Universal Health Coverage needs more than a bigger budget. It needs institutions and skills

As the nation is heading towards its 13th national election, the long queue of people's demands is lining up behind all the competitive political parties. Health sector experts are also sharing their demands across various platforms, and one common question that has repeatedly been raised and debated is what strategy the newly elected government will adopt to achieve Universal Health Coverage (UHC) by 2032. The question for the next government is not just whether they support UHC by 2032, but whether they have the political will to fund it. Currently, Bangladesh operates one of the most privatized health systems in the world-not by design, but by default. With public health spending remaining stagnant at a mere 0.74% to 0.8% of GDP and households covering nearly 73% of the costs, we have created a system where getting sick and hospitalized often means getting poor.

UHC is often mistaken for a charitable ideal. In reality, it is hard economics. A nation cannot sustain its middle-income ascent when-according to the Health Economics Unit, over 6 million of its citizens are pushed into poverty annually by medical bills. This is a massive drain on our already constrained economic resources. The consequences of this financing gap are most visible in the medicine market. In a recent roundtable at The Business Standard, experts noted that while the government spends roughly Tk 2,200 crore on medicines, households spend nearly Tk 38,000 crore out of pocket. This 67-70% out-of-pocket reliance is an anomaly even in South Asia. By comparison, our neighbors like Sri Lanka and even India have managed to secure higher public financing shares in healthcare and now shield their populations from the worst of these shocks.

Photo: TBS

While our financing model in healthcare requires modernisation, our disease burden has fast-forwarded to the future. The recently released Health and Morbidity Status Survey (HMSS) 2025 paints a worrying picture of a workforce in decline. Hypertension now affects 78 per 1,000 respondents, followed closely by peptic ulcers (64) and diabetes (43).

As a consequence, what we are seeing now is a shift from infectious deaths to productivity deaths. Non-communicable diseases (NCDs) now account for two-thirds of all deaths, but we still manage to allocate only about 4.2% of total health budget to their prevention. What we need is a paradigm shift to move our focus from a traditional curative-based model to preventive care to keep our doctors' hard, long-shift efforts sustainable. The tradition of visiting a tertiary hospital with late-stage diabetes or heart disease must change; treating these conditions is always exponentially more expensive than managing them at the primary level, if only the primary level existed where it is needed most.

To realistically move toward Universal Health Coverage, the next government must abandon our long-loved incremental copy-paste budgeting format and pursue interconnected structural reforms. 

The most crucial inequality in our health system is the penalty we pay to be an urban citizen. While rural Bangladesh relies on a structured tier of 14,000+ Community Clinics, our cities suffer from a void in public primary health care. The garment worker in Gazipur or the rickshaw puller in Mirpur has virtually no safety net, if they get sick and out of the work for a few days. Urban health, therefore, is crucial to consider. With more than 40% of the population now living in cities and a large proportion in informal settlements, functional primary health centers, referral systems, and emergency transport support for the urban people are a must. Pilot health cards or insurance schemes for the urban poor, combined with stronger urban health information systems, could significantly reduce these inequities and improve planning.

Public financing for health needs to increase substantially and predictably. With spending remaining below 3 percent of GDP, reducing out of pocket payments and protecting families from catastrophic health costs will remain out of reach. Aligning national targets with the World Health Organization's recommendation of allocating at least 5 percent of GDP to health, with a gradual move toward 6 to 8 percent, is essential. Equally important is increasing the government's share of total health expenditure.

However, money alone is not the cure. Higher budgets will fail to deliver UHC unless they are deployed by a capable workforce and managed through transparent systems. This underscores the necessity of  deep institutional reforms to decouple the Ministry's regulatory mandate from its service delivery functions to ensure public and private providers alike face the same rigorous standards. As long as the Ministry acts as both player and referee, inherent conflicts of interest will continue to shield public inefficiency from scrutiny while leaving the booming private sector without effective oversight. 
Along with institutional reforms, human resources for health require urgent attention. Bangladesh's chronic shortage of doctors, nurses, and midwives, especially outside major cities-undermines both service quality and equity. Addressing this crisis will require not only recruitment but also better deployment, incentives, and retention strategies to ensure health workers are actually available where they are most needed, rather than concentrated solely in urban centers.

We also need to modernize our procurement systems. To prevent wastage, the government must enforce e-procurement and real-time tracking of medicine stocks and expenditures. Furthermore, the gradual introduction of a unified electronic medical record system is essential to ensure patient data drives medical decision making.

Finally, achieving UHC will require stronger investment in research. Allocating a meaningful share of the health budget to research, institutionalizing policy–research units within the Ministry, and fostering regular dialogue between researchers and decision-makers would help ensure that policies are grounded in evidence rather than intuition. Importantly, incentives should reward research that demonstrably informs policies, guidelines, and programs, not just publication counts.

Though the situation may appear bleak, there are still reasons for hope. According to the World Economic Forum's Global Gender Gap Index 2025, Bangladesh ranked 24th globally, leading South Asia with a 77.5% gender parity score. The country has demonstrated notable progress, particularly in political empowerment and education, and remains the only South Asian nation within the global top 50. This achievement offers an important reminder that sustained policy commitment and strategic investment can deliver tangible results. Drawing pride and confidence from this progress, Bangladesh now has an opportunity to apply the same ambition and political will to the health sector, advancing steadily toward a more equitable, inclusive, and people-centered health system in the journey toward Universal Health Coverage.