Ensuring equitable healthcare: Policy reforms and individual responsibility

Ever since the Covid-19 pandemic broke out, the faults in our healthcare system are taking the centre stage of the country's popular discourse. The dengue epidemic of 2019 also exposed the vulnerabilities of the health service structure, making the populace look for novel solutions. Luckily, comprehensible plans for the reformation of the health financing system have already been proposed in our country. 

The Social Health Protection Scheme (SHPS) has been at the forefront of our attempt to reorganise the country's health service financing for almost a decade. It will contain a national programme with one pool and one package. 

It will primarily focus on people below the poverty line and the people working in the formal sector, as these portions of the population were either in dire need of assistance or easier to organise and coordinate. Along with determining other institutional arrangements, the SHPS requires the formation of a 'health equity fund'. 

It will be an autonomous institution, charged with receiving funds and financing SHPS and other government intervention programmes. An important part of the SHPS will be Shyastho Surokkha Karmasuchi (SSK), a completely government-funded financial protection scheme for the poorest of the citizens. 

Even though participants of the formal sector will contribute to the SHPS through payroll taxes and employer funding, primary and preventive care will remain free of cost for every part of the populace. But it is also crucial to accommodate 87% of the labour force that works in the informal sector of our country. 

Even though the government is committed to expanding SHPS coverage to all people, it will create community-based insurances or micro-insurances for the informal sector. Needless to say, this initiative not only requires a revolutionary political and strategic commitment but also demands a huge reallocation of resources. As a result, with the exception of pilot SSK programmes in three Upazilas, the plan was never implemented.

But other initiatives can also be taken to increase efficiency and increase equity. Publicly funded health insurance schemes like the SHPS are especially effective for the latter. It largely depends on two basic mechanisms: resource pooling and risk-sharing. 

To obtain health insurance schemes in our country, individuals need to pay a premium each year on an annual, bi-annual, quarterly or monthly basis. Of course, in the case of publicly funded insurance or single-payer insurance, the government contributes a significant portion of the premium if not the entirety of it. 

This accumulated resource is then shared among everyone covered by the programme, distributing the risk equally. Most people covered by the insurance will most likely remain healthy and will not incur significant medical expenses in a given year. So when some of the people under the scheme get sick, their expenses will be covered by the shared pool of resources, reducing the risk of financial doom for everyone. 

As a single-payer system is unlikely to be implemented in the near future, it is important that people take responsibility for their own financial actions to avoid catastrophic health payments. One of the ways for avoiding impoverishment due to healthcare spending is to acquire a health insurance scheme, which operates under the same basic principles stated previously. 

Companies like MetLife Insurance, Bangladesh General Insurance Company Ltd, Agrani Insurance, Pragati Insurance, and Green Delta Insurance Company provide health insurance for households. But most of these schemes are focused on basic packages and specialised packages for severe and chronic diseases are rare. 

Illustration: TBS

It also should be noted that insurance companies tend to favour younger customers. As young adults are less likely to get sick, they are often charged less for their premiums to more effectively share financial risk. Therefore, it is beneficial to sign up for health insurances as soon as feasible. 

But this is a relatively new field in Bangladesh. About 2% of the population is covered by insurance schemes. There is a reluctance on the side of the companies too. Among the 44 insurance companies, only 14 offer health insurances. 

Most of these are offered for a large group of people and not individual households. Even though most of the population can not afford this, the ratio is certainly more than 2%. Then why are people not taking these schemes?

Researchers have noted a lack of trust between the financial and healthcare apparatus of the country and its general populace. Due to a general lack of accountability and transparency in the system, the people do not trust the financial institutions with their savings, instead opting for paying out of pocket. Another reason for the lack of health coverage is that employers in our country are not mandated to provide health benefits for their employees by law.

Another important issue for the improvement of healthcare services is increasing efficiency and transparency. The Ministry of Health and Family Welfare has to assume the role of steward, promoter, provider, contractor, and regulator. 

It should develop ethical standards for health service delivery, ensure patients' charter of rights, form legal and regulatory norms, develop standard treatment guidelines and management protocols in collaboration with Bangladesh Medical Association and Bangladesh Diploma Medical Association and proactively promote the case for sufficient resources in the healthcare sector. To achieve the last objective, the ministry can pull resources from unusual sectors like public donations and fundraisings, zakat, and fitrah. 

The Bangladesh government plays the role of both provider and purchaser. It purchases health products and provides healthcare for the citizens. Dividing these two roles and playing only the role of the purchaser will make the process more efficient. 

This will require an increase in autonomy for healthcare facilities, which will make sure that the providers are managing their operations in the most cost-effective way. The facilities should be allowed to retain revenues from fees and hire and fire their staff. 

Resource allocation and production should be linked with population and performance, which will require need-based local level budgeting and planning, decentralisation of budget and development of financial management capabilities at all sectors. 

The government should also enter into public-private partnerships for the supply of medical equipment and medicines. It should also incentivise people to be trained nurses and technicians by providing financial assistance subsidies and scholarships. All of these changes will necessitate increased monitoring and evaluation capacity through expenditure tracking, ensuring maximum accountability and clarity.

All of these processes are time and resource-intensive, yet necessary. The catastrophic trend of rising out-of-pocket expenditure is pushing six million people below the poverty line each year, and it will continue to increase with the economic growth. 

So it is necessary to take individual responsibility and secure one's financial status. More people should look into the possibility of acquiring private health insurance schemes to reduce their financial burden. It will not only ensure financial security but also take some pressure off the government and allow them to restructure the health financing system to ensure equal access for everyone. 

The author is an Economics student from University of Dhaka.

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