The systemic failures plaguing the healthcare sector in Bangladesh

Since the first five-year plan following independence, the public healthcare system has grown. Yet, the 2022 Household Income and Expenditure Survey reveals that fewer than 15% of patients use public healthcare services. The current state of public healthcare facilities offers little promise of progress, largely due to policymakers' poor grasp of the sector. The intricate, dynamic nature of healthcare is often overlooked, with officials treating it like any other field. 

This stems from a mix of ignorance, self-interest, and a propensity for corruption. As a result, medical education institutions and healthcare facilities struggle to train skilled professionals, procure equipment, and secure adequate funding. Excessive bureaucracy further hampers efforts to foster supportive work environments. 

The most effective way to deliver healthcare is through government-funded facilities, while the least effective method is depending on out-of-pocket payments at private healthcare facilities. Alternative approaches, such as the Public-Private Partnership (PPP) model—where private entities manage public healthcare facilities with government funding—and the Strategic Purchasing (SP) model—where the state buys services from private providers for public use—offer potential solutions. However, their application in Bangladesh remains limited. 

Creating a robust, independent institution to oversee fair contracts with local organisations could enhance healthcare access through PPP and SP models, though their success in Bangladesh remains uncertain. 
  
In the government sector, promotions and benefits disproportionately favour the officials of certain cadres, widening gaps between medical professionals and those cadres. This diminishes the value of the medical profession in the public's eyes, and when a profession loses esteem, expecting top-tier services becomes unrealistic. 

Financial incentives have increasingly driven the medical community, mirroring trends in other fields, while pharmaceutical companies and diagnostic centres entice with lucrative offers. Politics, too, has shifted focus from individual merit to partisan loyalty, throwing the public healthcare system into disarray. 
 
Decades of weak rule of law have fuelled moral decline, selfishness, and widespread corruption. As the pursuit of extra income grips the nation, corruption has taken root in hospitals, health offices, and agencies like the Essential Drug Company Ltd. (EDCL), Central Medical Stores Depot (CMSD), Public Works Department (PWD), and Health Engineering Department (HED). A "do nothing" culture has also become entrenched in government offices.  

For example, a small-scale PPP for dialysis services at the National Kidney Disease and Urology Institute and Chittagong Medical College Hospital, introduced over a decade ago, has raised doubts about its contractual integrity and impact. Similarly, during the Covid-19 pandemic, strategic purchasing for testing and treatment of Covid-19 patients was marred by misuse and scandals.

Overcoming these challenges demands visionary, selfless leadership. If the "Health Reforms Commission" can pinpoint the root causes and propose effective solutions—and if present and future governments act on them—there is hope. I leave this to the future.  

Consequently, the private healthcare sector has emerged as the last resort for healthcare access in Bangladesh. Over the past five decades, it has expanded unchecked, now dominating nearly three-quarters of the system—far beyond the oversight of the Directorate General of Health Services (DGHS). 

Many officials tasked with regulating this sector are entangled in it, leading to lax supervision. Most private hospitals fail to deliver quality or safe care, despite the costs patients bear. Rather than a boon, the private sector has become a burden, pushing many to seek treatment abroad. Without improvement, this reliance on foreign care will grow, even for basic services, posing risks to public health, the economy, and national security.
  
The government has yet to establish an accreditation body to ensure healthcare quality and patient safety. Even if one is created, it risks being ineffective due to limited autonomy, capacity, and expertise—much like other institutions such as the "Quality Improvement Secretariat". This was set up to enhance healthcare standards, but its impact is doubtful due to similar constraints.
  
Furthermore, healthcare facilities are not required to seek approval from international accreditation bodies. While some elite private hospitals voluntarily pursue certification from organisations like Joint Commission International (JCI) or DNV Healthcare, most do not. 
 
In essence, the private healthcare sector is also shrouded in darkness. Yet, we must rise above this and chart a course toward light. A robust social enterprise (i.e., a not-for-profit entity) is needed to elevate healthcare quality in the private sector. 

This entity would work with stakeholders nationwide to establish and enforce quality standards, ensure patient safety, and serve as an accreditation body. It would also promote better health seeking behaviour and healthier lifestyles among communities, and fund healthcare for low-income groups through its own resources, crowdfunding, and philanthropy. Crucially, it would push for indemnity insurance to protect healthcare professionals from unintended errors. 

This enterprise will support private hospitals and train their workforce, build a referral network, and implement a unified "Standard Operating Procedure (SOP)" for quality care and safety. As more hospitals join, their reputation will grow, inspiring others to follow. If successful, this initiative could transform private healthcare quality and pave the way for strategic purchasing systems to benefit low-income families in the future.

It's worth noting that a similar idea I put forward, published in the 24 January 2024 edition of Prothom Alo under the title "Which Path for Bangladesh's Health Sector," led to a discussion with the chairman of a well-known non-profit healthcare network in Bangladesh. He remarked, "Golden stone bowls never appear," prompting deeper reflection that shaped the concept above. That conversation also bolstered my belief in establishing such a social enterprise. 

I am convinced that, with collective effort, this social enterprise can take root. I urge confident, courageous, honest, skilled, and dedicated citizens to join me in building it and illuminating the path from darkness to light.  

Dr Syed Abdul Hamid is a professor at the Institute of Health Economics, University of Dhaka. 

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.