coalition with NGOs working in the rural areas and vulnerable groups that would be inclusive of  marginalized groups, enabling them to access community healthcare services. If the government succeeds in implementing this system, that would represent a major improvement in  accessibility of public health.

Additionally, the budget allotted for the sector should be adequate. Stopping the misuse of the allocated resources is also important. Increasing the number of secondary, and tertiary hospitals, supported by the necessary number of doctors and nurses, well-equipped intensive care units in all hospitals at the district and upazila-level remain vital. 

Offering incentives to the healthcare workers willing to work in remote and rural areas, or with marginalized groups can be a very effective tool for achieving decentralisation. Other steps necessary for a modern system include introducing patient referral system through digital communication and connectivity in primary, secondary and tertiary hospitals, ensuring health care insurance system for all citizens and finally, monitoring and evaluating the healthcare system centrally to prevent corruption and establishing robust service. 

We also need to encourage people to seek medical treatment in government hospitals. But to attract patients, these facilities need to have skilled doctors, equipment, diagnostic facilities, healthier and patient-friendly environments.  

Initiatives also should be taken toward foreign partnerships, with the health authorities actively encouraging foreign investment with ain to modernize our hospitals. The government should also consider announcing an inclusive social package during any unstable socio-economic situation and environmental disasters. Overall, Bangladesh must aim for a better score on the healthcare index and do whatever it is necessary to achieve this. 

Professor Dr AHM Amanullah is a Sociologist and Public Health Researcher at the Department of Sociology, University of Dhaka. 

Laboni Khatun is a development worker and MPhil Researcher, Department of Sociology, University of Dhaka.