Health Systems in Transition

Vol. 5 No. 3 2015

Bangladesh Health System Review

Health Systems in Transition Vol. 5 No. 3 2015

Bangladesh Health System Review

Written by:
Syed Masud Ahmed, icddr,b and JPGSPH
Bushra Binte Alam, World Bank
Iqbal Anwar, icddr,b
Tahmina Begum, World Bank
Rumana Huque, Dhaka University
Jahangir AM Khan, icddr,b
Herfina Nababan, JPGSPH
Ferdaus Arfina Osman, Dhaka University

Edited by:
Aliya Naheed, icddr,b; Nossal Institute for Global Health, University of Melborne
Krishna Hort, Nossal Institute for Global Health, University of Melborne

Asia Pacific Observatory on Public Health Systems and Policies

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WHO Library Cataloguing-in-Publication Data

Bangladesh health system review
(Health Systems in Transition, Vol. 5 No. 3 2015)

1. Delivery of healthcare. 2. Health care economics and organization. 3. Health care reform. 5. Health
system plans – organization and administration. 7. Bangladesh. I. Asia Pacific Observatory on Health
Systems and Policies. II. World Health Organization Regional Office for the Western Pacific.

ISBN 978 92 9061 705 1 (NLM Classification: WA 540 JB2)

© World Health Organization 2015

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The named authors alone are responsible for the views expressed in this publication.

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Contents

Preface................................................................................................................. viii

Acknowledgements.............................................................................................. x

List of abbreviations............................................................................................ xi

Abstract................................................................................................................ xvi

Executive summary.......................................................................................... xvii

1 Introduction.................................................................................................. 1
Chapter summary.................................................................................................. 1
1.1 Geography and demography. ..................................................................... 1
1.2 Socioeconomic context................................................................................ 3
1.3 Political context............................................................................................ 5
1.4 Health status................................................................................................. 6

2 Organization and governance ................................................................ 24

Chapter summary................................................................................................ 24
2.1 Overview of the health system................................................................. 25
2.2 Historical background............................................................................... 27
2.3 Health system organization in Bangladesh........................................... 29
2.5 Planning ...................................................................................................... 36
2.6 Intersectorality. .......................................................................................... 38
2.7 Health information management............................................................ 39
2.8 Regulation................................................................................................... 42
2.9 Patient empowerment and accountability............................................. 48

3 Financing..................................................................................................... 54
Chapter summary ............................................................................................... 54
3.1 Health expenditure . .................................................................................. 55
3.2 Sources of revenue and financial flows ................................................. 61
3.3 Overview of the statutory financing system ........................................ 66
3.4 Out-of-pocket payments .......................................................................... 70
3.5 Private (Voluntary) health insurance. ..................................................... 73
3.6 Other financing........................................................................................... 76
3.7 Payment mechanisms .............................................................................. 78

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4 Physical and human resources. ............................................................. 82
Chapter summary................................................................................................ 82
4.1 Physical resources..................................................................................... 83
4.2 Human resources....................................................................................... 90

5 Provision of services............................................................................... 102

Chapter summary.............................................................................................. 102
5.1 Public health............................................................................................. 103
5.2 Patient pathways ..................................................................................... 109
5.3 Primary/ambulatory care. ...................................................................... 110
5.4 Inpatient care............................................................................................ 113
5.5 Emergency care........................................................................................ 114
5.6 Pharmaceutical care. .............................................................................. 115
5.7 Rehabilitation/intermediate care. ......................................................... 118
5.8 Long-term care. ....................................................................................... 119
5.9 Services for informal carers................................................................... 119
5.10 Palliative care. .......................................................................................... 120
5.11 Mental health care................................................................................... 120
5.12 Dental care................................................................................................ 122
5.13 Complementary and Alternative Medicine (CAM) and Traditional
Medicine..................................................................................................... 123
5.14 Health services for specific populations.............................................. 123

6 Principal health reforms. ...................................................................... 125

Chapter summary.............................................................................................. 125
6.1 Analysis of recent major reforms in Bangladesh............................... 126
6.2 Future developments............................................................................... 141

7 Assessment of the health system........................................................ 142

Chapter summary.............................................................................................. 142
7.1 Stated objectives of the health system................................................. 143
7.2 Financial protection and equity in financing........................................ 145
7.3 User experience and equity of access to health care. ....................... 147
7.4 Health outcomes, health service outcomes and quality of care...... 148
7.5 Health system efficiency......................................................................... 152
7.6 Transparency and accountability........................................................... 153

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8 Conclusions. ............................................................................................. 154
8.1 Key findings............................................................................................... 154
8.2 The complexity of the mixed health systems and
poor governance....................................................................................... 154
8.3 Inadequacy of health resources and impact on quality of care........ 155
8.4 Inadequate and disproportionate health service coverage............... 156
8.5 Health-care financing through catastrophic OOPP
by households........................................................................................... 157
8.6 Inequitable access to health services hindering universal
health coverage........................................................................................ 158
8.7 Remaining challenges ............................................................................ 159
8.8 Future prospects...................................................................................... 161

9 Appendices. .............................................................................................. 163

9.1 References. ............................................................................................... 163
9.2 Further reading. ....................................................................................... 180
9.3 Useful websites........................................................................................ 180
9.4 HiT methodology and production process. .......................................... 180
9.5 About the authors. ................................................................................... 181

List of Figures
Figure 1.1 Map of Bangladesh....................................................................2
Figure 1.2 Maternal mortality ratio by timing of deaths.......................... 10
Figure 1.3 Trends in child mortality (NNMR, IMR, U5MR) 1989–2011..... 12
Figure 1.4 Noncommunicable disease mortality increases
over time in rural Bangladesh, 1987–2011............................. 15
Figure 1.5 Trends in road traffic accidents Bangladesh 1999–2008........ 18
Figure 1.6 Trends in child nutritional status 2004–2011.......................... 19
Figure 1.7 Trends in maternal CED and overweight 1996–2010.............. 19
Figure 2.1 Organization of the health system in Bangladesh.................. 27
Figure 2.2 Health service delivery organizational structure in
Bangladesh.............................................................................. 31
Figure 3.1 Total Health Expenditure as a share of GDP in
WHO SEA Region, 2007............................................................ 57
Figure 3.2 Trends in THE as a share of GDP in Bangladesh and
selected SEAR countries, 1997–2007...................................... 57
Figure 3.3 Health expenditure in US$ PPP per capita in the
WHO SEA Region, 2007............................................................ 58

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Figure 3.4 Public sector health expenditures as a share of THE
in the WHO SEAR, 2007........................................................... 59
Figure 3.5 Financial flow in the Bangladesh health system.................... 64
Figure 4.1 Population per bed in public sector (medical college
and secondary and tertiary care) hospitals in different
divisions of Bangladesh in 2012.............................................. 88
Figure 4.2 Bangladesh Medical and Dental Council (BMDC)
registered health workforce in 1997, 2007 and 2012.............. 92
Figure 4.3 Density of health-care providers per 10 000 populations....... 94
Figure 4.4 Rural-urban distribution of health-care providers
by type (per 10 000 populations).............................................. 95

List of Tables
Table 1.1 Trends in population/demographic indicators,
selected years..............................................................................3
Table 1.2 Macroeconomic indicators, 1970–2010, selected years.............5
Table 1.3 Mortality and health indicators ..................................................7
Table 1.4 Healthy Life Expectancy (HALE) different sources ....................8
Table 1.5 All age mortality rates for main causes of death, 1990–2010....9
Table 1.6 Morbidity and risk factors for health status, 1990 and 2010.... 16
Table 2.1 Main regulatory authorities in the health sector
in Bangladesh............................................................................ 44
Table 3.1 Trends in health expenditure in Bangladesh, 1997–2011......... 56
Table 3.2 Public health expenditure on health by service programme,
selected years............................................................................ 60
Table 3.3 Sources of revenue as a percentage of total expenditure on
health by financing agent, selected years, 1997–2007 ............ 61
Table 3.4 Health-care services provided by public facilities
in Bangladesh............................................................................ 67
Table 3.5 Households’ OOP by different providers, 1997–2007................ 71
Table 3.6 Households’ OOP by functions, 1997–2007............................... 72
Table 3.7 Provider payment mechanisms................................................ 78
Table 4.1 Distribution of beds in the public sector at upazila
(sub-district) level and below.................................................... 85
Table 4.2 Distribution of beds in the secondary and tertiary hospitals
by year........................................................................................ 86

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Table 4.3 Distribution of utilization (bed occupancy) of
public hospitals, 2010................................................................ 88
Table 4.4 Informal health-care providers at PHC level in Bangladesh ... 91
Table 4.5 Projected workforce per 10 000 populations based
on WHO recommended skill mix ratio and MOHFW
targeted skill mix ratio using 2007 data.................................... 95
Table 4.6 Annual production capacity of health workforce including
private sector as of 2013........................................................... 98
Table 4.7 Academic institutions for teaching and training alternative
medicine in Bangladesh............................................................ 99
Table 4.8 No. of seats for postgraduate courses offered by different
institutions (Health Bulletin 2013).......................................... 100
Table 4.9 No. of fellowship and membership awardees by year and
category (Health Bulletin 2012)............................................... 101
Table 5.1 Availability and functional status of ambulance (2011) ......... 114
Table 6.1 Recent reforms and the accompanying changes in
the health system.................................................................... 127
Table 7.1 Health indicators and their targets......................................... 144

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Preface

The Health Systems in Transition (HiT) profiles are country-based reports

that provide a detailed description of a health system and of policy
initiatives in progress or development. HiTs examine approaches to the
organization, financing and delivery of health services and the role of
the main actors in health systems; describe the institutional framework,
process, content and implementation of health and health-care policies;
and highlight challenges and areas that require more in-depth analysis.
HiT profiles seek to provide information to support policy-makers and
analysts in the development of health systems. They are building blocks
that can be used:
• to learn in detail about different approaches to the organization,
financing and delivery of health services and the role of the main
actors in health systems;
• to describe the institutional framework, the process, content and
implementation of health-care reform programmes;
• to highlight challenges and areas that require more in-depth analysis;
• to provide a tool for the dissemination of information on health
systems and the exchange of experiences of reform strategies between
policy-makers and analysts in different countries; and
• to assist other researchers with more in-depth comparative health
policy analysis.

Compiling the profiles poses a number of methodological problems.

In many countries, there is relatively little information available on the
health system and the impact of reforms. Due to the lack of a uniform
data source, quantitative data on health services is based on a number
of different sources, including the World Health Organization (WHO),
national statistical offices, the Organization for Economic Co-operation
and Development (OECD) health data, the International Monetary Fund
(IMF), the World Bank, and any other sources considered useful by the
authors. Data collection methods and definitions sometimes vary, but
typically are consistent within each separate series.

viii
The HiT profiles can be used to inform policy-makers about experiences
in other countries that may be relevant to their own national situation.
These profiles can also be used to inform comparative analyses of health
systems. This series is an ongoing initiative and material is updated at
regular intervals. In-between the complete renewals of a HiT, the APO
has put in place a mechanism to update sections of the published HiTs,
which are called the “Living HiTs” series. This approach of regularly
updating a country’s HiT ensures its continued relevance to the member
countries of the region.

Comments and suggestions for the further development and

improvement of the HiT series are most welcome and can be sent to
apobservatory@WHO.who.int. HiT profiles and HiT summaries for Asia
Pacific countries are available on the Observatory’s website at http://
www.WHO.who.int/asia_pacific_observatory/en/.

ix
Acknowledgements

The Health Systems in Transition (HiT) profile on Bangladesh was written

by a team of authors led by Dr Syed Masud Ahmed from icddr,b and the
James P Grant School of Population Health (JPGSPH). The team included
authors from icddr,b, the World Bank, Dhaka University and the JPGSPH.
It was edited by Krishna Hort (Nossal Institute for Global Health) and Aliya
Naheed (icddr,b).The Asia Pacific Observatory is a partnership between
governments, development agencies and the research community that
works to link systematic and scientific analysis of health systems with
the decision-makers who shape policy and practice. The authors thank
the support and guidance provided by Dale Huntington, Director of the
Asia Pacific Observatory on Health Systems and Policies at key stages of
the HiT development. Thanks are also due to national statistical offices
that have provided data. The HiT profile reflects data available as of
October 2013.

The Authors would like to express their gratitude to the following for their
contributions:

Co-authors: Kuhel Islam, JPGSPH; Rashidul Alam Mahumud, icddr,b;

Kawkab Mahmud, JPGSPH; Shabnam Mostari (JPGSPH); Arshee Rahman
(World Bank); Nasima Selim, Senior Lecturer (on study leave for PhD),
JPGSPH.

Supported by: Abbas Bhuiya (icddr,b); Sadia A. Chowdhury (JPGSPH);

Timothy G. Evans (World Bank); Sabina F. Rashid (JPGSPH) and
Md. Abdus Sabur (Independent consultant).

Peer Reviewers on behalf of the Asia Pacific Observatory on Health

Systems and Policies:

Mushtaque R. Chowdhury, Vice Chair and Executive Director (a.i.),

Bangladesh Rural Advancement Committee (BRAC)

Indrani Gupta, Indian Institute of Economic Growth

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List of abbreviations

ADB Asian Development Bank

ADP Annual Development Programme
ADP Annual Development Plan
ALOS average length of stay [in hospitals]
APPs alternative private providers
ARI acute respiratory infection
BAMWSP Bangladesh Arsenic-Mitigation Water Supply Project
BBS Bangladesh Bureau of Statistics
BCC behavioural change communication
BCDS Bangladesh Chemist and Druggist Samity
BCG Bacillus Calmette–Guérin
BCPS Bangladesh College of Physicians and Surgeons
BDHS Bangladesh Demographic and Health Survey
BDS Bachelor of Dental Surgery
BHE Bureau of Health Education
BHW Bangladesh Health Watch
BIRDEM Bangladesh Institute of Research and Rehabilitation in
Diabetes, Endocrine and Metabolic Disorders
BMA Bangladesh Medical Association
BMDC Bangladesh Medical and Dental Council
BMRC Bangladesh Medical Research Council
BMMS Bangladesh Maternal Health Services and Maternal
Mortality Survey
BNC Bangladesh Nursing Council
BNHA Bangladesh National Health Accounts
BNP Bangladesh Nationalist Party
BPMPA Bangladesh Private Medical Practitioners Association
BPS Bangladesh Pharmaceutical Society
BSMMU Bangabandhu Sheikh Mujib Medical University
CAB Consumers Association of Bangladesh
CBHC community-based health care
CC community clinic
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CD communicable disease
CDC Communicable Disease Control
CDD Control of Diarrhoeal Diseases
CED chronic energy deficiency
CHCP community health-care providers
CHT Chittagong Hill Tracts
CHWs Community Health Workers
CME Centre for Medical Education
COPD chronic obstructive pulmonary disease
CRHCCs Comprehensive Reproductive Health-care Centres
CSBA community-based skilled birth attendants
CSR corporate social responsibility
CVD cardiovascular diseases
DAAR Disbursement for Accelerated Achievement of Results
DAM Dhaka Ahsania Mission
DCM Diploma in Community Medicine
DFP Directorate of Family Planning
DG Director General
DGDA Directorate General of Drug Administration
DGFP Directorate General of Family Planning
DGHS Directorate General of Health Services
DH district hospitals
DNS Directorate of Nursing Services
DOTS Directly Observed Treatment Strategy
DP Development partners
DPA Direct Project Aid
DPH Diploma in Public Health
DPHE Department of Public Health Engineering
DPT Doctor of Physical Therapy
DSF demand side financing
ECG electrocardiogram
EDL Essential Drugs List
EmOC emergency obstetrical care
EPI Expanded Programme on Immunization
ESD essential service delivery
ESP Essential Service Package
FCPS Fellow of College of Physicians and Surgeons

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FP family planning
FSNSP Food Security Nutritional Surveillance Programme
FWA Family Welfare Assistants
FWV Family Welfare Visitors
FY fiscal year
GAVI Global Alliance for Vaccines and Immunization
GDP gross domestic product
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GHWA Global Health Workforce Alliance
GNI gross national income
HA health assistants
HDI Human Development Index
HIES Household Income and Expenditure Survey
HIS Health Information System
HPN Health Population and Nutrition
HPNSP Health, Population and Nutrition Sector Programme
HPNSDP Health, Population and Nutrition Sector Development
Programme
HPSP Health and Population Sector Programme
HPSS Health and Population Sector Strategy
HRH Human Resources for Health
icddr,b International Center for Diarrhoeal Disease Research,
Bangladesh
ICMH Institute for Child and Maternal Health
IDU injecting drug users
IEDCR Institute of Epidemiology, Disease Control and Research
IEM Information, Education and Motivation
ILO International Labor Organization
IMCI Integrated Management of Childhood Illness
IMR infant mortality rate
IPGMR Institute of Postgraduate Medicine and Research
IPH Institute of Public Health
IPHN Institute of Public Health and Nutrition
LGED Local Government Engineering Department
LGIs local government institutions
MBBS Bachelor of Medicine and Bachelor of Surgery
MBF Ministry Budget Framework

xiii
MCH maternal and child health
MCPS Member of College of Physicians and Surgeons
MCWC Maternal & Child Welfare Centers
MDG Millennium Development Goals
MDRTB Multidrug-Resistant Tuberculosis
MI myocardial infarction
MIS management information system
MMED Master of Medicine
MMR maternal mortality ratio
MOCHT Ministry of Chittagong Hill Tracts
MOF Ministry of Finance
MOHFW Ministry of Health and Family Welfare
MOLGRDC Ministry of Local Government, Rural Development and
Cooperatives
MOWCA Ministry of Women and Children Affairs
MP Members of Parliament
MPH Master of Public Health
MPhil Master of Philosophy
MS micronutrient supplementation
MTM Master of Transfusion Medicine
MTMF Medium Term Macroeconomic Framework
NASP National AIDS and STD Programme
NBR National Board of Revenue
NCD noncommunicable diseases
NDP National Drug Policy
NGO nongovernmental organization
NHA National Health Accounts
NHP National Health Policy
NICRH National Institute of Cancer Research and Hospital
NICVD&H National Institute of Cardiovascular Disease and Hospital
NIKDU National Institute for Kidney Diseases and Urology
NIMH National Institute of Mental Health
NIPORT National Institute of Population Research and Training
NIPSOM National Institute of Preventive and Social Medicine
NITOR National Institute of Traumatology and Orthopedic
Rehabilitation
NLEP National Leprosy Elimination Program

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NNMR Neonatal mortality rate
NNP National Nutrition Programme
NTP National Tuberculosis Control Program
OOP out-of-pocket
OOPP out-of-pocket payment
OP operational plans
OPD outpatient department
PER public expenditure reviews
PHC primary health care
PHCCs Primary Health-care Centres
PPP purchasing power parity
PSC Public Service Commission
RDT Rapid Diagnostic Testing
RDU Research and Development Unit
RH reproductive health
RPA Reimbursable Project Aid
SES socioeconomic status
SIP Strategic Investment Plan
SMC Social Marketing Company
SMF State Medical Faculty
SWAp Sector Wide Approach
TBA traditional birth attendants
TFR total fertility rate
THE total health expenditure
TIB Transparency International Bangladesh
TTBA trained traditional birth attendants
U5MR Under-five mortality rate
UHC Upazila Health Complex
UHFWC Union Health and Family Welfare Centres
UNDP United Nations Development Programme
UNICEF United Nations International Children’s Emergency Fund
UPHCPII 2nd Urban Primary Health-care Programme
UPHCSDP Urban Primary Health-care Services Delivery Project
USAID United States Agency for International Development
VAT value-added tax
WHO World Health Organization
YLL years of life lost

xv
Abstract

Over 43 years after independence in 1971 the health system of

Bangladesh has gone through a number of reforms and established
an extensive health infrastructure in the public and private sectors.
Bangladesh has achieved impressive improvements in population health
status by achieving MDG 4 by reducing child death before the 2015
target, and rapidly improving on other key indicators including maternal
death, immunization coverage, and survival from some infectious
diseases including malaria, tuberculosis, and diarrhoea. However,
some challenges for the health system remain critical. First, lack of
coordination across two different ministries for implementing primary
health-care service delivery in rural and urban areas; second, critical
shortage of trained health providers with appropriate skill-mix in the
public sector and widespread increase in unregulated informal providers
for an alternative source of care; third, low annual allocation to health in
the government budget and high out-of-pocket payments by households;
and finally, inequitable access to health services between urban and
rural areas including variable health financing mechanisms, which
have slowed achieving universal health coverage. Mobilizing the private
sector to increase the production of health work force and bringing
informal health-care providers within the mainstream health system may
facilitate reducing the gap in human resources in a relatively shorter time
period. There is an urgent need for more investment of public funds and
stronger local accountability to improve the quality of public services,
and monitoring the quality of care provided by the private and informal
sectors.

xvi
Executive Summary

Bangladesh is one of the most densely populated countries in the

world. It is a unitary state and parliamentary democracy. Health and
education levels are relatively low, although they have improved recently
as poverty levels have decreased. Most Bangladeshis continue to live
by subsistence farming in rural villages. Bangladesh faces a number
of major challenges, including poverty, corruption, overpopulation and
vulnerability to climate change. However, it has been lauded by the
international community for its progress on the Human Development
Index. Bangladesh has made more notable gains in a number of
indicators than some of its neighbours with higher per capita income,
such as India and Pakistan.

The joint donor funded Health, Population, and Nutrition Sector

Development Programme (HPNSDP) has contributed to significant
improvement in a number of health indicators including reduction in
under-five mortality, immunization coverage, maternal mortality and total
fertility. The country has improved women’s education, and economic
conditions and life expectancy. Despite current economic growth, poverty
and income inequality remain persistent challenges in Bangladesh.
Simultaneous with the demographic transition, Bangladesh is undergoing
the health transition and manifesting the double burden of disease
attributable to the emergence of noncommunicable diseases.

The health system of Bangladesh is a pluralistic system with four key

actors that define the structure and function of the system: government,
private sector, nongovernmental organizations (NGOs) and donor
agencies. The Government or public sector is the first key actor which
by constitution is responsible not only for policy and regulation but for
provision of comprehensive health services, including financing and
employment of health staff. The Ministry of Health and Family Welfare,
through the two Directorates General of Health Services (DGHS) and
Family Planning (DGFP), manages a dual system of general health and
family planning services through district hospitals, Upazila Health
Complexes (with 10 to 50 beds) at subdistrict level, Union Health and

xvii
Family Welfare Centres at union level, and community clinics at ward
level. In addition, the Ministry of Local Government, Rural Development
and Cooperatives manages the provision of urban primary care
services. Quality of services at these facilities, however, is quite low
due to insufficient allocation of resources, institutional limitations and
absenteeism or negligence of providers.

Since 1976, to complement the Government’s limited capacity and

resources to provide basic health services, the private sector and NGOs
have established a network of facilities to provide health and family
planning services. The private sector consists of the formal sector which
provides both western and traditional (Unani and Ayurvedic) services
through a range of facilities from hospitals to clinics, laboratories and
drug stores; and the informal sector, which consists largely of untrained
providers of western, homeopathic and traditional (kobiraj) medicine.
However, private services are poorly regulated. The formal sector is
concentrated in urban areas, and the informal sector is the principal
provider in rural areas.

In response to the low quality of public services and their inability to

reach the entire population, particularly the poor, a vibrant and large NGO
sector has emerged as “third sector” of health providers in Bangladesh.
The role of NGOs is growing as donors are channeling significant and
increasing amounts of funding directly to them. In 2007, 9% of total
health expenditure was managed by NGOs, up from 6% in 1997. As a
response to both external and internal pressures, partnerships between
the Government and NGOs in the areas of financing, planning, service
delivery, capacity building, and monitoring and evaluation have produced
some health gains.

The Bangladesh public health system remains highly centralized, with

planning undertaken by the Ministry of Health and Family Welfare and
little authority delegated to local levels. The Health Information System
suffers from the bifurcation of the Ministry into DGHS and DGFP, with
separate and distinct reporting systems for each Directorate General.
While there exist a number of acts and ordinances to regulate the health
system, including regulation of different types of providers, practice
facilities and NGOs, many of these legal instruments date from several
decades ago. Separate councils for the registration and licensing of
medical practitioners, dentists and nurses have been established, but
their authority to investigate or discipline providers is weak. A number

xviii
of initiatives have been undertaken through the joint Government-donor
pooled programmes to encourage and support community empowerment
and accountability, with limited success. However, a number of NGOs
remain active in public reporting on government handling of the health
sector.

According to the latest Bangladesh National Health Accounts, Bangladesh

spends US$ 2.3 billion on health or US$ 16.20 per person per year, of
which 64% comes through out-of-pocket payments. While, according
to WHO estimates, Bangladesh currently spends US$ 26.60 per person
on health per year. Public funding for health is the main prepayment
mechanism with scope for risk pooling, which constitutes 26% of total
health expenditure. The other major funding source is international
development partners. Chronic underspending of the Ministry of Health
and Family Welfare’s budget indicates inefficiency in utilization of
resources as observed in the public sector review of the health sector.

Except for through the public budget, the existing funding mechanisms
of Bangladesh only slightly address (0.2% of total health expenditure)
any prepayment method, such as health insurance, either by private or
community initiatives. Several community initiatives for ensuring low-
cost services exist, while a number of private insurance companies offer
individual and group insurance to private persons and corporate clients.
These health insurance initiatives cover a very small share of the total
population.

The statutory health system, in principle, covers all citizens with a range
of services. However, many sick people every year are left untreated
in practice. In response to insufficient and unsatisfactory services in
the public sector, private initiatives have been taken since the 1980s.
The cost of services in private health facilities is unaffordable to many.
Bangladesh, therefore, still needs to travel a long way to reach universal
health coverage.

Bangladesh has an extensive PHC infrastructure in the public sector but

facilities are not adequately provided with human and other resources
such as drugs, instruments and supplies. During 2007–2013, the number
of both hospitals and total number of beds in the public sector has
steadily increased. The number of beds in PHC facilities at upazila level
and below reached 18 880 across 472 facilities in 2013, and 27 053 in 126
facilities at secondary and tertiary level. In the private sector, there were
2983 registered hospital and clinics, with 45 485 beds. Taken together,

xix
there is now one bed for every 1699 population, which is still inadequate.
Meanwhile, to bring health facilities closer to the doorstep of the
population, there is a community clinic for every 6000 population (n=12
527) which provides primary health care services.

In the public sector, the Central Medical Store is responsible for

procurement and supply of medical and surgical equipment and products,
including drugs. The public sector health facilities in Bangladesh lack
medical equipment and instruments. Many of the lower-level facilities
lack basic instruments like clocks and height-measuring scales. Supply
of drugs is also inadequate and the supply chain is frequently disrupted.
On the other hand, the private sector, especially the recently emerging
high-cost hospitals and clinics in the urban areas, have all the major
state-of-the-art diagnostic equipment and facilities.

Bangladesh is characterized by “shortage, inappropriate skill mix and

inequitable distribution” of its health workforce. At present there are 64
434 registered doctors, 6034 dentists, 30 516 nurses, and 27 000 nurse-
midwives in the country (cumulative figures unadjusted for attrition due
to deaths, retirements, migration, change of profession, or inactivity).
In addition, the health workforce is skewed towards doctors with a ratio
of doctors to nurses to technologists of 1:0.4:0.24, in stark contrast to
the WHO recommended ratio of 1:3:5. The involvement of the health
workforce in the private sector has increased over the years, as revealed
by an estimated 62% of the medical doctors working in the private sector
in 2013. The formal health workforce (doctors, dentists, nurses) is mostly
concentrated in the urban areas, with variation among regions. Retention
and absenteeism are two major problems in rural areas.

There is a large cadre of health care providers in the country in the

informal sector. This comprises semi-qualified allopathic providers
(e.g. community health workers, medical assistants, trained midwives),
unqualified allopathic providers (drug shop retailers, rural doctors, etc.),
traditional healers (practitioners of Ayurvedic, Unani and homeopathic
medicine) and faith healers. They are not a part of the mainstream health
system but a major health care provider for the poor rural population,
especially in remote rural and hard-to-reach areas.

Health services are delivered by both the public and non-public sector
in Bangladesh. In the public sector, the Ministry of Health and Family
Welfare is the main agency providing public health services, including
health promotion and preventive services. The public health services

xx
include programmes for the control of tuberculosis, now covering all
upazilas with the Directly Observed Treatment Strategy (DOTS); the
National Leprosy Elimination Programme, which reduced prevalence
rates to 0.24/10 000 by 2010; the Malaria and Parasitic Disease Control
Programme which targets approximately 11 million people in high risk
areas; Kala-azar (visceral leishmaniasis) control which has now expanded
to cover 27 districts; and the HIV/AIDS programme which has managed to
keep the incidence of HIV below 1% among high-risk populations. These
programmes are supported by National Public Health Institutes, while
health promotion is organized by the dedicated sections of DGHS and
DGFP.

Primary and ambulatory care is delivered through the public network

of facilities, particularly through the community-based health care
programme delivered by the community clinics; and by the private formal
and informal and NGO providers. In urban areas, patients tend to use
the outpatient units of the major urban hospitals for ambulatory care.
Secondary and inpatient care is provided through public facilities at
upazila, district, medical college and specialist urban hospitals, as well
as private hospitals mainly in urban areas. There is no structured referral
system, so that patients with minor ailments may also present directly to
hospitals for treatment.

Due to epidemiological and demographic change, Bangladesh is facing

the double burden of communicable and noncommunicable disease
including the emergence and re-emergence of other diseases. Moreover,
with recent incidents in garments factories, the focus is shifting towards
the occupational health and safety of workers in the ready-made
garment sector. The public health programmes need to be revisited and
redesigned to effectively address emerging challenges.

Bangladesh has made significant progress in the development of its

domestic pharmaceutical sector, with the introduction of the National
Drug Policy (NDP) in 1982. Domestic manufacturers now provide 75%
of total drug sales, and are expanding to develop an export market.
The Central Medical Store procures and distributes drugs to public
sector hospitals and facilities where they are provided free of charge.
However, outside the public sector, there is a chaotic market of some 64
000 licensed pharmacies and 70 000 unlicensed drug stores, selling all
types of medicines without requiring prescriptions. Polypharmacy and
dispensing by the prescriber is also common in the private sector and
constrains the rational use of medicines.

xxi
Recent health reforms in Bangladesh commenced with the Health and
Population Sector Strategy, developed by the government and donors in
1997. This strategy advocated a number of institutional and governance
reforms, notably the shift from a project basis towards a coordinated
sectoral programme. These reforms were then implemented through a
series of five year sectoral programmes, commencing with the Health
and Population Sector Programme (HPSP) of 1998–2003. Key reforms
included: pooling of donor funds in a Sector Wide Approach (SWAp),
provision of selected primary health care services under an Essential
Services Package to the poor, introduction of one-stop services through
community clinics, and unification as well as bifurcation of health and
family planning wings of the Ministry of Health and Family Welfare. Under
the latest five-year programme, the Health, Population and Nutrition
Sector Development Programme (HNPSDP), health sector activities
have been grouped into 38 operational plans implemented by 38 Line
Directors. While the SWAp has improved coordination and alignment
among multiple donor projects, there remains fragmentation within the
vertical programmes of the Ministry, continuation of a number of vertical
programmes funded outside the SWAp, and a lack of a comprehensive
ministerial plan.

Other key reforms include: the establishment of community clinics to

replace domiciliary visits; their withdrawal when coverage of major
programmes fell, and their reinstatement together with domiciliary
programmes by the new Government; unification of the DGHS and
DGFP in 2000, and then subsequent re-separation in the face of poor
performance by DGFP officers; attempts at decentralization of health
services to the upazila level, although with limited delegated authority;
and the recent maternal health voucher scheme.

Recently, in recognition that the high levels of out-of-pocket expenditure

form a barrier to utilization, a Health Care Financing Strategy (2012–2032)
has been developed to provide direction in achieving universal health
coverage. The strategy puts emphasis on prepayment mechanisms
with scope for risk-pooling, and separate mechanisms are suggested
for people in different economic sectors (formal sector, informal sector
and people in poverty). Taxes, social health insurance contributions and
community-based health insurance schemes have been recommended.
Over its 20-year implementation period, the strategy aims at reduction
of out-of-pocket payments from 64% to 32% of total health expenditure,
increase in government expenditure from 26% to 30%, increase in social

xxii
protection from less than 1% to 32% and reduced dependence on external
funds from 8% to 5%.

The stated objectives in the National Health Policy of 2011 are: (i)
strengthening primary health and emergency care for all, (ii) expanding
the availability of client-centred, equity-focused and high quality health
care services, and (iii) motivating people to seek care based on rights
for health. While theoretically all Bangladeshi citizens have the right
to receive health care according to need, low government investment
in public facilities, some user charges and payments for medicines,
and high use of the private sector have resulted in significant inequity
in access to services. Existing reforms such as community clinics and
maternal care vouchers provide access to only limited services, while the
proposal for health insurance for formal sector workers will not address
the majority of those engaged in the informal and rural sector. In relation
to user experience and equity of access, the general public perception
of the public health system is poor, with complaints of long waiting
times, absenteeism, poor behaviour of providers, and exclusion of some
marginalized groups. Access to care demonstrates much higher rates
of utilization of public and private services by the wealthier quintiles,
but there has been some improvement in equity in access over the last
decade.

Though there have been commendable gains in health outcomes

recently, grossly inequity remains. For example, differential levels of
early childhood mortality were observed according to socioeconomic
status (SES) (Demographic 2011). Neonatal mortality, infant mortality
and under-five mortality in the highest wealth quintile households (23,
29, 37 respectively per 1000 live births) were much lower than among the
lowest quintile households (34, 50, 64 respectively per 1000 live births).
Similarly, vaccination coverage (BCG, measles and three doses each of
DPT and polio) among children from highest quintile households was 93%
compared to 77% among lowest quintile households.

The same trend in SES differentials was observed in the case of child
nutritional status (Demographic 2011). Children of lowest quintile
households were proportionately more stunted (54% compared to 26%
for highest quintile households), underweight (50% compared to 21%
for highest quintile households) and wasted (17% compared to 12% for
highest quintile households). 51% and 64% of the pregnant women from
highest wealth quintile households were assisted during delivery by a

xxiii
qualified doctor or a medically-trained provider respectively, compared to
only 5% and 11% respectively in case of lowest wealth quintile households
(Demographic 2011). Only 10% of pregnant women from lowest quintile
households delivered in a health facility compared to 60% for the other
groups of women. The percentage of C-section deliveries was 3% and
41% respectively for the lowest and highest quintile households.

Despite many challenges, population health outcomes have shown

marked improvement, with falls in maternal, infant and under-five
mortality rates, and significant reductions in total fertility rate. In
comparison with MDG targets, infant and under-five mortality and total
fertility are on track to reach the 2015 targets; maternal mortality and
prevalence of underweight are not on track to reach targets despite
significant reductions, while targets for HIV, malaria and TB are
still potentially achievable. These outcomes have been achieved by
improvements in coverage with key interventions, such as delivery in a
health facility, childhood immunization, and management of diarrhoea
with oral rehydration salts, and treatment success rates for TB. However,
the provision and coverage of services for the growing burden of
noncommunicable diseases is only just beginning. Quality of care in both
public and private services is poor, with little assessment of the quality of
provider care, low levels of professional knowledge, and poor application.

Bangladesh has set an extraordinary example of gaining good health

at a very low cost and has been proposed as a role model for other
developing countries in the region. While the gains in health have been
credited to the Ministry of Health and Family Welfare, the progress of
other ministries relevant to public health catalyzed the success of the
overall health agenda of the Government. It is a paradox that despite the
lack of accountability of the Government to the public regarding health
and little coordination of the health ministry with other sectors, a number
of vertical health programmes, particularly in preventive care (such as
immunization, control of diarrhoea, TB and other emerging infectious
diseases) have been sustained successfully over a long period, impacting
positively on health outcomes. Mobilizing the huge informal health
cadres outside the official allopathic system would be a useful strategy
for strengthening human resources in health, especially in the remote
and hard-to-reach areas of the country and achieving universal health
coverage.

xxiv
1 Introduction

Chapter summary
Bangladesh, officially the People’s Republic of Bangladesh, is a country in
South Asia and one of the most densely populated countries in the world.
It is a unitary state and parliamentary democracy. Health and education
levels are relatively low, although they have improved recently as poverty
levels have decreased. Most Bangladeshis continue to live by subsistence
farming in rural villages. Bangladesh faces a number of major challenges,
including poverty, corruption, overpopulation and vulnerability to climate
change. However, it has been noted by the international community for its
progress on the Human Development Index. Bangladesh has made more
notable gains in a number of indicators than some neighboring countries
with higher per capita income. The Health, Population, and Nutrition
Sector Development Programme (HPNSDP) has contributed to significant
improvement in a number of health indicators, including a reduction in
under-five mortality, immunization coverage, maternal mortality and total
fertility. The country has improved women’s education, economic conditions
and life expectancy. Despite current economic growth, poverty and income
inequality remain persistent challenges in Bangladesh. Simultaneous
with the demographic transition, Bangladesh is also undergoing a health
transition and manifesting the double burden of disease with the emergence
of noncommunicable diseases.

1.1 Geography and demography

Bangladesh is bordered by the Bay of Bengal in the South, Myanmar in
the south-east, and India to the east, north and west. The majority of the
territory is a low-lying delta plain traversed by an extensive network of
large and small rivers vital to the socioeconomic life of the nation, with hilly
areas scattered in the north and east (Figure 1.1). Bangladesh is known as
the worst victim of the direct and indirect effects of global climate change
(DGHS, 2012). The country faces a number of natural disasters on a regular
basis,chiefly floods, cyclones and tidal bores (Anwar, Islam et al., 2012),
which have slowed down poverty reduction progress (World Bank, 2010).

1
Figure 1.1 Map of Bangladesh

Source: United Nations Cartographic Section (http://http://www.un.org/Depts/Cartographic/map/

profile/banglade.pdf)

Bangladesh has a population of 151 million, occupying 147 570 square

kilometres (World Bank, 2013). The population density of 1161 people
per square kilometre is one of the highest in the world (Table 1.1)
(World Bank, 2013). About 90% of the population are Muslims, 9% are
Hindus and 1% are Christians, Buddhists and other faiths (DGHS, 2012).

Bangladesh has experienced a remarkable demographic transition, with

a rapid decline in the fertility rate from 6.9 births per woman in the early
1970s to 2.3 in 2010 (World Bank, 2013) and a population growth rate of
only 1.37% between the 1991 and 2011 censuses (Bangladesh Bureau
of Statistics (BBS) and Ministry of Planning Statistics and Informatics
Division (SID) , 2012). In addition, Bangladesh is experiencing rapid urban
growth, with an urbanization rate of 3.5% annually (Banks, Roy et al.,
2011), which has increased the proportion of the population living in cities
and towns from 3.6% in the 1970s to 14.4%in 2010 (Table 1.1) (UPPR,
2012; World Bank, 2013).

2
Administratively, the country is divided into seven divisions, 64 districts
(zila) and 545 subdistricts (upazila) (NIPORT, Mitra and Associates et al.,
2013). The seven administrative divisions are, in order of population size:
Dhaka, Chittagong, Rajshahi, Rangpur, Khulna, Sylhet and Barisal. Each
rural area in the upazila is divided into union parishads, and mouzas
within a union parishad; an urban area in an upazila is divided into wards,
and into mohallas within a ward. These divisions allow the country as a
whole to be easily separated into rural and urban areas. There are no
elected officials at the divisional or district levels, and the administration
is composed only of government officials. Direct elections are held for
each union (or ward), electing a chairperson and a number of members.

Table 1.1 Trends in population/demographic indicators, selected years

Indicator 1970 1980 1990 2000 2010
Total population (million) 66 309 82 498 107 386 132 383 151 125
Population aged 0–14 (% of total) 44.7 44.4 42.1 37 31.7
Population aged 15–64 (% of total) 51.9 52 54.2 59 63.7
Population aged 65 plus (% of 3.5 3.6 3.7 4.1 4.6
total )
Population growth (%/year) 2.4 2.8 2.5 1.8 1.1
Population density (people/sq.km) 509.4 633.8 825 1017 1161
Fertility rate (TFR) 6.9 6.4 4.6 3.1 2.3
Crude birth rate / 1000 47 43.1 35.1 27 20.9
Crude death rate /1000 19.2 13.8 10.1 7.2 5.9
Age dependency ratio (% of 92.9 92.3 84.5 69.6 56.9
working age population)
Proportion population urban (% of 3.6 6.3 9.0 11.2 14.4
total population)

Source: http://publications.worldbank.org/WDI/indicators

1.2 Socioeconomic context

The Liberation War which led to the creation of the independent state of
Bangladesh in 1971 destroyed about a fifth of Bangladesh’s economy,
and postwar dislocations left the country on a slow growth trajectory
for the better part of two decades. However, the economy accelerated
dramatically from 1990, with gross national income (GNI) increasing
from US$ 100 per capitain 1973 to US$ 700 in 2010. The economy as
measured by gross domestic product (GDP) has grown at a remarkable
annual rate of 6% between 1990 and 2010 (Table 1.2) (World Bank,
2013). More than half of the GDP is generated by the service sector

3
(Table 1.2) (World Bank, 2013), whereas the contribution of agriculture
to Bangladesh’s GDP has been decreasing over time (World Bank, 2013)
even though it still accommodates the major rural labor force (DGHS,
2012). The other major factors fuelling continued economic growth have
been expansion in the export of ready-made garments, and remittances
sent back to Bangladesh from migrant laborers who work primarily in
unskilled positions in Malaysia and the Middle East (World Bank, 2010).
Garment exports totalling $12.3 billion and remittances from overseas
Bangladeshis totalling $9.7 billion accounted for almost 25% of GDP in
FY2009 (World Bank, 2010). In addition, the expanding garment industry
has improved women’s participation in the formal labor market in
Bangladesh (UNICEF, 2010).

Despite current economic growth, poverty and income inequality remain

persistent challenges in Bangladesh (Chowdhury, Bhuiya et al., 2013).
Regardless of modest improvements in the Human Development Index
(HDI), in 2012 the United Nations Development Programme (UNDP)
ranked Bangladesh as 146th of 187 countries in terms of HDI, placing it
among the“low human development”countries. It is estimated that 31.5%
of the population still live below the national poverty line (UNDP, 2013).
Even though poverty rates have demonstrated steady improvement, with
an average decline of 1.74 points per year during the past decade, the
gap in the speed of poverty reduction between urban and rural areas
has widened over the last five years (World Bank, 2013). This happens
apart from the increase in rural real per capita consumption, and has
kept extreme poverty as a rural phenomenon (World Bank, 2013). In
terms of inequality of income distribution as measured by the GINI index
of real per capita consumption, inequality remained stagnant over the
decade at the national level (Table 1.2). Nevertheless, Bangladesh has
demonstrated a remarkably steady improvement in poverty rates, with
a 26% decline in the population in poverty in the past ten years (World
Bank, 2013).

The adult literacy rate in Bangladesh has increased from 29.2% in 1981
to 57.7% in 2011, and surpasses some of its neighbors such as Nepal
(57.37%) and Pakistan (54.89%) but remains behind Sri Lanka (91.18%)
and Myanmar (92.68%) (World Bank, 2013). The expansion of female
secondary schooling since the 1990s has significantly reduced gender
disparity, especially in rural areas (General Economics Division (GED)
Bangladesh Planning Commission, June 2013). Adult female literacy also
increased considerably in the past two decades, from about 26% in 1991
to around 53% in 2011 (World Bank, 2013).

4
Table 1.2 Macroeconomic indicators, 1970–2010, selected years
Indicators 1970 1980 1990 2000 2010
GDP (in billions, current US$ ) 8.9 18 30 47 100
GDP, PPP (current international $) - 26 57 111 246
GDP per capita, PPP (constant 2005 - - - - -
international $) - 661 732 949 1464
GDP growth (annual %) 5.6 0.8 5.9 5.9 6.1
Agriculture, value added (% of GDP) - 32 30 26 19
Industry, value added (% of GDP) - 21 21 25 28
Services, etc., value added (% of - 48 48 49 53
GDP)
Cash surplus/deficit (% of GDP) - - - - -1
GINI index - - - 33 32
Real interest rate (%) - -5 9 13 6
Source: http://publications.worldbank.org/WDI/indicators

1.3 Political context

Bangladesh is a unitary state and parliamentary democracy . The
Government of the People’s Republic of Bangladesh comprises three
basic elements: the legislature, the judiciary and the executive (World
Bank 2010). The legislative power of the Republic is vested in the single-
house parliament known as the Jatiyo Sangshad, which consists of 300
Members of Parliament. They are chosen in a national election in which
all citizens aged 18 or over can vote every five years. The President is
the head of state but real power is held by the Prime Minister, who is the
head of government (World Bank, 2010).

After a period of military and quasi-military rule from 1975 to 1990,

mass agitation resulted in the restoration of democratically-elected
governments (World Bank, 2010). Consecutive failures in conducting
general elections have resulted in disruption of the democratic process
and the appearance of the army in national politics (Paul S and Goel PR,
2010). Successful public administration in Bangladesh has also been
hampered by these situations (Paul S and Goel PR, 2010).

In 1991, Bangladesh instituted a unique Caretaker Government system

through the thirteenth amendment to the Constitution, which gave power
to an elected government to transfer power to an unelected non-partisan
Caretaker Government to oversee new parliamentary elections upon
completion of its term. The system lasted for 15 years and four elections

5
were held under it, in 1991, 1996, 2001 and 2008. However, in 2011 the
incumbent government abolished the caretaker form of government
through the fifteenth amendment to the Constitution (Riaz, 2013). The
last election was held in 2014 under the Election Commission, and the
governing party won 232 of the 300 seats, including 153 seats elected
unopposed as a result of an election boycott by the alliance of the
opposition parties (Barry E, 2014).

Responsibility for implementing Government policies and programmes

is vested in Bangladesh’s civil service, a corps of trained administrators
who form the most influential group of civil servants, and the district
level is key in policy implementation (Balabanova D, McKee M et al.,
2011). The process of decentralization in Bangladesh started in 1959,
when Bangladesh was known as East Pakistan, with the introduction of
a four-tier local government system (Paul S and Goel PR, 2010). After
independence, several major events took place that reformed the local
government structure, including promulgation of the Local Government
Ordinance 1976; the introduction of a new local government ordinance
in 1982; the appointment of the Local Government Structure Review
Commission in 1991; the formation of the Local Government Commission
in 1996; and a change in the local government structure in 2001 (Sharmin,
Haque et al., 2011). Nevertheless, devolution of political power to the
local level is incomplete (Paul S and Goel PR, 2010). Central government
retains a high degree of control in terms of power, functions and
jurisdiction, which limits the autonomy and efficiency of local government
(Sharmin, Haque et al., 2011). In addition, budgetary allocation for
the local government institutions is inadequate, which leads to rural
poverty and widening economic disparity between rural and urban areas
(Sharmin, Haque et al., 2011).

1.4 Health status

During the past 40 years Bangladesh has made remarkable
improvements in life expectancy, child health (Table 1.3), literacy and
disaster preparedness (Balabanova D, McKee M et al., 2011). Bangladesh
has made more notable gains in a number of indicators than some of its
neighboring countries which have higher per capita income. For instance,
GDP per capita in Bangladesh ($1777) was half that of India ($3650) in
2011, and lower than that Pakistan ($2567), yet average life expectancy,
percentage of children immunized against diphtheria and measles, and
the literacy rate for young women were higher in Bangladesh than in

6
Pakistan and in India (Baxter, 2003). In the two decades between 1990
and 2010, under-five mortality has fallen by more than 60%, while infant
mortality and neonatal mortality have declined by around half (Table 1.3).
The under-five mortality rate (46 deaths per 1000) in Bangladesh is
significantly lower than India (41 per 1000) and Pakistan (86 per 1000).
(http://data.worldbank.org/indicator/SH.DYN.MORT).

Table 1.3 Mortality and health indicators

Indicator 1970 1980 1990 2000 2010
Life expectancy at birth, total (years) 42 55 59 65 69
Life expectancy at birth, female (years) 44 54 59 65 69
Life expectancy at birth, male (years) 40 56 60 65 68
Mortality rate, adult, female (per 1000 female adults) - - - 171 137
Mortality rate, adult, male (per 1000 male adults) - - - 179 163
Adolescent fertility rate (per 1000 women ages 15–19) - 195.38 163.68 116.63 83.83
Infant mortality rate (per 1000 live births) - 133 99.5 64.2 37.5
(Kassebaum, 2014)
Neonatal mortality rate (per 1000 live births) - - 54.1 40.7 27
Under-5 mortality rate (per 1000 live births) - 197.8 143.6 87.7 47.2
Maternal mortality ratio ( per 100 000 live births) - - 551.9 375 300
(Kassebaum, 2014)

Source: http://publications.worldbank.org/WDI/indicators

Estimates of healthy life expectancy (HALE) vary between those of

the WHO GBD group and the IHME group (Table 1.4). Both sources
demonstrate an increase in HALE between 1990 and 2010 / 2012,
although the IHME calculations suggest a more modest increase than the
WHO.

The difference between crude life expectancy and HALE illustrates the
growing significance of years lived with disability as life expectancy
increases.

7
Table 1.4 Healthy Life Expectancy (HALE) different sources
1990 2000 2010 2012
HALE 1
Male - 55 - 60
Female 55 - 61
Total - 55 - 60
HALE 2
Male 48.4 - 56.5 -
Female 49.5 - 58.9 -
Source: WHO Global Health Observatory http://apps.who.int/gho/data/node.main.3?lang=en
GBD Healthy life expectancy http://www.healthmetricsandevaluation.org/gbd/publications/healthy-
life-expectancy-187-countries-1990–2010-systematic-analysis-global-bu

1.4.1 Causes of death

With the decline in birth rate and death rate and an increase in the
proportion of mortality due to noncommunicable disease, Bangladesh has
entered the epidemiological transition. Table 1.5 illustrates the change in
leading causes of mortality in Bangladesh in twenty years between 1990
and 2010.

Mortality from communicable, maternal, neonatal and nutritional

disorders fell dramatically from 583/100 000 in 1990 to 178 /100 000 in
2010, with similar falls in males and females. This fall was principally
the result of falls in childhood infectious diseases, together with falls in
maternal mortality and nutritional deficiencies.

Mortality rates from noncommunicable diseases as a group remained

steady at around 360 deaths /100 000 population, although this masks
a rise in mortality among males, and a fall in mortality among females.
However death rates from cardiovascular and circulatory diseases,
including ischaemic heart disease rose, particularly among males. Death
rates from cancers and other NCDs remained fairly steady, with rises in
males balanced by falls in females.

Mortality rates from injuries also fell significantly during this period, in
both males and females.

8
Table 1.5 All age mortality rates for main causes of death, 1990–2010
All age mortality
1990 2010
rates/100 000
Causes of death Male Female Total Male Female Total
Communicable, 612.8 551.0 582.8 197.4 157.9 177.9
maternal, neonatal, and
nutritional disorders
Diarrhoea, lower 280.7 255.1 268.3 74.0 56.3 65.2
respiratory infections,
meningitis, and other
common infectious
diseases
Tuberculosis 39.5 19.2 29.6 27.0 8.7 18.0
HIV/AIDS 0.2 0.1 0.1
Maternal disorders 33.1 9.8
Nutritional deficiencies 37.2 49.8 43.3 7.9 13.4 10.6
Noncommunicable 381.5 334.1 358.5 401.5 312.2 357.5
diseases
Cardiovascular and 65.6 61.0 63.4 112.8 75.1 94.2
circulatory diseases
Neoplasms 72.4 80.0 76.1 87.6 74.8 81.3
Colon and rectum 2.0 1.6 1.8 2.0 1.7 1.9
cancers
Trachea, bronchus, and 9.0 3.2 6.2 14.3 3.4 8.9
lung cancers
Breast cancer 3.0 5.9
Cervical cancer 14.1 9.6
Diabetes mellitus 9.3 7.9 8.6 20.0 14.5 17.3
Mental and behavioral 2.7 0.8 1.8 2.2 0.7 1.5
disorders
Ischemic heart disease 15.5 11.8 13.7 45.5 19.7 32.7
Cerebrovascular disease 29.7 30.4 30.1 30.6 28.6 29.7
Chronic respiratory 87.2 65.1 76.4 71.6 45.1 58.5
diseases
Digestive diseases 27.1 19.8 23.6 19.2 15.7 17.5
(except cirrhosis)
Injuries 107.5 89.6 98.8 68.0 47.5 57.9
Transport injuries 5.9 2.0 4.0 7.8 1.8 4.8
Source: Global Burden of Disease Study 2010 http://ghdx.healthdata.org/record/bangladesh-global-
burden-disease-study-2010-gbd-2010-results-1990–2010

9
Maternal, neonatal and child mortality

Maternal mortality
According to the Bangladesh Maternal Health Services and Maternal
Mortality Survey (BMMS) 2010, major direct causes of maternal deaths in
Bangladesh include postpartum haemorrhage (31%), eclampsia (20%),
obstructed or prolonged labor (7%), complications of unsafe abortion
(1%), and other direct (5%) and indirect causes (35%). Haemorrhage
and eclampsia, as the dominant direct obstetric causes of deaths, are
responsible for more than half of all maternal deaths (NIPORT, Measure
Evaluation et al. 2012). According to the recent estimates of the Global
Burden of Disease study (2013), the maternal mortality rate has declined
from 551.9 per 100 000 live births in 1990 to 333.1 per 100 000 live births
in 2003, and in 2013 MMR has been estimated at 242.7 per 100 000 live
births (Kassebaum et al., 2014). Figure 1.2 shows maternal mortality
ratio by timing of death. There have been reductions in deaths during
pregnancy during the delivery and postpartum periods. The main declines
occurred around pregnancy and delivery periods; nonetheless,the
mortality ratio during the postpartum period is also high. According
to BMMS 2010, overall MMR and MMR due to direct obstetric deaths
are lower in urban areas (NIPORT, Measure Evaluation et al., 2012). By
region, Sylhet division has the highest risk of MMR while Khulna has the
lowest. On the other hand, maternal education and wealth quintiles have
no clear association with MMR (NIPORT, Measure Evaluation et al., 2012).

Figure 1.2 Maternal mortality ratio by timing of deaths

BMMS 2001 BMMS 2010

250 216

200
Maternal Mortality Ratio

142
150

100 71

35 36
50 18

0
During During Postpartum
pregnancy delivery

Source: BMMS 2001 and 2010

10
Bangladesh has had an impressive reduction in the total fertility rate,
from 6.3 births per woman during 1971–1975 to 2.3 births per woman
by 2010 (Ministry of Health and Population Control, 1978; NIPORT, Mitra
and Associates et al., 2013). The contraceptive prevalence rate has also
registered impressive growth – from a low rate of 8% in 1975 to more than
61.2% in 2011 (Ministry of Health and Population Control, 1978, NIPORT,
Mitra and Associates et al., 2013).

Child mortality
Bangladesh is one of the few countries that are on track to achieve
Millennium Development Goal 4, reducing the under-five mortality rate
by two thirds by 2015. Its significant progress in improving child health
has reduced the child mortality rate by more than half, from 133/1000 live
births in 1990 to 53/1000 in 2011 (NIPORT, Mitra Associates et al., 2013).
The infant mortality rate has also declined considerably, from 87/1000 live
births in 1990 to 43/1000 in 2011. However, over the last 20 years neonatal
mortality declined at a slower pace than infant and child mortality, and as
a result it has increased from 60% of all infant deaths in 1990 to 74% in
2011, and from 39% of under-five deaths in 1990 to 60% in 2011 (NIPORT,
Mitra Associates et al., 2013).

According to the Bangladesh Demographic and Health Survey (BDHS)

2011, there are differentials in childhood mortality between regions with
different characteristics (NIPORT, Mitra Associates et al., 2013). Child
mortality is higher in rural areas (NIPORT, Mitra Associates et al., 2013).
By region, Sylhet is performing the worst in terms of neonatal, infant and
under-five mortality rates. Mothers’ level of education also plays a role,
in that education is inversely related to the child’s risk of dying (NIPORT,
Mitra Associates et al., 2013). Infant mortality is 40% lower for children
whose mothers have completed secondary education than for those with
no education, at 33 and 55 deaths per 1000 live births, respectively. All
childhood mortality rates are lowest for children in the highest wealth
quintile (NIPORT, Mitra Associates et al., 2013).

At present, pneumonia is the top killer disease for under-five children in

Bangladesh (NIPORT, Mitra Associates et al., 2013). This is followed by
serious infections or sepsis (15%), birth asphyxia (12%), drowning (9%),
and pre-term birth (7%). Among neonates, serious infections are the
most important cause of death (24%), followed by birth asphyxia (21%),
pneumonia (13%), and pre-term birth (11%) (NIPORT, Mitra Associates
et al., 2013). This pattern of causes of death is different from that of

11
around 20 years ago, when more than a quarter of deaths were found
to be associated with diarrhoea (Salway and Nasim, 1994). Currently,
diarrhoea is responsible for only 2% of under-five deaths (NIPORT, Mitra
Associates et al., 2013). Of considerable interest is the emergence of
drowning as a key cause of death, especially among children aged 12–59
months (NIPORT, Mitra Associates et al., 2013). Changes in the pattern of
causes of death have important implications for the intervention package
being delivered by the public health system.

Figure 1.3 Trends in child mortality (NNMR, IMR, U5MR) 1989–2011

Neonatal mortality Infant mortality Under-five mortality

2015 Aim: 2016 Aim: 2016 Aim:
21 31 48

Deaths per 1000

live births

53

43
32
1989-93 1992-96 1995-99 1999-03 2002-06 2007-11

Source:BDHS

There are several factors that have contributed to the significant

improvement in maternal and child health in Bangladesh. Among
them are improved access to essential health programmes such as the
Expanded Program on Immunization (EPI), oral rehydration therapy
(ORT), and antenatal care; the use of skilled birth attendants and family
planning; higher levels of women’s education; and improved economic
conditions (NIPORT, Measure Evaluation et al., 2012; Adams, Rabbani
et al., 2013; Chowdhury, Bhuiya et al., 2013).

The target the Bangladesh Government has set through its Health,
Population, and Nutrition Sector Development Programme (HPNSDP)
is to increase the percentage of children under one year who are fully
immunized to 90% by 2016 (MOHFW, 2011). The latest assessment
suggests that coverage has already increased to 86% in 2011, compared
to 83% in 2007 (NIPORT, Mitra and Associates et al., 2013). In addition,
gender differentials and urban-rural differentials in coverage have

12
diminished (Mitra, Ali et al., 1994; NIPORT, Mitra and Associates et al.,
2013).

Dehydration caused by severe diarrhoea can be treated easily with

ORT (NIPORT, Mitra and Associates et al. 2013). In Bangladesh, the
Bangladesh Rural Advancement Committee (BRAC) initiated a national
ORT programme with a door-to-door educational delivery strategy,
which is estimated to have reached every woman in the country in the
past 10 years (Adams, Rabbani et al. 2013). The programme has enabled
mothers to treat their children’s diarrhoea through home-prepared oral
rehydration saline (Chowdhury, Bhuiya et al., 2013).

Reducing population growth has been a priority in Bangladesh. As a

result of the Government’s commitment, Bangladesh has experienced
a significant demographic transition over the few decades, with the
population growth rate declining to 1.37% between 1991 and 2011
censuses (Bangladesh Bureau of Statistics and Ministry of Planning,
2012). Total fertility rate (TFR) has also been reduced remarkably between
1970 and 2011, from seven to two births per woman (Chowdhury, Bhuiya
et al., 2013). This considerable reduction in fertility rate has contributed
to the speed and magnitude of improvements in mortality, particularly for
women (Chowdhury, Bhuiya et al., 2013).

Antenatal care from a medically-trained provider is important to monitor

the status of a pregnancy, identify the complications associated with the
pregnancy, and prevent adverse pregnancy outcomes (NIPORT, Mitra
Associates et al., 2013). Comparing the data from the current BDHS
with the 2004 and 2007 surveys, antenatal care from any provider has
increased by 17% since 2004, whereas antenatal care from a medically-
trained provider during the same period has increased by only 8%
(NIPORT, Mitra Associates et al., 2013). Inequity in antenatal care uptake
still remains. The current data show that women from the highest
wealth quintile were three times more likely than women in the lowest
wealth quintile to receive such care from a medically-trained provider
(NIPORT, Mitra Associates et al., 2013). In addition, between 2007 and
2011 there has been a decline in antenatal care uptake from a trained
provider among women without any education, women in the lowest
wealth quintile, and women in Sylhet and Khulna divisions (NIPORT, Mitra
Associates et al., 2013).

Good, hygienic medical practice can reduce the risk of complications

and infections that can cause death or severe complications for the

13
mother or the newborn. Therefore, increasing the proportion of births
delivered in safe, clean environments and under the supervision of
health professionals is important (NIPORT, Mitra Associates et al., 2013).
Currently in Bangladesh two in three births are assisted by traditional
attendants (NIPORT, Measure Evaluation et al., 2012). However, there has
been a considerable increase in the use of medically-trained providers,
from 12% in 2001 to 27% in 2010 (NIPORT, Measure Evaluation et al.,
2012). Births assisted by a trained provider are more common among
women having their first birth, women in urban areas, women who have
completed secondary or higher education, and women from the highest
wealth quintile (NIPORT, Mitra Associates et al., 2013).

It is widely accepted that higher female education is associated with

behaviours that can lower the risk of maternal and child mortality
(Adams, Rabbani et al., 2013). In Bangladesh, the level of education of
recent mothers as well as young women entering childbearing years
has risen dramatically in the past decade. It is suggested that this trend
has contributed to the remarkable rise in facility delivery, in the use of
medically-trained birth attendants, and in treatment-seeking for obstetric
complications (NIPORT, Measure Evaluation et al. 2012).

Bangladesh’s overall economy has advanced, which is reflected in better

housing, greater access to electricity, and presumably greater ability to
mobilize funds for medical emergencies (NIPORT, Measure Evaluation
et al., 2012). Nearly all indicators of use of health services by the poorest
quintile have shown considerable improvement and narrowing inequity
between the rich and the poor. Based on the Bangladesh Maternal
Mortality and Health care Survey 2010, the use of facility delivery and
skilled birth attendants by mothers from the poorest quintile increased
by 300%, and seeking help for obstetric complications doubled (NIPORT,
Measure Evaluation et al., 2012).

Noncommunicable diseases
Simultaneously with the demographic transition, Bangladesh is
undergoing a health transition and manifesting the double burden of
disease (the combination of communicable and noncommunicable
diseases). NCDs such as asthma and COPD, stroke/paralysis, heart
disease, hypertension, diabetes, drowning, accident/injuries, and cancers
were amongst the top 20 causes of death in 2000 (Bangladesh Bureau
of Statistics, 2000, 2007). Matlab HDSS data suggests that in the period
1986–2006 the proportion of deaths due to NCDs increased nearly

14
ninefold, whereas deaths due to injuries (including suicide and homicide)
remained stable at around 7%, maternal and neonatal (including
nutritional) deaths declined from 7% to 4%, and deaths due to unknown/
unspecified causes declined from 7% to 5% (Figure 1.4) (Karar 2009).

Figure 1.4 Noncommunicable disease mortality increases over time in

rural Bangladesh, 1987–2011

100%

80%

60%

40%

20%

0%
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Noncommunicable Communicable Accident/Injury
Maternal/Neonatal Unknown/Missing

Source: Karar et al. 2009

Although a reliable NCD surveillance system is not yet in place, according

to WHO estimates, over 59% of all deaths in Bangladesh were due to
NCDs in 2012 (WHO, 2014). Cardiovascular disease (CVD), in particular
ischaemic heart and cerebrovascular disease (stroke), unintentional
injury, cancer and chronic obstructive pulmonary disease (COPD) were
among the top ten causes of death in 2011 (MOHFW, 2012).

The national Sample Vital Registration System of the national statistical

agency, the Bangladesh Bureau of Statistics, confirmed the estimate
that cardio- and cerebrovascular diseases combined are the major
cause of death due to NCDs (El-Saharty, 2013). Ischaemic heart disease
is responsible for 12% of total deaths, while cerebrovascular disease
(stroke) is responsible for 6% of all deaths (El-Saharty, 2013). In addition,
among the population aged 30 years and above, ischaemic heart disease
accounts for 7.7% and stroke 8.9% of hospital admissions (El-Saharty,
2013).

15
A mortality projection made by the International Center for Diarrhoeal
Diseases Research, Bangladesh (icddr,b) stated that the death rate from
CVDs in Bangladesh would be 21 times higher in 2025 than the rate in
2003 (Karar, 2009). Various factors contribute to the increasing morbidity
caused by CVD. The INTERHEART Study, a global case-control study of
risk factors for acute myocardial infarction, reported that Bangladeshis
had the highest prevalence of CVD risk factors among the participating
countries. These risk factors include current and former smoking (59.9%),
abdominal obesity (43.3%), self-reported history of hypertension (14.3%),
depression (43%), and elevated ApoB100/Apo-I ratio (59.6%) (Saquib,
Saquib et al., 2012). In addition, Bangladeshis have the lowest prevalence
of regular physical activity (1.3%) and daily intake of fruits and vegetables
(8.6%) (Saquib, Saquib et al., 2012).

Rates of risk factors estimated from the Global Burden of Disease study
show declines in the contribution of risks from water and sanitation,
under-nutrition and household air pollution, and rises in the contribution
of NCD risk factors, such as smoking, high blood glucose, high blood
pressure and diet low in fruit and vegetables. (Table 1.6)

Table 1.6 Morbidity and risk factors for health status, 1990 and 2010
Risk factors 1990 2010
Rates per 100 000 Males Females Total Males Females Total
Water & sanitation 23.7 22.4 22.4 2.8 2.8 2.7
Ambient PM pollution 28.0 24.0 24.0 30.1 30.1 24.2
Household air pollution 78.4 76.4 76.4 59.3 59.3 52.6
Under-nutrition 144.3 147.7 147.7 13.9 13.9 14.9
Smoking 77.8 41.8 41.8 97.6 97.6 64.1
Alcohol & drug use 5.6 0.8 0.8 5.5 5.5 3.2
High fasting plasma 18.8 12.7 12.7 35.2 35.2 29.9
glucose
High blood pressure 35.7 38.3 38.3 61.6 61.6 55.8
Dietary risks 52.5 45.0 45.0 83.5 83.5 66.7
Physical inactivity 17.9 17.9 15.6
Occupational risks 23.6 9.3 9.3 19.9 19.9 12.1
Source: Global Burden of Disease study, Bangladesh country analysis: http://ghdx.healthdata.org/
record/bangladesh-global-burden-disease-study-2010-gbd-2010-results-1990–2010

16
Cancer: The overall population projections estimate that cancer
accounted for 7.5% of deaths in 2008. There is no national cancer registry;
however the facility-based data reveals that there are around 200 000 new
cases of cancer per year. For its economic impact, the National Cancer
Control Strategy and Plan of Action 2009–2015 confirms cancer as a high
priority for Bangladesh. Cancer screening is limited to a few secondary
and most tertiary level facilities and needs to be expanded in both the
public and private sectors.

The National Institute of Cancer Research and Hospital (NICRH), the

national and referral centre for cancer treatment in Bangladesh,
reported that the most frequently cancer-affected organs among their
male patients were lungs (27.1%), lymph nodes (9.6%), and oesophagus
(6.15%), while for females the most frequently cancer-affected organs
were breast (26.3%), cervix (21.1%) and lymph nodes and lymphatics
(5.2%) (DGHS, 2012).

Diabetes: The estimated prevalence of diabetes is at 6.9%, with the vast

majority being Type 2 diabetes. The International Diabetes Federation
estimates that by 2025, 7.4 million people in Bangladesh will have
diabetes, placing Bangladesh among the top ten countries for number of
people living with diabetes. Rapid urbanization, with a sedentary lifestyle
and an altered diet consisting of more energy-dense processed foods,
puts the country at risk for increased obesity and the emergence of the
disease (WHO, 2005).

Road accidents: In the last two decades, traffic accidents have increased
in Bangladesh (Figure 1.5) and now cause vast social and economic loss
through fatalities and property damage. According to national statistics,
road accidents in Bangladesh claim, on average, 3000 lives, and injure
another 4000 per year. WHO estimates actual fatalities of 20 038 each
year. In proportion to vehicle ownership rates, Bangladesh has one of
the highest fatality rates internationally, with over 100 deaths per 10 000
motor vehicles (WHO, 2009).

17
Figure 1.5 Trends in road traffic accidents Bangladesh 1999–2008

Fatality Grievous Simple injury

3500

3000

2500

2000

1500

1000

500

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source: BRTA annual report

Emerging and re-emerging diseases: These include drowning, dengue,

and avian influenza. Since May 2008, Bangladesh has been in the
Pandemic Alert Phase indicating active circulation of the avian influenza
virus among poultry and transmission from poultry to humans. The
Ministry of Health and Family Welfare leads the response to the epidemic
and sentinel surveillance.

Malnutrition: Malnutrition is a challenge in the South Asian region,

particularly in Bangladesh. While the country has reduced the rate of
underweight children under five, the country is well behind in reducing
the rate of stunting. Malnutrition is also high among women (adolescents
and pregnant women). Obesity is another growing concern. At present,
emphasis needs to be directed towards preventing women’s and
children’s malnutrition, micronutrient deficiencies and obesity.

During 2004–2011, modest improvements in child nutritional status were

also observed: stunting (height-for-age) of children under-five decreased
from 51% to 41%, while the proportion of underweight (weight-for-age)
children decreased from 43% to 36% (Figure 1.6).

18
Figure 1.6 Trends in child nutritional status 2004–2011

2004 BDHS 2007 BDHS 2011 BDHS

Percent of children under age five 2016 Aim: 38%

51
43 41 43 41
36

Stunting Underweight
(height-for-age) (height-for-age)

Based on the 2006 WHO growth standard

Source: BDHS

Malnutrition among women is characterized predominantly by

undernutrition, but the prevalence of overweight is also increasing
substantially (Figure 1.7). Over 16 years, the proportion of chronic energy
deficiency (CED) in women has been reduced by more than half to 25%
and the proportion of overweight has increased from 6% (Bangladesh
Bureau of Statistics,1997) to 25% (Waid, 2010). Now Bangladesh faces a
double burden of malnutrition, but CED remains the dominant nutritional
phenotype.

Figure 1.7 Trends in maternal CED and overweight 1996–2010

CED (BMI<18.5) Over weight (>23)

60
52
50 45
38
Percent

40 33
32
30 25 25

17 16
20
12
9
6
10

0
BDHS BDHS BDHS 2004 CMNS BDHS 2007 FSNSP
1996-1997 1999-2000 2005 2010

Source: BDHS

19
Mental health: A national survey in 2003–2005 reported that 16.05% of
the adult population of Bangladesh suffered from mental health disorders
(WHO, 2007). Data from the National Institute of Mental Health and
Research show that the number of new mental health patients visiting
both outpatient and inpatient departments, including emergency cases,
increased over time between 2007 and 2011 (DGHS, 2012). According to
this data, schizophrenia ranked first among all types of mental diseases
diagnosed, followed by bipolar mood disorder and depression (DGHS,
2012). Similarly, a study conducted in Dhaka investigating the types of
psychiatric diagnoses among admitted patients in a private hospital also
revealed that schizophrenia was the leading psychiatric disorder (39.4%)
(Fahmida, Wahab et al., 2009). This was followed by substance-related
disorders (29.6%), bipolar mood disorder (12.17%), and major depressive
disorders (6.58%) (Fahmida, Wahab et al., 2009). Diabetes mellitus is
frequently associated with co-morbid depression, and in 2000 Bangladesh
had 3.2 million people with diabetes, putting it 10th globally in terms
of disease prevalence and contributing to the mental health burden
(Rahman, et al., 2011).

In Bangladesh, no mental disorder is covered by social insurance, no

human rights review body exists to inspect mental health facilities, no
specific mental health authority has been established, and there are only
limited resources allocated for mental health (WHO, 2007). There are 50
outpatient mental health facilities available, in addition to 31 community-
based psychiatric inpatient units, 11 community residential facilities,
and one 500-bed mental hospital (WHO, 2007). The density of human
resources working in mental health facilities or private practice is 0.49
per 100 000 population (WHO, 2007).

Disability: To date, no comprehensive empirical study has been conducted

to determine the incidence and prevalence of disabilities in Bangladesh
(Alam, 2014). Disability is not included in any routine data collection or
surveillance system in the health sector (Danish Bilharziasis Laboratory,
2004; Titumir and Hossain, 2005), but it was included in national censuses
in 1982, 1986 and 1991 even though the reported prevalence rates are
far below international and national estimates (Danish Bilharziasis
Laboratory, 2004). Several surveys by different development agencies and
NGOs have been conducted to quantify disability in Bangladesh, but they
only cover limited types of disability or are limited in coverage (Danish
Bilharziasis Laboratory, 2004; Alam, 2014). As no reliable national
data exists, the prevalence of disability in Bangladesh is estimated at

20
5–12% (Alam, 2014), close to WHO’s global estimate which predicts that
approximately 10% of all people have a disability of one kind or another
(Titumir and Hossain, 2005). The prevalence of disabilities in children
below 18 years is estimated to be 6%, and among those above 18 years to
be around 14%. In 2004, with 44.3% of the population of 129 million below
18, there were about 3.4 million children with disabilities and 10 million
adults with disabilities (Danish Bilharziasis Laboratory, 2004).

Surveys conducted by Action Aid Bangladesh revealed the distribution of

types of disability in 10 surveyed locations, including locomotor, visual,
hearing and speech, cognitive or mental disability, epilepsy and multiple
disability, with visual disability proving to be the most prevalent type of
disability followed by hearing and speech (Danish Bilharziasis Laboratory,
2004). Most studies in Bangladesh have not distinguished between
congenital disability and disabilities occurring later in life (Danish
Bilharziasis Laboratory, 2004), but a microstudy from one area suggests
that 50% of impairments were due to disease and malnutrition, over 17%
were due to birth defects, 15% were due to accidents, and 8% due to old
age (Danish Bilharziasis Laboratory, 2004). While Bangladesh is making
progress in other health indicators, a decline in the incidence of disability
is unlikely. Disabilities due to natural calamities and road accidents imply
that the prevalence of people with disability will continue to rise, even
though their nature and distribution are likely to change (Alam, 2014).

Indoor air pollution: In developing countries, indoor air pollution

resulting from burning wood, animal dung and other biofuels is a
major cause of acute respiratory infections, which constitute one of the
most important causes of child mortality (Dasgupta, Huq et al., 2006).
These fuels produce smoke which contains a mixture of particles and
chemicals that bypass the body’s defenses and increase the risk of
respiratory illnesses such as bronchitis and pneumonia (Khalequzzaman,
Kamijima et al., 2007). Middle- and upper-income households in urban
areas of Bangladesh usually utilize clean cooking fuels such as natural
gas, whereas households in periurban and rural areas rely primarily
on biomass fuels (Dasgupta, Huq et al., 2006). The results from BDHS
2011 showed that half of households in urban areas use solid fuel for
cooking, while almost all rural households use solid fuel, including wood,
agricultural crops, animal dung, straw, shrubs, grass, and charcoal
(NIPORT, Mitra Associates et al., 2013). The same data source suggests
that Bangladesh is slowly making some progress towards reducing
the proportion of the population that relies on solid fuels, from 91% in

21
2007 to 86% in 2011 (NIPORT, Mitra Associates et al., 2013). In addition to
a switch to clean fuels and clean stoves (Khalequzzaman, Kamijima et al.,
2007), changing ventilation characteristics (construction materials, space
configurations, cooking locations, and placement of doors and windows)
and ventilation behaviour, such as keeping doors and windows open after
cooking, can help to improve the quality of the air (Dasgupta, Huq et al.,
2006).

Water and sanitation: Access to safe water and sanitation are basic
determinants of health, and limited access to safe drinking water and
sanitation facilities, as well as poor hygiene, are associated with various
diseases such as diarrhoea (NIPORT, Mitra Associates et al., 2013). The
proportion of the population with access to clean water increased from 76%
in 1990 to 83% in 2011 (World Bank, 2013). In urban areas, drinking water
comes from various sources including: tube well or borehole (55%), piped
into the dwelling (21%), water piped into the yard (16%), and a public tap
or standpipe (7%). In contrast, tube well or borehole is the only source of
drinking water in rural areas (NIPORT, Mitra Associates et al., 2013).

Sanitation facilities that are shared are considered not to be as hygienic as

those that are not shared, and a facility is considered improved when it is
not shared (NIPORT, Mitra Associates et al., 2013). The proportion of the
population using an improved sanitation facility in Bangladesh increased from
38% in 1990 to 55% in 2011 (World Bank, 2013). Households in rural areas are
more likely to use a toilet facility that is not shared than urban households
(62% and 55% respectively) (NIPORT, Mitra Associates et al., 2013).

Arsenic contamination: Arsenic is present everywhere in the environment,

and has been recognized as a toxin of varying carcinogenicity depending on
its chemical and physical forms, concentration, and duration of exposure
(Hossain, 2006). Health effects resulting from prolonged exposure to arsenic
include cancer of the skin and internal organs and several nonmalignant
adverse health effects including weakness, oedema, conjunctival congestion,
diabetes mellitus, hypertension, and respiratory conditions (Milton, Smith
et al., 2005). The main source of chronic arsenic exposure in Bangladesh
is through drinking contaminated groundwater, which has been the
main source of drinking water for most of the population (Milton, Smith
et al., 2005). A survey conducted by British Geological Survey together
with the Department of Public Health Engineering (DPHE) found that the
groundwater of 60 surveyed districts out of 64 was contaminated with arsenic
(Hossain, 2006). The solution for this situation could be the treatment of tube

22
wells, which are used to extract groundwater, or by using water collected
from alternative sources such as surface or rainwater (Chowdhury, 2010).
Several efforts have been made to overcome the situation, including the
Bangladesh Arsenic-Mitigation Water Supply Project, supported by the
World Bank, which tried to implement a community-based approach to
the problem (Hossain, 2006).

23
2 Organization and governance

Chapter summary
The health system of Bangladesh is pluralistic, with four key actors that
define its structure and function: Government, the private sector, NGOs
and donor agencies. The Government or public sector is the first key
actor who, by constitution, is responsible not only for setting policy and
regulation but also for providing comprehensive health services, including
financing and employing health staff. The Ministry of Health and Family
Welfare, through the Directorates General of Health Services (DGHS)
and Family Planning (DGFP), manages a dual system of general health
and family planning services through 53 District Hospitals, 425 Upazila
Health Complexes, 1469 Union Health and Family Welfare Centres, and
12 248 community clinics at ward level. In addition, the Ministry of Local
Government, Rural Development and Cooperatives manages the provision
of urban primary care services. The quality of services at these facilities,
however, is quite low, due mainly to insufficient resources, institutional
limitations and absenteeism or negligence of providers.

Since 1976, to compensate for the government’s limited capacity

to provide basic health services, the private sector and NGOs have
established a network of facilities to provide health and family planning
services. The private sector consists of the formal sector, which provides
both western and traditional (Unani and Ayurvedic) services through
a range of facilities from hospitals to clinics, laboratories and drug
stores, and the non-formal sector, which consists of largely untrained
providers of western, homeopathic and traditional (kobiraj) medicine.
However, private services are poorly regulated, while the formal sector
is concentrated in urban areas, and the informal sector is the principal
provider in rural areas.

In response to the low quality of service provision by Government and its

inability to reach the entire population, particularly the poor, a vibrant
and large NGO sector has emerged as a“third sector”of health providers
in Bangladesh. The role of NGOs is growing as donors channel significant
and increasing amounts of funding directly to them. In 2007, 9% of total

24
health expenditure (THE) was managed by NGOs, up from 6% in 1997.
As a response to both external and internal pressures, there have been
partnerships between government and NGOs in the areas of financing,
planning, service delivery, capacity building, and monitoring and
evaluation that have produced some health gains.

Bangladesh’s public health system remains highly centralized, with

planning undertaken by the Ministry of Health and Family Welfare and
little authority delegated to local levels. The Health Information System
suffers from the bifurcation of the Ministry into the DGHS and the DGFP,
with separate and distinct reporting systems for each. While there exist a
number of Acts and Ordinances to regulate the health system, including
regulation of different types of providers, practice facilities and NGOs,
many of these legal instruments date from several decades ago. Separate
councils for the registration and licensing of medical practitioners,
dentists, and nurses have been established, but their authority to
investigate and discipline providers is weak. A number of initiatives
have been undertaken through the joint Government-donor pooled
programmes to encourage and support community empowerment and
accountability, with limited success. However, a number of NGOs remain
active in public reporting on government handling of the health sector.

2.1 Overview of the health system

The provision of basic health services in Bangladesh is a constitutional
obligation of the Government (IGS, 2012). Article 15 of the Constitution
stipulates that it shall be a fundamental responsibility of the State
to secure for its citizens the provision of the basic necessities of life,
including food, clothing, shelter, education and medical care. In addition,
Article 18 of the Constitution asserts that the State shall raise the level
of nutrition of its population and improve public health as some of its
primary duties. In line with this broad legal framework, the health sector
has developed policies and programmes which are implemented through
the central control of the Ministry of Health and Family Welfare. Despite
the constitutional obligation to secure health services for the people, in
practice this responsibility has been significantly shared with the private
sector. The country has an entrepreneurial health system, i.e. access to
health services is considered the individual’s responsibility depending on
his or her economic condition.

The health system of Bangladesh is pluralistic, referring to the existence

of multiple actors performing diverse roles and functions through a mixed

25
system of medical practices. There are four key actors that define the
structure and functioning of the broader health system: Government,
the private sector, NGOs and donor agencies. Government, the private
sector and NGOs are engaged in service delivery, financing and employing
health staff; donors play a key role in financing and planning health
programmes. The public sector is mandated not only to set policy and
regulations but also to provide comprehensive health services and to
manage financing and employment of health staff. The Government
regulates the functions of public, private and NGO providers through
various acts and legislation. It delivers services through its nationwide
infrastructure by employing doctors, dentists, nurses, pharmacists and a
huge number of auxiliary health workers.

Public sector care includes curative, preventive, promotive and

rehabilitative services, while the private sector provides mostly for-profit
curative services and not-for-profit curative services to a limited extent
at the national and subnational level. NGOs, on the other hand, provide
mainly preventive and basic care. The private sector, with its limited
infrastructure, employs more providers than the public sector, including
traditional healers, unqualified allopaths, and doctors who are already
employed by the Government. On the other hand, NGOs provide mostly
not-for-profit services to the underserved population.

The Ministry of Health and Family Welfare regulates both public and
private sector health services. As per Schedule I of the Rules of Business,
the Ministry has been empowered to act as the central body for policy
formulation and planning, regulating the medical profession and
standards, managing and controlling drug supply, administering medical
institutions, providing health services and much more. The Ministry,
with its two wings of Health and Family Planning, manages public sector
health services ranging from primary to tertiary care (excluding urban
primary care), stretching from the central level to the grassroots and
covering both rural and urban areas. It is worth noting that although the
Ministry is the leading agency for institution-based health care delivery
at the national level and in rural areas, primary health care in urban
areas is the responsibility of respective local government institutions
(municipalities and city corporations) which are under the Ministry
of Local Government, Rural Development and Cooperatives. Private
sector infrastructure, on the other hand, is limited to medical colleges,
hospitals, clinics of various natures and qualities, pharmacies, and
untrained healers. Service coverage by the private sector is wider than
the public sector (http://uphcp.gov.bd/Responsibilities).

26
Figure 2.1 Organization of the health system in Bangladesh

Constitution

Parliament

Directorate of Ministry of Health Regulatory Ministry of Local Government & Rural

Nursing and Family Welfare Bodies Development (LGRD)
(MOHFW)

Drug Municipalities, City

Administration Corporations

Health Directorate of Directorate of Private Providers/ NGO

Engineering Health Services Family Planning (for profit & not for profit)

Medical Colleges (21) Specialist level services at National Institute of

Specialized Research national level Population Research
Institute of Public
Health, Institute of Secondary care at District
Epidemiological level
Disease Control
Research, Institute of Referral care at Thana FP related services.
Public Health and
Nutrition Primary care at Union and At Union level, DGFP has
Community level facilities UHFWCs.
Post Graduate
Institutes (6), Institute At sub-district level, the FP
of Health Technology, wing at UZHC, at district
Medical Assistant level MCWCs
Training Schools (5),
Specialized Institute
and Hospital

Source: Asia Pacific Observatory on Health Systems and Policies

2.2 Historical background

Modern health systems evolved in Bangladesh, as in many developed
countries, within the premises of Government-owned health-care
establishments largely funded by government tax revenues. Bangladesh
was a part of India when it was a British colony and later became the
eastern province of Pakistan (East Pakistan) at the time of the partition
of British India on 14 August 1947. Thus Bangladesh inherited a highly
centralized health-care system from the former British colonial power,
which was then influenced by health policies in Pakistan until its
independence in 1971 (Mahmood, 2009). In 1946, a Health Survey and
Development Committee was formed, popularly known as the “Bhore
Committee”, with the objective of exploring conditions and health
service provision and putting forward recommendations for further
development. The Committee proposed a comprehensive health-care
service provision system; inter alia, integration of curative and preventive
services, production of basic doctors for rural health institutions, and the
establishment of rural health centres. During the early 1960s, several

27
initiatives were undertaken to strengthen health systems. Important
among them were (i) the scheme of Rural Health Systems, comprising one
rural health centre and three subcentres for every 50 000 people; (ii) the
Malaria Eradication Programme; and (iii) the Family Planning Programme
that over time turned into a department under the Ministry of Health and
Family Welfare.

After independence in 1971, the country inherited a health-care delivery

system comprising eight medical college hospitals, 19 district hospitals,
a number of sub-divisional hospitals, and rural and urban health centres
(dispensaries). In the early days of independence, overpopulation was
recognized as the major obstacle to national development. Accordingly, a
separate division for family planning activities under the Ministry of Health
was created. In 1975, the Ministry of Health was bifurcated into two wings
and population control received new impetus in health sector planning.

The First Five Year Plan (1972–1978 and then extended to 1980)
emphasized primary health care (PHC) as the key to improving health
care, as stated in the Alma-Ata Declaration of 1978 (Anwar, Islam et al.,
2012).The plan established 31-bed Upazila Health Complexes (UHCs)
in most rural subdistricts, while the second and third Five Year Plans
(1980–1990) strengthened human resources for health (Anwar, Islam
et al., 2012). During the third and fourth planning periods (1986–1998), the
Government implemented a number of child health programmes including
the Expanded Programme on Immunization (EPI), Control of Diarrhoeal
Diseases (CDD), the Acute Respiratory Infection (ARI) Control Project and
the Night Blindness Prevention Programme (Anwar, Islam et al., 2012).
These health development projects were impressive in reducing mortality
and morbidity.

Since the late 1990s the health sector has gone through massive
institutional reform to promote greater equity and efficiency in resource
use under the influence of external donors. In 1996, the World Bank and
other consortium members indicated to the Government that they would
not proceed with further credits until a comprehensive, sector-wide
strategy had been adopted (Vaughan, Karim et al., 2000). This included
substantive structural and organizational reforms by the Ministry of
Health and Family Welfare (Buse, Gwin, 1998). Accordingly, the Health
and Population Sector Strategy (HPSS) approved in 1997 gave the health
sector a new direction towards efficiency and cost-effectiveness through
advocating certain institutional and governance reforms in the health
sector.

28
The HPSS fed into two consecutive policy documents – the Fifth Five Year
Plan (1997–2002) and the National Health Policy approved in 2000. As a
result, these three documents advocated for a common set of institutional
reform strategies, including the provision of primary health services in an
ESP, introduction of the Sector Wide Approach (SWAp), one-stop services
through community clinics at the village level, unification of the Health
and Family Planning Directorates, administrative decentralization, and
the creation of static clinics (community clinics). Accordingly, in 1998
the first-ever five-year operational programme, called the Health and
Population Sector Programme (HPSP) (1998–2003) was designed and
implemented. With the termination of HPSP, the Health Population and
Nutrition Sector Programme (HPNSP) for 2003–2010 was launched, with
similar strategies but an added emphasis on nutrition. With its expiry
in 2011, the country has designed another operational programme
called the Health, Population, and Nutrition Sector Development
Programme (2011–2016), with a renewed emphasis on improving nutrition
by streamlining this service at various levels of the health system
(MOHFW, 2011).

2.3 Health system organization in Bangladesh

2.3.1 Administrative structure of the statutory health system
The Ministry of Health and Family Welfare implements its programmes
and provides services through different executing and regulatory
authorities. The executing authorities include five Directorates of
the Ministry and some other organizations. The Directorates are:
the Directorate General of Health Services (DGHS); Directorate
General of Family Planning (DGFP); Directorate General of Drug
Administration (DGDA); Directorate of Nursing Services (DNS); and the
Health Engineering Department (formerly known as the Construction
Management and Maintenance Unit). The DNS and the DGDA are attached
to the health wing of the Ministry of Health and Family Welfare. The
DNS is responsible for nursing education and nursing services, while
the DGDA implements drug regulations. Other executive organizations
accomplishing significant tasks of the Ministry include the Transport
and Equipment Maintenance Organization, National Electro-medical
and Engineering Workshop, and the Essential Drugs Company Limited.
The regulatory bodies of the health sector are the Bangladesh Medical
and Dental Council (BMDC), Bangladesh Nursing Council (BNC), State
Medical Faculty (SMF), the Ayurvedic, Homeopathy and Unani Board, and
the Bangladesh Pharmacy Council.

29
To facilitate research and training in medical science, different public
sector institutions under the control of the Ministry of Health and Family
Welfare operate at the national level. There are 21 government medical
colleges, six postgraduate institutes, three specialized institutes, two
institutes of health technology and five medical assistant training schools
in Bangladesh (DGHS, 2012). For research there are two institutions, the
Bangladesh Medical Research Council (BMRC) and the National Institute
of Population Research and Training (NIPORT). In addition there are a few
public health research and training institutions, including the Institute of
Epidemiology, Disease Control and Research (IEDCR), Institute of Public
Health (IPH), Institute of Public Health and Nutrition (IPHN) and National
Institute of Preventive and Social Medicine (NIPSOM).

Additionally, the Government of Bangladesh delivers health-care

services in partnership with NGOs. The Urban Primary Health-care
Services Delivery Project (UPHCSDP) covers all seven city corporations
and five municipalities (Bogra, Comilla, Madhabdi, Savar and Sirajgonj)
in Bangladesh (UPHCSDP, 2014). The goal of the project is to improve
the health status of the urban population, especially the poor, through
improved access to and utilization of efficient, effective and sustainable
PHC services. The Ministry of Local Government, Rural Development and
Cooperatives is responsible for managing this project through a Project
Management Unit established in the six city corporations and the five
selected municipalities.

At least 30% of the total services provided by this project are targeted
to the poor free of cost. UPHCSDP service providers are contracted
to deliver an agreed “Essential Services Package +” (ESP+) through
partnership agreements with a focus on access for the poor. The services
are provided through Comprehensive Reproductive Health-care Centres,
Primary Health-care Centres and PHC Outreach Centres (satellite clinics)
in 24 Partnership Areas. The centres are generally managed and run by
12 partner NGOs. UPHCSDP provides services for reproductive health-
care, child health care, communicable disease control, limited curative
care, management and prevention/control of reproductive tract/sexually
transmitted infections, voluntary confidential counselling and testing for
HIV/AIDS, management of violence against women, primary eye care, TB
control and treatment, behaviour change communication, and diagnostic
services.

30
2.3.2 Public sector health services
The Ministry of Health and Family Welfare has an extensive health
infrastructure. The service delivery structure follows the country’s
administrative pattern, starting from the national to the district, upazila,
union and finally to the ward levels. It provides promotive, preventive,
and curative services such as outdoor (outpatient), indoor (inpatient), and
emergency care at different levels – primary, secondary and tertiary. The
chart below (Figure 2.2) summarizes the organization of the Ministry of
Health and Family Welfare service delivery structure. The details of the
number of various health facilities and resources have been included in
Chapter 4.

Figure 2.2 Health service delivery organizational structure in

Bangladesh

Ministry of Health and Ministry of Local

Family Welfare (MOHFW) Government Rural
Development and
Cooperatives
(MoLGRDC)

Directorate General of Directorate General City Corporation

Health Services of Family Planning (MoLGRDC)
(DGHS) (DGFP)

Medical College District & Maternal and Child Local NGO or Private
& Specialized General Welfare Centres provider
Hospitals Hospitals (MCWC)

Upazilla Health Union Health &

Complex Family Welfare
(UHC) Centres
(UHF&WC)
Union Sub- Centres
(USC)
Rural Su-Centres
(RSC)
Community Clinic
(CC)

Community Clinic
(CC)

Source: Asia Pacific Observatory on Health Systems and Policies

2.3.3 Private sector health services

In the private sector, providers can be grouped into two main categories.
First, the organized private sector (both for-profit and nonprofit) which
includes qualified practitioners of different systems of medicine.

31
Apart from modern medicine, traditional medicine is widely practiced in
the private sector. Second, the private informal sector, which consists
of providers not having any formal qualifications such as untrained
allopaths, homeopaths, kobiraj, etc., known as Alternative Private
Providers. These informal/traditional private service providers mostly
serve the poor in rural areas. On the other hand, the formal, for-profit or
nonprofit service institutions are mostly located in urban areas. Private
facilities including medical colleges, hospitals, clinics, laboratories, and
drug stores are being established in increasing numbers in the capital city
as well as other divisional headquarters. This causes geographic inequity
in health service provision. The private facilities are often staffed with
public sector health personnel. Many health professionals hold two jobs.

The growth of the private sector compared to the public sector is

significant. Along with the increasing number of hospitals and hospital
beds, over the last few years the private sector has witnessed a
tremendous growth of teaching institutions. For instance, in 1996 there
were no medical colleges or any teaching institutions in the private
sector, but by 2011 the private sector had 44 medical colleges (MOHFW,
2013).

2.3.4 Diagnostics
Along with private clinics and hospitals, the number of diagnostic centres
in the private sector is growing. In 2000, approximately 838 laboratories
and other diagnostic centers were registered with the Ministry of Health
and Family Welfare. This number has risen to 5122 in 2012 (MOHFW,
2012). In the private for-profit sector, there are some large diagnostic
centers in the cities (Lab-aid, Popular Diagnostics) providing laboratory
and specialized radiological tests. Some of these facilities maintain a
high standard. In the nonprofit private sector, there are centres like the
International Centre for Diarrhoeal Diseases and Research, Bangladesh,
located in Dhaka, which has a modern laboratory providing research
facilities and extends laboratory services to the general community.

2.3.5 NGOs
The NGO sector has emerged as the third sector, providing new options
and innovations. Bangladesh is known worldwide for having one of
the most dynamic NGO sectors, with over 4000 NGOs working in the
population, health and nutrition sector (Perry, 2000). NGOs have been
active in health promotion and prevention activities, particularly at the

32
community level, and in family planning, maternal and child health areas.
The role of NGOs is growing as donors are channelling significant and
increasing amounts of funding directly to them. In 2007, 9% of total health
expenditures were managed by NGOs, up from 6% in 1997; upwards of
80% of NGO funding comes from donors (Health Economics Unit, 2010).
The larger national NGOs (BRAC, Gonoshasthaya Kendra, Grameen
Bank) have strong organizations and the management capacity to provide
both preventive and curative services. These NGOs are well-equipped
with training and research facilities and information management
systems. NGO partners provide services for the Expanded Programme of
Immunization across the country, in urban and rural areas.

There is generally a good working relationship between the government

and NGOs, as exemplified by the number of public-private partnerships.
The Fifth Five Year Plan (1997–2002) encouraged promotion of the role
of the private sector and NGOs in health development. In later years,
health sector diversification was emphasized, implying a shift from
Government’s role being as a “provider”of services towards being a
“purchaser” of services. This established formal collaborations between
the public and private sectors –public private partnerships.

2.3.6 Donors
Multiple donors, both multilateral and bilateral, have been actively
engaged in health-care financing and planning. The main bilateral donors
to the health and population sector in Bangladesh are the governments
of Australia, Belgium, Canada, Germany, Japan, Netherlands, Norway,
Sweden, the United Kingdom and the United States (Vaughan, Karim
et al., 2000). The multilateral donors include the World Bank, European
Union, UNICEF, ADB, Global Fund to Fight AIDS, Tuberculosis and Malaria
(GFATM), and the GAVI Alliance.

2.3.7 Professional groups

In Bangladesh there are a number of professional organizations who
address the rights of medical professionals at different levels, such
as the Bangladesh Medical Association (BMA), Bangladesh Private
Medical Practitioners Association (BPMPA), Public Health Association
of Bangladesh, Bangladesh Paediatric Society and the Nephrology
Society of Bangladesh. However, there is no organized body, either in
the public or private sector, for overseeing the interests of patients. The
Consumers Association of Bangladesh is an NGO addressing the rights

33
of consumers in general, and does not have a separate agenda on health
focusing on the rights of consumers as patients (Consumers Association
of Bangladesh, 2014).

2.3.8 Health policy formulation

Health planning is the sole responsibility of the central government. The
health-care system is exclusively controlled by the Ministry of Health
and Family Welfare with deconcentration of some power to the local
level. At the central level, power is always centralized towards higher-
level officials:“Officials who are closer to project execution do not take
decisions and prefer to defer them to the higher layers who are distant
from project execution”(Task Forces, 1991).

Bangladesh had its first National Health Policy (NHP) formally approved
by the Parliament in 2000. The key objectives of the policy include:
providing basic health services to the people at all levels, particularly to
the poor; ensuring the availability of primary health-care services at the
union and upazila/thana levels; improving maternal and child health and
reproductive health services; and strengthening family planning services.
The policy saw many revisions until 2011, but without any dramatic shift
in its focus. The latest policy revision in 2011 emphasizes primary health
and rural health, as before, and new issues that have been introduced
include a health insurance scheme for formal institutions and the
provision of health cards for the ultra-poor and deprived (MOHFW, 2011).

2.4 Decentralization
The health-care system of Bangladesh corresponds to a hierarchically
arranged pyramidal structure where the ultimate authority lies with
the Ministry of Health and Family Welfare. At the local level, the
deconcentrated health administration is fully controlled by the Ministry
of Health and Family Welfare. The field-level health administration is
responsible for implementing government programmes by managing
the huge number of health staff and coordinating their activities.
Responsibility for financing, functionaries, supplies, maintenance and
infrastructure development for service delivery lies with the Ministry.
It also manages appointment, transfer, posting and salary of frontline
service providers. Although selection of some field-level staff (4th grade)
is done at the district level, recruitment is done at the central level. With
regard to supplies, each level of local administration (Union Health and
Family Welfare Centre/Sub-centre/community clinic, Upazila Health

34
Complex, District Hospital) can submit their needs to the central level,
but actual supply depends on the decision of the centre. For development
of infrastructure/facilities, local administration collects data (e.g. land
availability, local needs) from the ground to inform the central decision
(Osman, 2004).

In parallel with the deconcentrated structure of health administration,

down towards the grassroots level, there are also local government
institutions which are bestowed with responsibility for delivering health
services at the local level. In practice, local bodies in rural areas mainly
perform motivational, awareness building, and some facilitative roles
in service delivery (Ministry of Local Government, Rural Development
and Cooperatives, 2004). They have no formal role in determining
supplies, finance, or even monitoring the performance of the local-level
service providers/facilities. The local providers are accountable to their
departmental superiors rather than the locally-elected bodies. Local
government has been authorized to supervise the facilities with a view
to identifying irregularities or prevailing problems, but this supervision
creates no impact on service delivery.

Local government institutions are also heavily dependent on the

central government for financing, which creates inefficiency in financial
management. Capital and funds for routine maintenance, repairs, etc.
are exclusively controlled from the centre. Funds are spent strictly in
accordance with rules and regulations rather than the demands of
the situation. Financial matters are so centralized and circumscribed
with bureaucratic rules and regulations that local officials, even DGHS
officials, cannot switch money between budgetary subheads without the
concurrence of the Ministry of Health and Family Welfare.

In contrast to the negligible role of rural local government in health

service delivery, urban local government institutions called city
corporations (large cities) and municipalities (small cities) play a key
role in the delivery of health care, specifically primary health services.
The mandate for providing primary health care in urban areas is
vested with the Ministry of Local Government, Rural Development and
Cooperatives. The locally elected bodies operating under the legal control
of this ministry are responsible for financing the service, recruiting the
functionaries (3rd and 4th grade staff) and establishing the facilities.
Urban local bodies have one sanctioned post for a doctor and around
eight paramedics and other support staff, whose salaries are paid by the

35
concerned local body. Local bodies perform all these functions from their
own sources of revenue and from donor-funded projects implemented by
NGOs.

It is also worth noting that although urban primary health services are
managed and provided by local government institutions, decision-making
authority is hardly transferred to this level. Dominance of bureaucracy
over the local representatives ultimately makes the local bodies
accountable to the Ministry of Local Government rather than the people,
which consequently makes the overall administration unaccountable.

2.5 Planning
2.5.1 Current Planning
The health sector plan of Bangladesh is an integral part of the national
Five Year Plan. The Planning Commission, which is the central planning
agency, is responsible for preparing the framework of the Five Year
Plans, with inputs from the Ministry of Health and Family Welfare. The
country is currently under its Sixth Five Year Plan (2011–2016). The health
plan under the Five Year Plan provides guidelines describing the broad
sectoral goals, targets, and strategies for a five-year period (MOHFW,
2011).

In line with the national Five Year Plan, the Ministry of Health and Family
Welfare prepares a Strategic Investment Plan (SIP) which sets out the
sector’s strategic priorities and defines an overall strategic framework
to guide investments in the health sector accordingly. The SIP provides a
framework for health service delivery, planning, budgeting, implementing
and monitoring for the five-year-long sectoral programmes. One
of the focuses of the SIP is medium-term planning and budgeting.
Medium-term planning intends to draw a link between revenue and
the development budget and between Government and other (internal
and external) sources of funding. Like the national budget, the health
budget is compartmentalized into revenue and development budgets. The
revenue budget includes the budget for salary, wages, and allowances
for functionaries and maintenance costs, while the development budget
is programme-based. However, Ministry of Health and Family Welfare
revenue and development budgets are still prepared independently and
on different timelines (MOHFW, 2004). The SIP is intended to provide
the basis for Policy Implementation Plan preparation and health sector
investments over the next five years; thus, the SIP is an operational

36
document for the Five Year Plan. The SIP is prepared with input from
both internal and external stakeholders, with the objective of defining
the Government’s intentions for the health sector as the basis for
negotiating assistance from development partners in the medium term.
It also provides inputs into the Five Year Plan, National Health Policy and
operational programmes like HNPSDP.

For the preparation of both the plans and programmes, certain

participatory techniques are adopted for securing inputs from the field,
but the Ministry of Health and Family Welfare has the authority to make
the ultimate decision (Osman, 2004). Broad participation by stakeholder
groups has ensured the inclusion of professional and civil society groups,
along with experts deployed by key development partners and donors.
The last sector programme the country implemented was the Health,
Nutrition and Population Sector Programme in 2003–2010. Each health
sector programme undergoes mid-term reviews as well as annual
reviews by external teams comprised of national and international
experts. These also open a window for policy advocates to supply research
evidence. The Ministry of Health and Family Welfare has developed the
next Sector Development Plan– the HPNSDP – for implementation during
2011–2016 (MOHFW, 2011). The Ministry functions closely with external
donor agencies in preparing its plans and programmes, and the field-
level health administration provides necessary information.

Human resource planning

Currently Bangladesh does not have a structured policy for human
resource planning in the health sector. The Ministry of Health and
Family Welfare published the Bangladesh Health Workforce Strategy
in 2008. The goal of the Ministry is to implement the HR strategy in
collaboration with the private sector, development partners and other
stakeholders that work towards the greater good of Bangladesh, and to
review it every five years for necessary updates (MOHFW, 2008). The first
stakeholder dialogue on Human Resources for Health (HRH) took place
in Bangladesh in 2012 with the objective of starting advocacy on the need
for an adequate and skilled health workforce for a well-functioning health
system, but it has not been effective yet (WHO, 2014).

37
2.5.2 Role of development partners in planning
In the process of policy development, the Ministry of Health and Family
Welfare acts as the apex organization, vested with responsibility for
designing national programmes and policies and coordinating and
implementing all activities related to health and family planning in the
country. In policy formation the Ministry has always been closely influenced
by donor agencies, particularly in agenda-setting. Externally-generated
issues have ultimately shaped the health policy of Bangladesh. Amongst
the internal forces, political parties play the most important role in setting
the policy agenda (Osman, 2004).

The SWAp-based HPNSDP for planning and pooling funds has ample
room to engage in partnerships with development partners and other
stakeholders. The basket of funds comprises pool funds, non-pool funds,
the government contribution, and parallel funding mechanisms. The
Government has made continuous efforts to harmonize donor support and
align it with national plans and strategies. Various joint working groups
and technical committees are active within the networks of the sector
programme (WHO, 2014).

2.6 Intersectorality
The Ministry of Health and Family Welfare is mainly responsible for
managing prevention and treatment of diseases, and medical education.
In regard to other sectoral issues, such as access to water, sanitation,
adequate food, pollution-free environments, and health education and
awareness, various other ministries are involved: the Local Government
Engineering Department (LGED) of the Ministry of Local Government,
Rural Development and Cooperatives, the Ministry of Food and Disaster
Management, the Ministry of Agriculture, the Ministry of Fisheries and
Livestock, the Ministry of Water Resources, the Ministry of Environment
and Forestry, the Ministry of Women and Children Affairs, the Ministry
of Education, and the Ministry of Social Welfare. The Ministry of Local
Government provides a significant portion of health services, as it has
responsibility for providing public health services, waste management
and water supply in urban (city corporation and municipalities) areas, as
well as in rural areas through the LGED. Primary health-care services
provided directly by the DGHS are confined to those supplied by medical
college hospital outpatient departments, district hospitals, government
outpatient dispensaries, and maternal and child health services provided
by the Family Planning Directorate (MOHFW, 2004). In the planning of the

38
health sector, these realities were never reflected adequately in the past
(MOHFW, 2011). The main policy challenges for urban health are improved
coordination between the Ministry of Local Government and the Ministry of
Health and Family Welfare, an enhanced stewardship role for the Ministry
of Health and Family Welfare with regard to regulation of urban for-profit
health services, and strengthened public-private partnerships (MOHFW,
2004).

2.7 Health information management

2.7.1 Health information system in Bangladesh
The Ministry of Health and Family Welfare comprises nine executing
authorities (directorates). As noted, two are directly involved with provision
of health and family planning services, namely the Directorate General of
Health Services and the Directorate General of Family Planning. Four have
routine Management Information Systems (MIS):
• MIS Health (DGHS) and its subsystems;
• MIS Family Planning (DGFP) and its subsystems;
• MIS National Nutrition Programme (NNP); and
• MIS 2nd Urban Primary Health-care Programme (UPHCPII).

MIS-Health and MIS-FP are being implemented by the DGHS and the DGFP
independently. There is poor linkage between them (both at peripheral and
central level), although both provide summarized data to the Ministry of
Health and Family Welfare regularly. There is also little coordination with
the national statistics office, the Bangladesh Bureau of Statistics.

HIS resources

Policy and planning

No specific written policy exists for MIS in health in Bangladesh, although
the country has a legislative framework for health information that covers
vital registration and notifiable diseases reporting.

HIS institutions, human resources and financing

Most data management in health and family planning follows the
administrative hierarchy of the departments, where service providers
at different levels of the health-care delivery system report routine data
monthly to the level above them (Health Metrics Network & MOHFW, 2009).

39
At the central level there is one Line Director MIS at the office of the
DGHS. All data from the field (health facilities or communities) are
collected, compiled, analyzed and reported from this office to the
peripheral level reporting units. Annual and periodic reports are produced
by the Line Director MIS-Health to support policy decisions. The DGFP
works through administrative structures and institutes at national,
divisional, district and lower levels (MOHFW, 2011).

Data sources

A. Censuses
A census is carried out at least once every 10 years and the report
published within two years of the data being collected. There is no
mortality-based information in the last census.

B. Vital statistics
Although the Government has made birth registration obligatory, the
countrywide infrastructure is not well developed due to a shortage of
human resources and financial support. The Bangladesh Bureau of
Statistics conducts regular Sample Vital Registration Surveys to collect
data on births, deaths, and marriages.

C. Population surveys
Periodic population surveys are conducted by the BBS, NIPORT, and
BDHS.

D. Health and disease records (including disease surveillance)

Facility-based disease profiles are reported from all health facilities, but
this disease profile does not include private sector facilities, which are
the prime caregivers in curative health care in Bangladesh. Community-
based epidemiological surveillance is conducted for certain diseases such
as polio, neonatal tetanus, diarrhoea and few other notifiable diseases.

E. Health service records

The MIS-Health includes service statistics, logistics, human resources
and financial information. The service statistics are better organized
than other statistics such as human resources, logistics and finance.
Previously there was paper-based system for data collection, compilation
and onward transmission. Now it is mostly computerized, at least up
to subdistrict level Upazila Health Complexes. Separate health and

40
family planning MIS are maintained in the absence of sharing of routine
performance data between these two departments at all tiers of the
health system.

F. Other data sources

MIS-Health also collects data from other programmes and organizations
for consolidated report preparation and distribution. Information is
collected from programmes such as Essential Service Delivery (ESD),
Communicable Disease Control (CDC), the noncommunicable disease
control programme, the Micronutrient Supplementation (MS) programme,
NNP, and Mycobacterial Disease Control Programme; and organizations
like the Institute of Epidemiology, Disease Control and Research (IEDCR),
Institute of Public Health (IPH), the ICMH, the DGFP, the DGDA, the DNS,
and from a number of NGOs (Health Metrics Network & MOHFW, 2009) .

Dissemination and use

The routine MIS-Health publications include Health Bulletin, Year Book
on Health, IMCI newsletter, EmOC newsletter, and Voice of MIS-Health.
The Digital Health Guidebook is a popular publication. Most of the
information collected by MIS-Health focuses on the supply side: what
the facilities have done, and what type of inputs they have used. The MIS
has not yet been able to track information on the demand side of the
equation. Recent hospital reform has introduced some demand-side
information (waiting time, perception and satisfaction) into the system.
More importantly, the growing private and NGO health sector facilities are
by and large beyond the formal MIS of the Ministry of Health and Family
Welfare. MIS-Health data is rarely used for health planning purposes. The
collected data are of poor quality in terms of timeliness, completeness
and accuracy. Managers and policy planners in Bangladesh rely mainly on
survey data, not routine MIS data (MOHFW, 2011) .

41
2.7.2 Health technology assessment
Currently there is no national health technology assessment programme
for planning health technology requirements in public or private facilities
in Bangladesh. However, the DGHS is trying to engage in the process
through participation in regional conferences. A few local nongovernment
institutions have conducted research on health technology assessment
(Sivalal, 2009).

2.8 Regulation
National health policy provides for the promulgation of appropriate laws,
rules and regulations regarding the control, management and quality
of services of medical colleges and private clinics. Parliament has
enacted various Acts in relation to health services. These can be mainly
categorized into communicable disease control acts, drug control acts,
medical education acts, health practice acts and environmental health
acts. In addition to the Acts, the Parliamentary Standing Committee
constituted for the Ministry of Health and Family Welfare under the
Rules of Procedure of Parliament (Rule 246) serves as a watchdog of the
Ministry. According to Rule 248, the Standing Committee should meet
at least once a month to review works relating to a Ministry which falls
within its jurisdiction, and to inquire into any activity or irregularity and
ensure compliance in respect of the Ministry. However, the absence of
the standing committee on health in some regimes, belated committee
formation, irregular committee meetings and poor attendance have
weakened the effectiveness of parliamentary oversight (Alamgir F,
Mahmud T, 2006). In addition to this, the parliamentary committee has
also failed to ensure compliance with their recommendations. There is no
time limit for the concerned ministries, persons or executive branches to
respond to committee recommendations and decisions.

Several Acts and ordinances exist to regulate health service activities.

The Drug Ordinance of 1982 brought traditional Unani, Ayurvedic
and homeopathic medicinal products under regulatory control. The
Bangladesh College of Physicians and Surgeons Order 1972 (Presidents
Order No. 63 of 1972) provides guidelines for maintaining and promoting
specialist practice of all medical sciences and arranging postgraduate
medical training. Nursing services are regulated by the Bangladesh
Nursing Council Ordinance 1983.

42
To regulate private practice and the functioning of the private clinics
and private laboratories, the Medical Practice, Private Clinics and
Laboratories Ordinance 1982 was promulgated. The ordinance prescribes
the process of application, the criteria for issuance of licenses for running
private clinics, and lays down the maximum charges and fees for private
practice, private clinics and private laboratories, rules on inspection of
private facilities, and penalties for violation of the rules.

There also exist certain rules and laws to regulate the activities of NGOs.
The Government regulates the organizations through (i) Voluntary Social
Welfare Agencies (registration and control) Ordinance 1961; (ii) the
Foreign Donations (voluntary activities) Regulation Ordinance 1978; and
(iii) the Foreign Contribution (Regulation) Ordinance 1982. NGOs need to
be registered with the Department of Social Services/NGO Affairs Bureau.
In the case of health and family planning projects receiving foreign
assistance, NGOs are to obtain clearance for their projects from the
Economic Relations Division of the Ministry of Finance and the Ministry of
Health and Family Welfare (Shahid AM, 1997).

Table 2.1 on the next page summarizes the major regulatory authorities
in the health sector in Bangladesh.

43
Table 2.1 Main regulatory authorities in the health sector in Bangladesh
Name of Agency Function
Ministry of Health and Family Welfare Set standards
Director General Health Services License health facilities to function
License the administration of controlled
medicines
Approve non-medical and non-nursing health
cadre training institutions
SOPs for operation of laboratory and
diagnostic centres
Director General Family Planning License the administration of controlled family
planning methods
Director Drug Administration License pharmacy cadres
Quality assurance and registration of
pharmaceuticals
Joint Secretary Development and Approve medical colleges
Medical Education
Director Homeopathy and Traditional Accredit training
Medicines
Civil Surgeons Inspectors for health and safety in factories
Bangladesh Medical and Dental Council Accredit medical colleges for the training of
doctors and dentists
Register medical and dental officers
Pharmacy Council of Bangladesh Accredit training institutions for pharmacy
cadres
Bangladesh Nursing Council Register nursing cadres
Accredit nursing training institutions
Ayurvedic, Homeopathy and Unani Register practitioners
Board Quality assurance and registration of
traditional medicines
Source: World Bank Health Sector Profile 2010

2.8.1 Regulations and governance of third-party payer

The concept of third-party payer is absent in Bangladesh; however, various
organizations including the Health Economics Unit of the Ministry of Health
and Family Welfare and icddr,b have been conducting research on identifying
a health payment mechanism suitable for the country (Ensor 1998).

2.8.2 Regulation and governance of providers

In the arena of medical education and practice, the Medical and Dental
Council Act 1980 provides regulations for establishing a uniform minimum
standard of basic and higher qualification in medicine and dentistry and

44
matters connected there with. In addition, different professional
regulatory as well as statutory bodies have been established in order to
(i) develop skilled manpower (doctors, medical practitioners, nurses and
pharmacists); (ii) ensure the standard of health services by regulating
the activities of professionals; (iii) protect people’s rights; and (iv) ensure
access to health services. In this regard, the BMDC, BNC, State Medical
Faculty (SMF) and Bangladesh Pharmacy Council (BPC) have evolved to
play a stewardship role in health sector governance in Bangladesh.

The BMDC, established in 1980, regulates the registration and awards

of medical practitioners and dentists for the purpose of establishing
a uniform standard of basic and higher qualifications in medicine and
related matters. To ensure the standard of nursing education and
practice, the BNC was constituted in 1983. According to the Act, the BNC
acts as a national education board to ensure a good quality of education
for nurses. The SMF was established in 1914 to coordinate examinations
and certify diplomas for compoundership, dressership, paramedical
technicians, medical assistant courses, and the awarding of diplomas
and certificates to successful candidates of medical assistantships. In
1976, the BPC was established to regulate the practice of pharmacy.
The Bangladesh Board of Unani and Ayurvedic Systems of Medicine was
established to maintain educational standards at the relevant teaching
institutions and to register duly qualified persons.

In practice, these bodies have been struggling with limited legal power
and resources. While the BMDC has the power to punish medical and
dental practitioners for malpractice, in reality it has failed to enforce
its power to regulate professional behaviour, although negligence and
malpractice by doctors is quite frequent.

Moreover, the BMDC cannot act independently, but requires approval

from the Ministry of Health and Family Welfare. The BMDC also
cannot initiate independent investigations against doctors working in
government/public hospitals. It can only issue “show cause”notices to
the director of the concerned hospitals. If the hospital forms a committee
to investigate the complaints, the BMDC has to follow the decision of the
committee.

The SMF has been authorized to issue diploma certificates since 1962.
The SMF is the authority for approving all medical courses in the country.
In reality, the authority of the SMF is ignored by the Ministry of Health
and Family Welfare and Bangladesh Technical Education Board. Currently

45
any institute which intends to provide diploma certificates has to acquire
permission from the health ministry for approval from the state medical
faculty. This two-tier approval system is time-consuming for potential
medical educational institutions.

Despite the existence of various institutions assigned with regulating the

behaviour of health-care providers and standardization of services, in
practice regulatory power is highly concentrated at the health ministry.
The stewardship role of the public sector is constrained by a weak legal
framework and the institutional inadequacies of regulatory functionaries.

2.8.3 Registration and planning of human resources

Doctors and dentists are registered by the BMDC after graduation and
completion of internship, while nurses are registered by the BNC after
graduation. The registration is to be renewed every 10 years, but no
licensing examination is held.

The Ministry of Health and Family Welfare decides admission policies

for the graduation courses of physicians and dentists for both public and
non-public institutions, while the curricula are approved by the BMDC.
Currently, 23 government and 54 private medical colleges are engaged
in offering graduation degrees to the physicians, with an annual intake
of 3010 doctors (DGHS, 2012). The medical course is five years plus one
year in-service pre-registration training. As per the BMDC Act 1980, the
BMDC accredits medical colleges for training of doctors and dentists
and regulates the registration and awards of medical practitioners and
dentists for the purpose of establishing a uniform standard of basic and
higher qualifications in medicine and related matters. The BNC, on the
other hand, approves the curricula of nurse training and education and
offers registration to trained nurses.

Various health technicians such as laboratory technicians, pharmacists,

radiographers, blood bank technicians, physiotherapists, medical
technologists and occupational therapists are employed in the health
system. Health technicians are one of the most significant auxiliaries to
the health system. The DGHS arranges three-year diploma courses for
pathologists and radiologists. After obtaining the diploma degree they
are appointed as medical technologists. They are directly recruited by the
DGHS and deployed in both rural and urban areas.

46
The Ministry of Health and Family Welfare prepares admission policies
for alternative medical doctors (homeopathic and Unani/Ayurvedic). The
Bangladesh Homeopathic Board approves curricula for homeopathic
courses and Bangladesh Unani and Ayurvedic Board approves curricula
for Unani-Ayurvedic courses. Both boards are appointed by the Ministry of
Health and Family Welfare.

As of today, Bangladesh does not have any comprehensive and

independent policy document on HRH. Various health sector policy
documents developed at different times in response to diverse global and
local contexts have provided guidelines for managing human resources.
Currently, the revised 2011 Health Policy and the Sixth Five Year Plan
(2011–2015) provide guidelines for HRH planning. Broadly, during the
last two decades, the HRH policy has experienced a shift of focus from
emphasizing the expansion of the workforce to improving their efficiency
through training and education, and from imparting training to doctors
and nurses to providing training to community health workers like
midwives. In recent years, HRH policy has focused on the deployment as
well as retention of health staff in rural areas, ensuring an appropriate
skill mix and equity in distribution of human resources.

Since independence, development partners have played a lead role in

HRH policy formulation, especially at the stage of idea generation. The
medical profession, the next dominant set of actors, has over the years
played the determining role in the increased production of doctors. The
third set of key actors are the bureaucrats and the politicians who attempt
to rationalize the role of the doctors through imposing various rules and
regulations. Support staff – nurses and field level health workers – do not
get scope for meaningful participation in policy-making. As a result their
interests are mostly left unattended. This unbalanced power composition
in the policy process has a significant influence on policy performance.

2.8.4 Regulation and governance of pharmaceuticals

The DGDA is the supreme regulatory authority in the country for drug-
related affairs such as licensing, production, import, export, quality
control and pricing. (DGDA, 2014). In the recently reorganized structure,
the DGDA is headed by a director general, who is assisted by four
directors, responsible for manufacturing, registration and import/export
including administration and licensing, veterinary, quality control and
surveillance, and drug testing. There are two drug testing laboratories

47
– one in Chittagong under the DGDA and another one in Dhaka under
the DGHS’ Institute of Public Health. These ill-equipped laboratories are
supposed to test the quality of pre-registration as well as post-market
drugs. The regulatory mechanism for the production, marketing and use
of drugs is limited by the Drugs Act 1940 (and the rules made under it in
1946) and the Drugs (Control) Ordinance 1982 (DGDA, 2014).

Pricing of drugs
One of the main objectives of the National Drug Policy of 1982 was to
make quality essential drugs available at an affordable price. Since the
introduction, a pricing committee with experts from stakeholder groups
decides on the price of locally-produced drugs and also endorses the
prices of imported drugs/non-essential drugs produced locally after
review. From 1981 to 1991, the retail price of drugs increased by only 20%
in local currency. However, this trend could not be sustained. The drug
policy committee was restructured with greater inclusion of corporate
interests, which ultimately changed the spirit of NDP 1982 (“quality drugs
at low cost”). The first revision of the Essential Drugs List in 1993 reduced
the number of regulated drugs to 117, while the second revision in 2007
increased it to 2009, which resulted in a loosening of control in fixing
the prices of non-essential drugs in particular, and all drugs in general.
Currently, the government fixes the maximum retail prices of 117 listed
essential drugs (MOHFW, 2008). For other “non-essential”drugs, an
“indicative price”is fixed by the pharmaceutical companies themselves
(inflating hugely the profit margin), to which the government adds 15%
VAT, resulting in a steady increase in prices. Since 2010, the leading
pharmaceutical companies have significantly increased the prices of
drugs, including commonly used drugs (e.g., the cost of a Square or
Beximco paracetamol tablet strip of 10 increased from BDT 8 to 10–12),
on the basis that raw material import has become costlier because of the
appreciation of US dollar in the country (Embassy of the Kingdom of the
Netherlands, 2012).

2.9 Patient empowerment and accountability

2.9.1 Patient information
The level of patient information available in the public domain is very poor
in Bangladesh, and health-care providers of all categories are reluctant
to supply the required information to their patients. Studies have shown
that a lack of appropriate information about the availability of health
services is an important barrier to accessing health care (Jahan, 2000).

48
Health systems are not responsive and are not obliged to inform patients
or their relatives about the condition of the patient, the treatment to be
started and the prognosis of their illness. Health education campaigns on
preventive issues such as immunization, family planning, hand washing
and sanitary practices, etc. are frequent and conducted by both public
and private nonprofit sectors. When there is an epidemic (e.g., diarrhoea,
avian influenza), intensive health education campaigns on disease
transmission and prevention are also organized as an epidemic control
measure. However, due to the country’s low literacy level, achievement
of health literacy in its true sense (capacity to internalize information
provided by health education campaigns or otherwise for informed
health-related decision-making) is mostly limited to the educated
section of the population (Wolf, Gazmararian et al., 2005). Health-related
information is mostly provided in Bangla, and in some cases English. It is
blind to any other languages spoken by ethnic minorities.

2.9.2 Patient choice

Bangladesh has formal and informal health-care providers providing
outpatient and inpatient care. Health-care expenditure by patients is
mostly OOPP, and thus patients have the liberty to choose any provider
ranging from a qualified medical doctor to a faith healer. Informal
providers are more prevalent in rural areas, as opposed to public
facilities, and there are a wide range of options among the unqualified
providers, such as village doctors, drug sellers, traditional birth
attendants (TBA) trained or untrained, traditional healers (including
faith healers), homeopaths, and others (circumcision practitioners, ear
cleaners, tooth extractors, etc.) (Ahmed, Hossain et al., 2009; Rahman,
Islam et al., 2011). About 75% in rural areas and 84% in urban areas
depend on private, small, informal health-care service providers who
are mostly semi-skilled with no professional training. In Bangladesh,
13% of treatment-seekers use government services, 27% use private/
NGO services, and 60% use unqualified services (Cockcroft, Milne et al.,
2004). Easy access, low-cost treatment, and availability of the provider
on demand are some of the factors that drive patients in choosing an
informal provider over a formal provider in rural areas (Hamid, Sadique
et al., 2005). The private sector is booming in urban areas in Bangladesh
and there has been 15% growth in privately-run facilities between 1996
and 2000 (MOHFW, 2003). Unavailability of doctors and nurses, their
attitudes and behaviour, lack of drugs, waiting time and travel time
contribute to the low use of public hospitals in general; albeit the overall

49
patient load in public medical college hospitals is higher than that in
other general hospitals due to the availability of specialist services and
their low cost (Rannan-Eliya, Somanathan, 2003).

2.9.3 Patient rights

The HPNSP proposed a number of activities aimed at strengthening
consultations with communities and stakeholders, particularly the poor
and women, in order to make their participation more effective. The
following mechanisms for promoting the voice of the community were
suggested.

National Health Service Users’ Forum

This was proposed and specified by the HPNSP with the aim of promoting
government and civil society initiatives, including a patients’ charter of
rights and health watch groups. The Forum was designed to involve all
stakeholders – government, service providers, clients and communities –
in working together to organize their own services through public health
facilities. Forums were also planned, to be established at the local levels,
and were expected to form the basis for local planning, monitoring and
evaluation. However, the concept has remained a policy document without
being implemented (World Bank, 2010).

Health Advisory Committee

This mechanism was established under the HPNSP for promoting
community voices and ensuring accountability of service providers
through oversight. Health Advisory Committees chaired by Members
of Parliament were to be composed of elected public representatives,
service providers, local government officials and NGOs. The committees
were to meet and oversee service provision in health facilities and provide
recommendations up to Line Directors and the Secretary of the Ministry
of Health and Family Welfare. These committees for the most part have
not been active because of limitations of membership, information and
resources (World Bank, 2010).

Citizens’ Charter of Rights

This was developed at the initiative of the Ministry of Health and Family
Welfare, emphasizing the citizens’ rights to health. In 2004, the Ministry
and some NGOs launched a media campaign to publicize the charter, the
latest version of which was published in 2007. The charter introduced a
standard set of clients’ rights to health-care services. Individual charters
covering services at medical college hospitals, district hospitals, Upazila

50
Health Complexes and union subcentres have also been developed. The
charters suffer from some drawbacks: (i) they lack institutional and
legal mechanisms for use both by citizens and the Government; (ii) the
majority of the population, including service providers, are unaware
of their existence; and (iii) they were developed by a small group of
Government and health service personnel without the involvement of
the community. Currently, the Citizens’ Charter of Rights serves only to
display information (World Bank, 2010).

2.9.4 Complaints procedures

There is no formal body for arbitration of complaints against health
providers in Bangladesh. Any complaint or dispute received by a hospital
or clinic authority is dealt with independent of involvement by Government
or legal entities, and is often resolved through mutual understanding.
Non-state actors including NGOs, civil society organizations, consumer
associations and the media usually play an active role in amplifying
the voices of the poor to make service providers accountable, and to
generate information through public disclosures (World Bank, 2010). A
few important initiatives have been taken by the Government to increase
accountability of health-care providers in recent times, as follows.

The Bangladesh Health Watch (BHW) is a civil society network formed

in 2006 to establish a tradition of holding the State as well as non-state
actors to account for their performance in delivering quality health care
to the citizens. BHW produces an annual report on the state of health in
Bangladesh focusing on a theme that deserves priority attention. The
intent of the BHW is to raise awareness about aspects of the theme and
catalyze concrete action to address these challenges so as to bring about
better health services delivery to citizens. BHW has produced three
Health Watch Reports – 2007 Health Equity, 2008 Health Workforce and
2009 Healthy Governance. The Secretariat to the Health Watch is located
in the James P Grant Public Health School of BRAC University (World
Bank, 2010).

The Reality Check, started in 2007, is structured as a qualitative

longitudinal “listening”study over five years. The overall goal of the
Reality Check is to listen to and understand the perspectives of people
living in poverty on national health and education programmes in
Bangladesh. It gathers the experiences, opinions and insights of people
living in poverty, which complements the more conventional monitoring
and evaluation mechanisms within the Health and Education SWAps.

51
2.9.5 Public participation
The Ministry of Health and Family Welfare in both the HPSP and in HNPSP
has emphasized the role of community empowerment in making health
services responsive, effective and need-based. The HPSP considered
clients to be the main stakeholder and emphasized their inclusion in
planning and implementing service delivery. The service provider was the
other stakeholder. The HPSP also emphasized increasing the involvement
of local communities in delivering several elements of the Essential
Services Package, for instance the EPI and MCH, by including their
representatives in various management committees. During the period
of HPSP, the major community empowerment initiatives included the
following.

Community Groups
During 1998–2001, under HPSP, around 11 000 community clinics
were established throughout the country for providing basic primary
health-care services at the village level. These clinics were to have
been managed jointly by government representatives and local people
through Community Groups that were formed for the purpose.Group
members were given orientation and training. However, with the change
of government in 2001, the functioning of the community clinics was
discontinued. Since 2009, with the advent of the current Government,
these clinics are being reactivated and Community Groups formed once
again (World Bank, 2010).

Local-level planning
Introduced during HPSP, local-level planning was aimed at involving local
communities in the planning process, effectively utilizing local resources
and reflecting local needs in the national plans.It was meant to serve
as a monitoring tool for managers at the upazila and district levels.
Implementation of local-level planning has so far been largely limited
to training and developing a toolkit. Problems encountered included
inadequate capacity for assisting upazila managers in planning, weak
supervision, and limited understanding of the overall objective of local-
level planning among programme managers. Implementation of local-
level planning and budget piloting in six districts and 14 upazilas is at
the stage of preparation. The Ministry of Health and Family Welfare has
decided to form a national committee and six district committees to carry
forward the task of decentralizing planning (World Bank, 2010).

52
National Stakeholder Committee
This was formed in 1999 under HPSP along with a number of community-
based stakeholder committees in pilot unions and upazilas. The
objectives of the pilot committees were to: (i) ensure participation of
health service users and other stakeholders in the implementation and
monitoring of HPSP; (ii) facilitate transparency; and (iii) establish a basis
for programme accountability. However, the involvement of health service
users was low. The National Stakeholder Committee hardly met and
the community-based committees did not receive any official support. A
strategy for stakeholder participation could not be developed because the
consultative process was given low priority (World Bank, 2010).

2.9.6 Patients and cross-border health care

There is no policy for cross-border health care in Bangladesh. Patients
who need to arrange access to health facilities outside Bangladesh bear
the cost of treatment from out-of-pocket. Although health services are
improving in both public and private sectors, medical tourism is quite
popular among those who can afford to pay (Ali MM, Parvin R, 2010).

53
3 Financing

Chapter summary
According to the latest Bangladesh National Health Accounts, Bangladesh
spends US$ 2.3 billion on health, or US$ 16.20 per person per year, of
which 64% comes from out-of-pocket payments (MOHFW, 2010). WHO
estimates that currently Bangladesh spends US$ 26.60 per capita in
total. Public funds for health are the main prepayment mechanism for
risk-pooling, and constitute 26% of total health expenditure. The other
major funding source is international development partners. Chronic
underspending of the Ministry of Health and Family Welfare’s budget
indicates inefficiency in utilization of resources, as observed in a public
review of the health sector (MOHFW, 2011).

Except for through the public budget, very few of the existing funding
mechanisms of Bangladesh (0.2% of total health expenditure), private or
public, use any prepayment method such as health insurance. Several
community initiatives for ensuring low-cost services have been initiated.
While a number of private insurance companies offer individual and
group insurance to private persons and corporate clients, these health
insurance initiatives cover a very small share of the total population of
Bangladesh.

The statutory health-care system of Bangladesh in principle covers

all citizens with a range of services. However, many sick people every
year are left untreated in practice. In response to insufficient and
unsatisfactory services in the public sector, private initiatives have been
taken since the 1980s. The cost of services in private health facilities is
unaffordable to many poor people. Bangladesh, therefore, still needs
to travel a long way to reach universal health coverage. The first ever
health-care financing strategy has addressed how to generate new
resources for health, how to ensure efficient and equitable utilization of
resources, and how to utilize financial risk protection to achieve universal
health coverage (MOHFW, 2012). In its 20-year implementation period
(2012–2032), the strategy aims at a reduction of OOPP from 64% to 32%
of total health expenditure, an increase in government expenditure from

54
26% to 30%, an increase in social protection from less than 1% to 32%,
and reduced dependence on external funds from 8% to 5%. The strategy
provides a pathway to achieve universal health coverage in Bangladesh by
providing universal financial risk protection.

3.1 Health expenditure

National estimates on internationally comparable health expenditures
are available from 1997 to 2007 through the Bangladesh National Health
Accounts (BNHA). Since 1998, Bangladesh has conducted three rounds
of National Health Accounts (NHA) covering the period 1997–2007. The
fourth (ongoing) round, expected to be produced by August 2014, is based
on the System of Health Accounts 2011 framework.

However, the BNHA estimate for public spending on health for 2007
is significantly different from WHO estimates for 2008 (see Table 3.1).
The main reason for this difference, firstly, is that BNHA estimates are
based on actual expenditure while WHO estimates are based on budget
allocation. Often the original budget is revised downwards and the revised
allocation is also not fully utilized. Secondly, the development budget
suffers from double counting in case of Direct Project Aid (DPA). For
example, some aid agencies channel funds to UN agencies. The same
amount may have appeared twice under both funding agencies. Thirdly,
some aid agencies which provide funds through DPA spend money
for their own overheads (in-country and at headquarters) which is not
captured in the statement for DPA expenditure. The first two factors
cause WHO estimates to be higher while the third reason causes BNHA
estimates to be lower.

According to BNHA estimates, total health expenditure in nominal terms

grew from BDT 48.7 billion (US$ 1.1 billion) in 1997 to BDT 160.9 billion
(US$ 2.3 billion) in 2007 (HEU, 2010). In per capita terms, THE was US$
16.20 in 2007 and US$ 9.20 in 1997. Currently Bangladesh spends US$
26.60 per capita, according to WHO NHA estimates.

The period 1997–2007 coincides with the implementation of two sector-

wide programmes. 1998–2002 was the implementation period of the
first such programme, the HPSP, and 2003–2007 was the first half of
the implementation period of the second sector-wide programme, the
HNPSP. Therefore, 1997 can be considered the baseline for the first
sector-wide programme. Further analysis of change and trends in health
expenditure considered these distinct time periods.

55
THE in nominal terms grew at a faster pace during 2003–2007 (14.2%)
than during 1998–2002 (11.2%). However, when considered in real
terms, THE grew at a faster rate during 1998–2002 (8.5%) than during
2003–2007 (7.6%). Per capita THE in nominal terms grew at 9.7% annually
during 1998–2002 and at 12.4% annually during 2003–2007. Per capita
THE growth rate in real terms was 7% during 1998–2002 and 6% during
2003– 2007 (HEU, 2010).

THE grew at a faster pace than the GDP during 1998–2007, both in
nominal and real terms. During this period, THE grew at 12.7% annually
in nominal terms and at 8% annually in real terms, while the GDP growth
rate was 10% in nominal terms (MOHFW, 2010). Similarly, per capita THE
grew at a higher pace (11%) than per capita GDP (8%) (HEU, 2010).

Table 3.1 Trends in health expenditure in Bangladesh, 1997–2011

National reports WHO estimates
1997 2000 2003 2005 2007 2008 2009 2010 2011
Total Health Expenditure in 20 24 30 37 46 52 58 61 67
PPP$ per capita
Total Health Expenditure in US$ 9.2 10.1 115 13.7 16.2 19.4 22.4 24.8 26.5
per capita
Total Health Expenditure as % 2.7% 2.8% 3.0% 3.2% 3.4% 3.5% 3.7% 3.7% 3.7%
of GDP
Mean annual growth rate in THE 10% 8% 15% 16% - - - -
Mean annual growth rate in GDP 8% 10% 11% 14% - - - -
Public expenditure on health as 36% 31% 28% 26% 26% 36% 37% 37% 37%
% of THE
Public expenditure on health as 1% 1% 1% 1% 1% 1% 1% 1% 1%
% of GDP
OOP as % of total health 57% 59% 61% 64% 64% 62% 61% 61% 61%
expenditure
NGO expenditure as % of THE 1% 2% 2% 2% 1% - - - -
External assistance to NGOs as 5% 7% 9% 8% 8% - - - -
% of THE
Other private expenditure as % 1% 1% 1% 1% 1% - - - -
of THE

Source: MoHFW, 2010; World Bank, 2012a

Despite the impressive growth in health spending, throughout this period

THE in Bangladesh as a share of GDP has remained one of the lowest in
WHO South-East Asian Region, higher only than Myanmar and Indonesia
(Figures 3.1).1

1 For regional comparison WHO NHA estimates have been used

56
For comparison, countries in the Region with GDP per capita comparable
to Bangladesh have been selected. Figure 3.2 shows that throughout the
period 1997–2007, THE as a share of GDP in Bangladesh has remained
among the lowest in the Region, ahead only of Myanmar.

Figure 3.1 Total Health Expenditure as a share of GDP in WHO SEA

Region, 2007

Timor-Leste 15.4%
Maldives 6.8%
Nepal 5.2%
Bhutan 5.0%
India 4.0%
Sri Lanka 3.7%
Thailand 3.6%
Bangladesh 3.5%
Indonesia 2.7%
Myanmar 2.0%
0.0% 5.0% 10.0% 15.0% 20.0%

Note: According to Bangladesh NHA estimates in 2007 THE accounted for 3.4% of GDP while WHO
NHA database shows 3.5%. Source: WHO NHA Database

Figure 3.2 Trends in THE as a share of GDP in Bangladesh and

selected SEAR countries, 1997–2007

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Bangladesh India Myanmar Nepal Timor-Leste

Source: WHO NHA database

57
THE measured in Purchasing Power Parity dollars (PPP$) in Bangladesh
is also one of the lowest per capita among the countries of the region,
only higher than Myanmar (Figure 3.3). WHO NHA estimates slightly
differ from Bangladesh NHA estimates for per capita THE in PPP$. Per
capita THE in PPP$ in 2007 according to WHO NHA is PPP$47.4, while
Bangladesh NHA estimates it to be PPP$ 46.

Figure 3.3 Health expenditure in US$ PPP per capita in the WHO SEA
Region, 2007

160
140

120
100
80
60

40
20

0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Bangladesh India Myanmar Nepal Timor-Leste

Source: WHO NHA database

However, if a comparison is made with outcome indicators such as

maternal and child mortality, Bangladesh has obtained high value from
its low health spending compared to other countries in the region (World
Bank 2009).

Public expenditure
The public sector has remained the second-largest financing agent
since 1997 (MOHFW, 2010). However, public expenditure on health in
Bangladesh, according to BNHA, decreased from 36% in 1997 to 26% in
2007 (Table 3.1), although in absolute terms it grew at an average rate of
9% annually. This is a slower rate than the growth rate of private finance
(14.5%) during 1998–2007.

During 1997–2007, public expenditure on health as a share of GDP

remained flat at around 1%. The elasticity of nominal public spending
on health in relation to nominal GDP during 1997–2007 is estimated to
be 0.93. This implies that a 1% increase in GDP is associated on average

58
with a 0.93% increase in public expenditure on health. This is very low
compared to the average in other low-income countries (Tandon and
Cashin, 2010).

To compare public expenditure on health as a share of THE in the WHO

South-East Asia Region, WHO NHA estimates are used. Figure 3.4 shows
that public expenditure on health as a share of THE in Bangladesh was
higher than in Myanmar, India and Nepal. WHO NHA estimates (34.4%)
for public spending on health as a share of THE are much higher than the
Bangladesh NHA estimates (26%) due to differences in what is counted as
public expenditure on health.

Figure 3.4 Public sector health expenditures as a share of THE in the

WHO SEAR, 2007

Bhutan 84.8%

Thailand 76.3%

Timor-Leste 74.3%

Sri Lanka 49.4%

Indonesia 45.8%

Bangladesh 34.4%

Nepal 26.5%

India 25.8%

Myanmar 11.7%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Source: WHO NHA database

An examination of the composition of public expenditure on health reveals

that during 1997–2007, public spending on medicines and medical goods
increased almost 7–fold as an absolute amount, and as a share of total
public expenditure on health it increased from 5% in 1997 to 14% in 2007.
Public spending on public health and prevention almost doubled as an
absolute amount, but as a share of THE decreased by 8% (Table 3.2). The
share of hospital care (including inpatient and outpatient care) remained
at one third of THE.

59
Table 3.2 Public health expenditure on health by service programme,
selected years
% of public % of total health
Service program
expenditure on health expenditure
1997 2007 1997 2007
Inpatient care 20 21 7 5
Outpatient care 13 12 5 3
Medicines and medical goods 5 14 2 4
Health administration and insurance 5 4 2 1
Public health and prevention 35 27 13 7
Capital formation 18 18 7 5
Health education and training 3 4 1 1

Source: MOHFW, 2010

Fiscal context
Fiscal context refers to the capacity of the Government to finance the
health sector. The more money the Government has, the more money
it can spend on health. Sustained economic growth usually leads to
increases in Government spending on health. Even if Government health
spending as a share of GDP remains the same, Government health
spending in real terms will grow at the same rate as the real GDP growth
rate given that the changes in price of health are not significantly different
from the changes in overall price level (Tandon, Cashin, 2010).

Government health expenditure as a share of GDP has remained stagnant

at around 1% of GDP between 1997 and 2007 despite sustained economic
growth. Government health spending in real terms grew at around 4.7%
while real GDP grew at 5.6% per year during the same period. This
indicates that economic growth alone may not be adequate for increasing
Government expenditure on health.

Besides economic growth, other fiscal factors such as revenue

generation, fiscal deficit and debt are also important for fiscal context.
The revenue–GDP ratio and tax–GDP ratio indicate revenue generation
capacity. During past decades, both ratios for Bangladesh have been
the lowest in the region and lower than the average for low-income
countries. In Bangladesh between 2000 and 2012, the revenue–GDP ratio
increased from 9.6% to 12.6%. The tax–GDP ratio increased from 7.9% to
10.5% between 1997 and 2012 thanks to an expansion of the tax net and
improvement in tax collection administration.

60
The budget deficit has remained below 5% of GDP, and the public debt–
GDP ratio has been declining throughout the last decade due to prudent
fiscal management (World Bank, 2012). The latter trend implies that
fewer resources are required for debt servicing.

Despite increases in the revenue–GDP ratio and tax–GDP ratio of more

than 2%, the health sector budget has never exceeded 7% of the total
government budget. Recently, allocation to the health sector has been
further reduced to less than 5% of the total government budget due to
other competing needs, especially increased subsidies (MOF, 2013).
Subsidies accounted for 3% of GDP in 2012 (World Bank, 2012).

3.2 Sources of revenue and financial flows

Like many other countries, funding for health comes from several sources
through different mechanisms and the payments are made to different
types of health-care providers. The financing of health care in Bangladesh
is dominated by out-of-pocket payments, the Government’s revenues, and
development partners’ funding directly to NGOs (Table 3.3).

Table 3.3 Sources of revenue as a percentage of total expenditure on

health by financing agent, selected years, 1997–2007
Source of revenue 1997 2000 2004 2007
General government expenditure on health (GGHE) 36 31 29 26
MOHFW 35 30 28 25
Out-of-pocket expenditure (OOP) 57 59 60 64
Nonprofit institutions (e.g. NGOs) 1 2 2 1
Private insurance 0.1 0.1 0.2 0.2
Private firms 1 1 1 1
Rest of the world funds/external resources to NGOs 5 7 9 8
Source: MOHFW 2010

Public spending on health is financed from national tax, foreign

development funds, and corporations and autonomous bodies. Tax and
non-tax revenue and foreign loans and grants are channelled by the
Ministry of Finance to the Ministry of Health and Family Welfare and other
ministries. Figure 3.5 (page 64) illustrates the funding flows from the
sources of revenue to the expenditure.

61
Public expenditure is financed from the non-development or revenue
budget and the development budget2 or Annual Development Programme
(ADP). The ADP reflects donor financing. The share of non-development
budget in the total Ministry of Health and Family Welfare budget was
49% in 1996–1997, which increased to 60% in 2011–2012. The non-
development budget is solely financed by the government, while the ADP
is financed by the Government and donors. Donor contribution to the ADP
was 44% in2010–2011, which increased to 54% in 2012–2013. See details
about donor financing in section 3.6.2.

According to several public expenditure reviews of the health sector, a

substantial proportion of the ADP allocation for the Ministry of Health
and Family Welfare remains unspent (MOHFW, 2011). However, a recent
change in this trend is noted. For 2012–2013, utilization of the ADP
allocation to the Ministryis 91%, which is in line with the utilization of
the total ADP (96%). This rate is the highest in 17 years due to greater
efficiency in the overall ADP utilization of the Ministry (PMMU, 2013).

The chronic underspending of ADP before 2012–2013 was due to poor

absorption capacity, delays in fund disbursement, weak capacity in budget
planning, especially inflated budgeting (World Bank, 2009), and poor
procurement planning causing long processing times and slow spending
(PMMU, 2013).

The majority of public sector health financing is dedicated to the Ministry

of Health and Family Welfare, which used 97% of total public financing
(BDT 41 billion) in 2007. The Ministry, in addition to financing its own
providers, also implements health, family planning and maternal and
child health activities through transfers and grants-in-aid to NGOs. Under
HNPSP, NGOs were contracted to provide nutrition and HIV/AIDS-related
services.

Besides the Ministry of Health and Family Welfare, other ministries

contributing to the health sector are the Ministries of Local Government,
Defense, Home Affairs, Social Welfare and Railways. Other ministries’
spending on health was BDT 1.222 billion, which was 3% of total public
health spending in 2007 and 1% of THE (MOHFW, 2010).

2 Development budget includes ADP allocation and non-ADP allocation. Non-ADP allocation
includes Food For Work and transfers of food sales proceeds.

62
Foreign development partners channel their funds to the health sector
through the Government and NGOs. In absolute terms, donor funding to
the Ministry of Health and Family Welfare more than doubled between
1998 and 2011. However, as a share of the health sector programme
budget, it fluctuated between 24% and 27% over the same period. During
1997–2007, donor grants to NGOs as a share of THE varied between 5%
and 8%(MOHFW, 2010).

Households are the main source of financing for health care in

Bangladesh, comprising 64% (BDT 103.459 billion) of Total Health
Expenditure (THE) in 2007, growing from 57% in 1997. Household
expenditures have been rising progressively as a share of GDP, from
1.5% in the late 1990s to slightly over 2% in recent years. Out-of-pocket
payments by households and individuals go directly to the providers in the
public, private and NGO sectors.3

Besides OOPP, other sources of private financing include private firms,

private insurance companies and NGOs. As a financing agent, private
firms’ outlay was BDT 1.325 billion in 2007. Their share of THE has
remained at around 1% over the period between 1997 and 2007. Health-
care spending by insurance companies was BDT 314 million in 2007, or
less than 0.2% of THE. The share of NGO self-financing from their own
resources has ranged between 1% and 2% of THE over the 1997–2007
period (HEU, 2010). Private firms’ expenditure constitutes mainly of
health benefits to their employees and spending on health activities as a
corporate social responsibility. The role of private insurance companies
as a financing agent is very limited. Social and private insurance comprise
a very small proportion of total funding.

3 To avoid double counting, official user fees collected at public facilities are deducted from public
sector spending during NHA analysis. Data on user fee collection is obtained from the Ministry of
Finance.

63
 Figure 3.5 Financial flow in the Bangladesh health system

Funding sources Financing intermediaries

Ministry of Finance MOHFW

- Revenue budget
- Development budget

Public Sector
Financing
National taxes Other Ministries
-Ministry of Home Affairs
- Local government
Foreign
- Others
Development Fund

Corporations and Corporation Health

Autonomous bodies Office

Non-profit institu-

Private Sector
NGOs tions / NGOs

Financing
Private insurance /
Firms Voluntary health
insurers

Medical College Hospitals

Specialized Hospitals

District Hospitals and Upazila

Health Complex
Citizens /
populations Union Health & Family Welfare
Centers and Community Clinics
Cost sharing
Local Government Facilities

Providers
Direct payments
for services not
Patients Other Ministry Facilities
(out-of-pocket covered informal
payments payment
Corporation / enterprise
Facilities

NGO Clinic and NGO

Public financing Hospitals
Corporation financing
Private hospitals / clinics /
Private insurance financing diagnostic

Donor financing
Drug and medical goods
Out-of-pocket payment outlets

Source: Asia Pacific Observatory on Health Systems and Policies

64
Figure 3.5 describes the pathways of health-care funds from financing
sources to health-care providers through financing agents. The Ministry
of Finance collects taxes (income, corporate, value-added etc.), tariffs
and fees from the citizens of Bangladesh. The main source of finance for
the national budget is taxes. MOF allocates funds from the tax-financed
national budget annually to the Ministry of Health and Family Welfare
and other ministries. The Ministry of Health and Family Welfare then
allocates the health budget to health-care providers at different levels,
from primary to tertiary and from national to community levels. Other
ministries such as Defence and Home Affairs operate health facilities
for their employees. Ministries such as Health and Family Welfare, Local
Government and Social Welfare channel funds to NGOs to provide health
services. Spending on health by other ministries is financed from their
respective budgets.

Foreign development partners contribute to the development budget

of the Ministry of Health and Family Welfare that finances their health
programmes and health facilities. They also finance NGO health services,
either by directly providing funds to NGOs or through the Ministry of
Health and Family Welfare or the Ministry of Local Government.

Corporations (state-owned enterprises) and autonomous bodies (for

example, national universities) finance health care spending from
their own budget. Some corporations and autonomous bodies operate
their own health facilities, some reimburse employees’ medical
treatment costs through voluntary health insurance schemes, and some
finance health programmes of NGOs as part of their corporate social
responsibility.

NGOs allocate funds from their own sources to finance NGO health
programmes and health facilities, primarily for providing health care
to poor and low-income people. NGOs receive funding directly from
development partners and from the Government through ministries
such as the Ministry of Health and Family Welfare, the Ministry of Social
Welfare and the Ministry of Local Government. NGOs also receive funds
from corporations and enterprises to provide health services, especially
for target groups such as poor and vulnerable populations.

Some private firms/enterprises develop health funds, which are often

transferred to private or voluntary insurance schemes, to secure health
care for their employees. Besides financing health insurance, some
enterprises operate their own health facilities to provide health care

65
to their employees or finance NGO health activities as part of CSR. The
health funds of NGOs and corporate firms also go to private health-care
facilities (hospitals/clinics/diagnostic tests) and drug and medical goods
retail outlets to provide services on NGOs’ and firms’ behalf.

The health funds described above are generally pooled funds, with scope
for risk-pooling. Individuals and households fully or partially share
the costs of their health care through out-of-pocket payments. When
receiving care from public facilities, the patients pay a small user charge;
for treatment from private providers, the payments are often fully borne
by the patients.

3.3 Overview of the statutory financing system

3.3.1 Coverage
Breadth: who is covered?
According to Article 15(a) of the Constitution, all citizens have the right
to medical care. In principle, public health facilities are accessible to
all citizens of the country irrespective of their social position, race or
religion. Access to health services does not require a contribution, and
while all citizens are provided with an identity card, this is rarely checked
at the service delivery point.

Scope: what is covered?

Primary, secondary and tertiary medical care is provided in public health
facilities through the health service network spread all over the country,
from community clinics to tertiary level medical college hospitals and
specialized hospitals. Table 3.4 presents the health services that are
provided in the statutory system in Bangladesh.

66
Table 3.4 Health-care services provided by public facilities in
Bangladesh
Level of
Service facility Services
care
Primary Ward
level care Community clinics Maternal and neonatal health care,
integrated management for childhood
illness, reproductive health and family
planning services, EPI, nutrition education
and supplement, health education and
counselling, identifying severe illnesses like
tuberculosis, malaria, pneumonia, EmOC,
life-threatening influenza, anthrax etc.
treatment of minor ailments and first-aid,
referral to union level facilities, upazila
health complexes and district hospitals. Out-
Patient Services
Union
Hospitals
Union Sub-Centre Out-Patient Department (OPD)
Union Health and Family Out-Patient Department (OPD)
Welfare Centre
Secondary Secondary
and Upazila (Sub-district) Health Comprehensive emergency obstetric care
tertiary Complex services (EOC), gynaecology, anaesthesia,
level care nursing and basic laboratory facilities.
District hospital Medicine, surgery, orthopaedics, Eye, ENT
General hospital Medicine, surgery, orthopaedics, Eye, ENT
Tertiary
Medical college hospitals Medicine, surgery, orthopaedics, Eye, ENT,
Eye and ENT, ARI, Reproductive care etc.
Infectious disease hospital Treatment of infectious diseases
Specialized hospital Selected services
Chest disease/TB hospitals Chest disease
Leprosy hospital Leprosy
Specialized centers Selected relevant services
Specialized hospital Selected relevant services
affiliated with postgraduate
Other hospitals
Source: Asia Pacific Observatory on Health Systems and Policies

67
Depth: How much of the benefit cost is covered?
In public hospitals, the user charge for outpatient consultation is low
(BDT 10 per visit). Drugs on the Essential Drug List and some other
medicines are free of cost. Hospital beds in the wards are free, but there
are charges for shared rooms (BDT 150 per day) or individual rooms (BDT
600 per day). While normally medicines and medical and surgical supplies
are provided free of charge, it is common for patients to have to purchase
and provide items such as syringes, intravenous fluids, plaster, x-ray
plates, and even surgical items such as suture material or dressings
when supplies in the facility are inadequate.

3.3.2 Revenue collection

Government revenues are collected from tax and non-tax revenues by
the Ministry of Finance. The National Board of Revenue is the agency
responsible for tax collection. The central tax revenue budget includes
revenue from income tax, corporate tax, VAT, excise duty, import duty,
supplementary duty, taxes on vehicles, land revenue and stamp duty.
Non-tax revenues are collected from dividends and profits, interest,
borrowing from the domestic market, tolls, levies and rents. There are no
earmarked taxes for health in Bangladesh.

In 2011–2012, the total revenue receipt of the Government was 114 885
Crore Taka (US$ 1.443 billion)4. In Bangladesh, revenue is generated
mainly from indirect rather than direct taxes.

The burden of direct taxes in Bangladesh is heavily concentrated on the

better-off, both in absolute terms and relative to ability to pay (O’Donnell,
Van Doorslaer et al., 2008). The concentration index is around 0.9,
indicating that direct taxes are paid almost exclusively by the better-off,
and the Kakwani index is about 0.55, suggesting strong progressivity of
direct tax. The burden of indirect taxes is also concentrated on the well-
off but to a much lesser extent than for direct taxes, as the concentration
index (0.5) as well as the Kakwani index (0.1) are smaller but positive
(O’Donnell, Van Doorslaer et al., 2008). However, by comparing the
results with and without VAT exemptions, VAT in Bangladesh has been
found overall to be regressive (Faridy, Sarker, 2011).

4 US$ 1 = BDT 79.6

68
3.3.3 Pooling of funds
Pooling of revenue mainly occurs at the level of the Government budget,
and through the budget preparation process. Some revenue pooling also
occurs through the separate health insurance-specific funds operated by
public and private employers for their employees.

The Government budget is prepared by the MOF based on an annual

Medium Term Macroeconomic Framework (MTMF).Based on the MTMF,
the MOF provides an indicative resource ceiling along with revenue
targets for each ministry including the Ministry of Health and Family
Welfare. On the basis of that indicative budget ceiling, all ministries
develop/update respective Ministry Budget Frameworks (MBF). Following
review by the MOF and the Planning Commission, each Ministry submits
detailed estimates based on the MBF, which become the basis for the
budget approved by Parliament.

Individual ministries are responsible for distributing this resource

envelope between the revenue and development budgets. Within the
Ministry of Health and Family Welfare, the Budget Unit and the Planning
Unit prepare the revenue and development budgets, respectively, within
the budget ceiling. Though both top-down and bottom-up approaches are
followed for preparing budgets, ultimate allocation decisions are made
centrally, based on the previous year’s actual expenditure, availability of
resources and the policy focus of the Government.

In addition to the pooling of funds through public financing, there are a

few organizations in public and private sectors that create pooled funds
for securing health care, to a certain extent, for their employees. For
civil servants, the Bangladesh Employee Welfare Board pools a fund
by deducting BDT 90 per month from each employee, against which a
certain level of health benefits is ensured. The teachers and students of
public universities (such as Dhaka University) access health care through
a health insurance scheme to which both employers and employees
contribute. Icddr,b ensures health care for its employees with a health
insurance scheme including contributions from staff members. BRAC has
recently initiated health insurance for its employees against a premium
of BDT 150 per month. In the private corporate sector, Grameen Phone
among others secure health care for its employees with contributions
from the employer. Despite the examples of pooled funds above, it needs
to be emphasized that such funds correspond to a very small proportion
of the total health-care fund of Bangladesh.

69
3.3.4 Purchasing and purchaser-provider relations
The Ministry of Health and Family Welfare generally plays the dual role
of purchaser and provider, where health services are provided through
a range of facilities at different tiers. Salaries of Ministry of Health and
Family Welfare personnel are mainly paid through the revenue budget,
though salaries of staff under some vertical programmes are also being
paid through the development budget. In both cases, salaries remain
fixed with no opportunity of performance-based payment. It is only under
the Demand Side Financing Programme (the maternal voucher scheme
currently operating in 53 upazilas) that health-care providers receive an
additional payment per case for providing facility-based delivery care.
The cost of medicine and diet at different tiers is paid based on some set
norms and are paid through both budgets. Funds are disbursed quarterly
to cost centres (for revenue budget) and Line Directors (for development
budget) under the two Directorates.

There remain exceptions in a number of programmes where the Ministry

of Health and Family Welfare contracts out service provision to NGOs.
The National Tuberculosis Control Programme and National AIDS and
STI Programmes are two such examples. The Urban Primary Health-care
Project, under the Ministry of Local Government, also contracts out to
NGOs to provide primary health care to the urban population. The NGOs
are chosen through an open competitive bidding procedure for a certain
period. These NGOs provide services at a subsidized price to the urban
population and are allowed to recover costs through charging pre-agreed
user fees for services. However, as per their agreement with the ministry,
a certain proportion of their services has to be provided free of cost to the
extremely poor.

3.4 Out-of-pocket payments

Health services in Bangladesh remained predominantly financed by
households’ OOPPs during 1997–2007. OOPP grew at 14% annually, faster
than the annual growth rate of THE (12.7%) and GDP (10%). The growing
reliance on OOPP leaves the population at risk.

Direct payment for the purchase of pharmaceuticals and medical goods is

the predominant contributor to OOPP, either through self-purchase or on
the advice of a formal or informal health-care provider. User charges and
informal charges are relatively low.

70
Table 3.5 demonstrates that drug and medical retail outlets (notably
pharmacies) were the main recipients of OOPP over the period
1997– 2007. Households spent money at pharmacies for several
reasons: (i) to purchase medicines prescribed by providers at public
facilities where those medicines were not available; (ii) to buy medicines
prescribed by private providers; (iii) to buy medicines to self-treat; or (iv)
after consulting drug sellers (most of whom are not qualified providers)
at pharmacies and buying recommended medicines from them. Spending
at pharmacies grew on average 13% annually, although its share of OOPP
dropped from 74% in 1997 to 63% in 2007. During the same period, OOP
payments at hospitals increased 30% per year, and as a share of OOPP
increased fourfold (Table 3.5). This indicates a shift in OOP spending in
favour of qualified providers.

Table 3.5 Households’ OOP by different providers, 1997–2007

Providers Year
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Hospitals 4% 5% 6% 7% 8% 10% 11% 12% 15% 16% 16%
Drug and medical 76% 74% 73% 72% 71% 70% 69% 68% 66% 66% 66%
goods retail outlets
Medical and 5% 6% 6% 7% 7% 6% 7% 7% 6% 6% 6%
diagnostic facilities

Source: MOHFW, 2010

An analysis of OOP by functions reveals that the share of OOP spending

on medicines has decreased over the period 1997–2007 while the share
spent on inpatient care has increased (Table 3.6). In absolute terms, OOP
spending on medicines increased 13% annually, while OOP spending on
inpatient care grew at 26% annually. Spending on inpatient care grew
twice as fast as spending on outpatient care. The declining share of
medicines and rising share of inpatient care in OOP can be explained by
the fact that over the decade,the share of public spending on medicines
and medical supplies more than doubled. Moreover, most of the
medicines available at the public facilities are provided to inpatients.

71
Table 3.6 Households’ OOP by functions, 1997–2007
Year
Providers
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Inpatient care 4% 5% 5% 6% 7% 8% 9% 10% 10% 11% 11%
Outpatient care 14% 14% 14% 14% 14% 14% 14% 14% 13% 13% 12%
Ancillary 5% 6% 6% 7% 7% 7% 7% 8% 7% 8% 7%
services
Medicines 74% 72% 71% 70% 69% 67% 66% 65% 64% 63% 63%
Medical goods 2% 2% 2% 2% 2% 3% 3% 3% 3% 3% 3%
OOP 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Source: MOHFW, 2010

3.4.1 Cost sharing (user charges)

A policy initiative was undertaken in 2009 to increase existing user fees
and introduce user fees at primary level hospitals, that is, upgraded
50-bed Upazila Health Complexes, and to distribute 50% of some user
fees (such as lab test and imaging service fees) among providers such as
doctors, nurses and medical technicians. A High Court bench ordered the
Government not to increase user fees and also prohibited VAT charges on
private clinics/hospitals.

Public facilities are required to deposit collected fees in the treasury.

Under several pilot projects, Ministry of Health and Family Welfare
facilities were allowed to retain user fees (but only during the pilot stage).
User fees do not generate significant amounts of revenue. Bangladesh
National Health Accounts 1999–2001 reported that the Ministry of Health
and Family Welfare generated BDT 77 million, BDT 89 million, and BDT
125 million as user fees from health and family planning services in
1999– 2000, 2000–2001 and 2001–2002 respectively (HEU, 2003). These
amounts were below 0.2% of THE estimated for respective years. About
BDT 109 million was collected at different Ministry of Health and Family
Welfare facilities in 2007, representing only 0.26% of total public health
spending in the same year (Begum T, 2012).

3.4.2 Direct payments

OOPPs are mostly direct payments made at private and NGO facilities
and also to informal providers. NGOs used to provide primary care,
particularly reproductive services, mostly free or at nominal fees. Since
the major health-care reforms of the first SWAp (1998–2003), some NGOs
have introduced user fees for cost recovery with the aim of sustainability.

72
In 2007, households spent BDT 16.284 billion at private and NGO
providers as direct payment, accounting for 16% of total OOP payments.
Households spent BDT 1.987 billion as direct payment to alternative
medical practitioners including homeopaths and Ayurvedic/Unani
practitioners in 2007 (HEU, 2010). This represents 2% of OOPP.

3.4.3 Informal payments

Various surveys and studies have reported unofficial or informal
payments at public health facilities in Bangladesh (Killingsworth,
Hossain et al., 1999; Bangladesh Bureau of Statistics, 2011; Rannan-
Eliya RP et al., 2012). There are no household survey-based estimates
on the extent and volume of informal fees at public facilities. A recent
study based on exit patients (funded by the Asian Development Bank
and AUSAID) reports that among outpatients, less than 1% reported
making informal payments, averaging BDT 0.6. Less than 9% of inpatients
reported informal payments, paying BDT 19.0 on average (Rannan-Eliya
RP et al., 2012).

According to Rannan-Eliya RP et al. (2012), patients make informal

payments for various reasons. These include: (i) to obtain medicines;
(ii) to ensure that the doctor or nurse saw the patient; (iii) to ensure that
the provider gave the patient better treatment; (iv) to ensure laboratory
tests or x-rays were carried out; (v) to transfer from the floor to a bed; (vi)
to transfer to a paying bed; and (vii) to obtain assistance for the care of
an inpatient. The most common reasons for informal payments cited by
patients were to obtain medicines, to get better treatment, and to ensure
laboratory tests or x-rays are done (Rannan-Eliya RP et al., 2012).

3.5 Private (Voluntary) health insurance

Health insurance as a mechanism for financing health care has not yet
been used significantly in Bangladesh. There are a number of employer
operated schemes, both in the public and private sector. These schemes
are essentially complementary, covering the costs of user charges and
additional payments required in Government facilities or user charges in
private facilities.

Government employees
All civil servants are enrolled in a number of limited Government
schemes that can be classified as social insurance or payroll-based
systems. A sum of BDT 700 is paid monthly as a medical allowance to

73
each Government employee. A payment of BDT 90 is deducted from
the monthly salary of employees for a group insurance and benevolent
fund, against which a maximum total of BDT 100 000 can be claimed
for expensive medical treatment once in a lifetime period. Further,
Government employees are entitled to a reimbursement (not-fixed share)
of up to BDT 20 000 for health-care payments from the Bangladesh
Employee Welfare Board.

Formal sector employees

The first law regarding sickness and maternity care was passed in
1939, and amended in 1998 as a labor law (SSA, 2012). Employees in
manufacturing and in establishments of five or more workers are entitled
to certain benefits. Employed women have access to cash maternal
benefits. Some employers provide onsite medical facilities and may also
use Government hospitals. To be entitled to these benefits, the workers
must be in insured employment and the female employees must have
an employment of at least six months with the same employer on the
expected date of childbirth. The Ministry of Labor and Employment
administers the programme, while Public Health Services administer the
health services.

A law passed in 1923 and amended in 2006 as a labor law allows

provisions for protection against work injuries (accidental injuries and
33 occupational diseases). Employees of railways, docks, estates and
factories with five or more workers are covered by this law. Employers are
supposed to bear all costs related to this protection. A three-day waiting
period is applied before accessing the benefits. The benefit is 100% of
salary for the first two months, 66.7% for the next two months and 50%
for subsequent months of disability up to one year, whichever is shorter.
Recently, the Government started to revise the labor law and changes
are expected to be made in the near future. Household workers, self-
employed and informal workers are not eligible for these benefits, but are
eligible to access the Government-provided public health facilities.

Employment-based health insurance

A number of private companies have started to provide health insurance
for their employees. Grameen Phone is one such entity. According to
the Human Resources Unit of Grameen Phone, the company provides
health insurance to their 4100 employees (approximately) and some
10 000 dependents against a premium, paid solely by the employer in
2012. Entitlement to health-care benefits in terms of number of visits

74
and hospitalization days has no ceiling, but a maximum of BDT 5000 per
hospitalization day can be charged.

Recently, BRAC has initiated a health insurance scheme for its employees
(both regular and contracted). Against a premium of BDT 150 per month,
the employees, their spouses and dependents (up to age 25) will get
specific health benefits. For any hospitalization, a maximum of BDT 100 000
can be claimed, while the beneficiary will bear 10% of total expenditure as
well as the amount above the maximum ceiling.

Community financing and not-for-profit health insurance schemes

Bangladesh microfinance NGOs started to introduce health insurance
services to their clients in the late 1990s and early 2000s. The important
bodies in health microinsurance are Gonoshatho Kendro, Grameen Kalyan,
BRAC, Sajida Foundation, Shakti, Dhaka Community Hospital, Nari Uddug
Kendra, Dushtha Shasthya Kendra, Integrated Development Foundation and
Society for Social Services. Most of the schemes cover loan, life insurance
and health insurance. Though most of these schemes reported good rates
of operational cost recovery to finance the non-recoverable expenditures,
these NGOs have external funding or they are cross-subsidizing the
resource gap from their other programme’s income (WEEH, 2003).

Private health insurance

Private insurance is limited to a small proportion of overall funding, and
was only 0.003% of the formal sector in 1996–1997 (MOHFW, 2003). The
proportion is unlikely to grow in near future due to the economic status of
the population of Bangladesh. Since private insurance schemes are profit-
oriented, these schemes may refuse insurance coverage or charge very
high premiums, especially from at-risk groups such as the elderly, disabled
or those suffering from serious health problems such as cancer or AIDS. It
has a low effect on resource mobilization and equity in the health sector.

Currently, there are about 44 firms listed as insurance companies

mainly focusing on general, life and accident insurance; however, limited
information is available on the entire inventory of their health insurance
products (Rabbani, 2011). The dominant mode of delivery appeared to be
group health plans the insurance companies offer to employers, followed
by individual policies (while giving group ones additional discounts on
premiums) and mediclaim policies for people travelling abroad (as required
by the visiting country).

75
Benefit packages are often connected to a range of financial benefits
in the range of BDT 25 000–150 000, which may cover room rent,
consultation fees, routine investigations, medicines, surgery, ancillary
services and cash benefits for hospitalization in public hospitals. Special
payments may apply for normal delivery and caesarian delivery.

3.6 Other financing

3.6.1 Parallel health systems
Other ministries besides the Ministry of Health and Family Welfare
accounted for only 1% of THE in 2007. Ministries such as Defense, Home
Affairs and Railways disburse their funds to the health facilities they
operate. These health facilities provide health care to their respective
employees and their dependents. The Ministry of Home Affairs is also
responsible for the health care of prisoners. The Ministry of Local
Government contracts out NGOs to provide primary health care in urban
areas. The Ministry of Social Welfare provides funds to NGOs to provide
health services, which are mostly used to build hospitals.

3.6.2 External sources - donor financing

Historically, external or donor financing has been an important source
of health financing in Bangladesh. Donor financing accounted for 24% of
HPSP budget (US$ 2.9 billion), 27% of HNPSP budget (US$ 5.4 billion) and
24% of HPNSDP budget (US$ 7.7 billion)5.

Donor financing in the health sector is characterized by a variety of

funding mechanisms. Some donors pool their funds and channel that
through the government system, which is known as Reimbursable Project
Aid (RPA). Besides the pool funders, there are other funding agencies
that spend money either directly or through the project, not channelling
through the government system. This is known as Direct Project Aid
(DPA). Some pool funders also finance through DPA. Special funding
arrangements such as GAVI and GFATM provide funding for priority health
interventions such as immunization, HIV/AIDS, TB, maternal health and
health systems. GAVI funding is reflected in the non-development budget
and ADP. GFATM is also reflected in ADP.

5 Sources include Project Appraisal Documents (PAD) and Program Implementation Plans (PIP) of
HPSP, HNPSP and HPNSDP.

76
According to the BNHA (HEU, 2010), in 2007 donors disbursed 71% of
money to pool funds, 14% to parallel funds through Operational Plans,
and 15% to parallel funds other than Operational Plans (MOHFW,
2010). For FY2012/2013, 80% of HPNSDP expenses were financed from
Government funds, while donor financing accounted for 20% of actual
expenditure. Of the donor financing, 16% was from pooled funds while 4%
was from parallel financing according to the Annual Programme Review
(APR, 2013)

In addition to the usual RPA/DPA mode of financing, the health

sector programme uses performance-based financing. During the
implementation of HNPSP, in order to promote achievement of its key
outputs and reforms, a certain percentage of the pooled funds was
allocated to a specific category. Disbursement of funds from this category
was made only if performance was evaluated as satisfactory by the
Independent Review Team during APR. This disbursement percentage
was determined from year to year depending on performance.

In HPNSDP, the Ministry of Health and Family Welfare gets additional

funds upon attainment of agreed targets that demonstrate accelerated
achievement of programme results. Disbursement against the
achievement of targets relies heavily on agreed and verifiable
Disbursement for Accelerated Achievement of Results (DAAR) indicators
of performance. No punitive measures are attached in the event of failure
to achieve DAAR indicators. This shows that the performance-based
funding in HNPSP was punitive while DAAR in HPNSDP is rewarding.

Both multilateral and bilateral donor agencies directly provide funding to

NGOs. GFATM also provides funding to NGOs. Some international private
sector foundations (e.g. Gates Foundation, Open Society) provide direct
funding to NGOs.

3.6.3 Other sources of financing

Corporate social responsibility (CSR) is a growing funding source for
the health sector. Commercial banks, pharmaceutical companies,
telecommunications companies, and consortiums are the key players in
health-related CSR. According to Bangladesh Bank (2012), CSR funds
from commercial banks for health activities increased tenfold, from BDT
68.6 million to BDT 689 million between 2007 and 2010. In 2011 it dropped
to BDT 520 million, accounting for about 24% of total CSR funds of the
commercial banks. The existing CSR health activities include establishing

77
and operating hospitals, health centres and medical training institutions;
providing funds and equipment to established hospitals, providing funds
to civil society organizations and NGOs in raising awareness and providing
preventive services, and providing free treatment, free medicines and
prostheses.

3.7 Payment mechanisms

Payment mechanisms are different for different providers. In public
facilities, the government funds are disbursed by the Ministry of Health
and Family Welfare mostly on the basis of the planned budget. Private
providers receive the payments from the patient directly on a fee-
for-service basis. Table 3.7 below provides an overview of payment
mechanisms by service type.

Table 3.7 Provider payment mechanisms

Cost sharing
Ministry of

Ministry of
Local Govt

payments
Employer
insurers*
Health

Direct
Service program

Private GP practice FFS FFS FFS

Public PHC facilities (rural) B FFS FFS
Public PHC facilities (urban) CT FFS FFS FFS
Public Hospital outpatients B FFS FFS
Public Hospital inpatients B FFS FFS
Pharmacies FFS FFS FFS
Public health programs B

B = Budget
CT=Contract
FFS=Fee for Service
*Note: Mechanism of payment varies by policies of different organizations
Source: Asia Pacific Observatory on Health Systems and Policies

3.7.1 Payment for public providers

Public budgets are divided between the revenue/non-development
budget and ADP or development budget. Revenue budget follows a line
item-based institutional budgeting approach while the development
budget follows a programme budgeting approach. The revenue budget
generally includes allocations for recurrent line items such as salaries
and allowances, drugs and medical supplies, operating costs and
maintenance. It also includes some capital line items. Budgetary

78
allocation to institutions/facilities is based on capacity and historically
determined normatives6.

ADP includes allocation for 32 Operational Plans under the Health,

Population and Nutrition Sector Development Programme, allocation
for more than 20 vertical projects outside HPNSDP, and a block amount
for unapproved projects. The development budget or ADP includes both
capital and recurrent line items.

Once budgets are approved, district and lower levels have little flexibility
over the use of funds. Virement between line items is only possible within
rules set by the MOF, which only allow transfer between different line
items in the same economic category, such as within pay and allowances
codes or within supplies codes, but not between pay and non-pay.

Budgetary line items include allocations:

• Per bed annually for facilities with beds;
• Vehicle operational costs per vehicle; and
• Salaries and allowances for staff.

Some key activities/items (e.g. medical and surgical supplies) are

commonly funded from both the revenue and development budgets.
Lack of coordination in the planning and budgeting for those activities
leaves scope for duplication as well as under-allocation of resources
(Chaudhury, Hammer, 2003).

The current increment list allocation system fails to discriminate between

population needs across areas. For historical reasons, the existing
infrastructure is often poorly distributed, so in practice this method of
resource allocation perpetuates inequitable patterns of distribution.
In response to this, the Ministry of Health and Family Welfare has now
developed a needs-based formula for allocating health-care resources
across districts. The formula will be piloted after approval.

It is observed that actual final expenditure falls short of the approved

budget in almost every year within the Ministry of Health and
Family Welfare (Huque, Barkat et al., 2011). Underspending of the

6 Capacity and historic normatives mean that budget setting is based both on the size of physical
capacity as measured by the number of facilities, staff or beds and also funding provided to the
same facilities in previous years. Likewise, historic patient flows are taken into account in setting
the budgets for food.

79
allocation is significantly higher in the case of the development budget
(MOHFW, 2011).

3.7.2 Payments to private providers

In Bangladesh, most transactions (64% of THE) are made directly from
patients to providers as out-of-pocket payments. Providers in such cases
receive a specific amount directly from the patients for defined care,
called fee-for-service. However, it is observed that the fees may vary
according to geographic area, the type of clinics/hospitals, and even in
some cases the socioeconomic status of the patient. The payments are
generally made to the providers or their representatives.

3.7.3 Payments for voucher scheme

Due to weaknesses in supply-side interventions, interest has grown in
demand-side financing (DSF) in order to improve the efficiency of health-
care providers in many developing countries, including Bangladesh
(Ensor, Dave-Sen et al., 2002). In DSF initiatives, individuals are provided
with vouchers or coupons that can be exchanged for services with
Government and nongovernment providers as a potential method of
overcoming some demand-side barriers. This arrangement thus involves
channelling a part of the Government subsidy for health services directly
to households by allowing them to purchase health services themselves
or through an agency (Bhatia, Yesudian et al., 2006). This initiative aims
to raise the overall consumption of a specific service (such as maternal
care) and consequently, increase access to quality health care in identified
vulnerable groups.

The Ministry of Health and Family Welfare is using DSF to implement a

maternal health voucher scheme in 53 subdistricts around the country
under the HPNSDP. The programme aims to increase the use of qualified
birth attendants and remove the financial barriers for safe delivery. The
programme additionally includes private and NGO facilities as potential
providers of maternal care, which can stimulate competition among
providers so that efficiency as well as quality of care can improve.

3.7.4 Paying health workers

Public service providers are paid salary and allowances according to
standard rates set by the Public Service Commission. These rates are
based on the civil service classification. Additional allowances may be

80
paid for particular locations. In addition, most public service providers also
work after hours in private practice, where they receive fees for service
in direct payments from patients, or payments from employer insurance
agencies.

81
4 Physical and human resources

Chapter summary
Bangladesh has an extensive PHC infrastructure in the public sector but
these are not adequately provisioned for human and other resources such
as drugs, instruments and supplies. During 2007–2013, there has been
a steady increase in the number of both hospitals and total number of
beds in the public sector. The number of beds in PHC facilities at upazila-
level and below reached 18 880 across 472 facilities in 2013, and 27 053
in 126 facilities at secondary and tertiary level. In the private sector,
there were 2983 registered hospital and clinics, with 45 485 beds. Taken
together, there is now one bed for every 1699 population which is still
inadequate. Meanwhile, to bring health facilities closer to the doorstep
of the population, there is a community clinic for every 6000 people
(n=12 527) providing primary health-care services.

There is a large cadre of health-care providers in the informal sector. This

comprises semi-qualified allopathic providers (such as community health
workers, medical assistants and trained midwives), unqualified allopathic
providers (e.g., drug shop retailers, rural doctors), traditional healers
(practitioners of Ayurvedic, Unani and homeopathic medicine) and faith
healers. They are not part of the mainstream health system but a major
health-care provider for the poor rural population, especially in remote
and hard-to-reach areas.

In the public sector, the Central Medical Store is responsible for

procurement and supply of medical and surgical equipment and products
including drugs. Public sector health facilities in Bangladesh are poorly
equipped with medical equipment and instruments. Many of the lower-
level facilities lack basic instruments like clocks and height measuring
scales. Supply of drugs is also inadequate and the supply chain is
frequently disrupted. On the other hand, the private sector, especially the
recently emerging high-cost hospitals and clinics in the urban areas, have
all the major state-of-the-art diagnostic equipment and facilities.

82
The Bangladesh health workforce is characterized by “shortage,
inappropriate skill mix and inequitable distribution”of health workforce.
At present there are 64 434 registered doctors, 6034 dentists,
30 516 nurses, and 27 000 nurse-midwives in the country (cumulative
figures unadjusted for attrition due to deaths, retirements, migration,
change of profession or inactivity). In addition, the health workforce is
skewed towards doctors with a ratio of doctors to nurses to technologists
of 1:0.4:0.24, in stark contrast to WHO recommended ratio of 1:3:5. The
engagement of the health workforce in the private sector is increasing,
as revealed by an estimated 62% of the medical doctors working in the
private sector in 2013. The formal health workforce (doctors, dentists,
nurses) is mostly concentrated in the urban areas, with variation among
the different regions. Retention and absenteeism of health workers are
two major problems facing rural areas.

4.1 Physical resources

4.1.1 Capital stock and investments
The major share of total health expenditure in 2007 was spent on drug
retail services (46.1%) and curative care services (28.6%) followed by
prevention and public health services (11.2%) (Ministry of Health and
Family Welfare, 2003). The latter include maternal and child health
services, family planning, and health awareness building services. Capital
formation, i.e. capital consumption of domestic health-care provider
institutions (including depreciation but excluding retail sale and other
providers of medical products) amounts to around 6.3% of THE.

When disaggregated by provider, the top three investments (of THE)

were as follows in 2007: drug outlets and medical goods retailers (43%),
hospitals (27%) and ambulatory health services (22%). Ambulatory
services primarily include outpatient services offered by physicians,
family planning centres, and diagnostic laboratories. The increase in
expenditure for hospitals as a share of THE is the most significant change
in the period 1997–2007. Overall hospital spending increased from 17%
to 27% of THE. This change was due to expenditure at private hospitals
increasing much faster (from 25% of THE in 1997 to 54% in 2007) than
expenditure at public hospitals (from 75% in 1997 to 46% in 2007)
(Ministry of Health and Family Welfare, 2003).

Public expenditures at District and General Hospitals across the country

in 2007 were around 8.7% of total expenditure on hospitals. Although
public hospitals at upazila-level and below continue to be major providers

83
of health services, their relative share of total hospital expenditures has
declined from 34.1% in 1997 to 24.1% in 2007 (Ministry of Health and
Family Welfare, 2003). For public sector health facilities, allocation is
based on the number of beds following a pre-determined norm, and thus
biased towards secondary and tertiary health facilities (Rahman, 2000).
This is supplemented by other allocations to meet special requirements
and urgent institutional needs, which are by definition unfixed and
irregular.

4.1.2 Infrastructure
Bangladesh has an extensive public sector health infrastructure spanning
the country and consisting of primary, secondary and tertiary health care
facilities. PHC facilities are the first level of care at the community level
while the secondary and tertiary facilities are those where more advanced
and specialty care is provided.

PHC level health facilities

The core of the PHC facilities is the community clinics, a flagship
programme of the current government. With one for every 6000 people,
a community clinic brings family planning, preventive, and limited
curative services closer to the population, usually within 30 minutes’
walking distance. Each clinic consists of two rooms with drinking water
and lavatory facilities, and a covered waiting area. Funds for building
the clinics were provided centrally, but communities were required to
donate land so that there was a sense of ownership. To boost this sense,
each community was required to set up a group to support and assist
with their management, although the staff and supplies are provided by
the Government. As of 2012, there were 12 527 functional community
clinics in the country (Ministry of Health and Family Welfare, 2013).
They are staffed by one Health Assistant (DGHS), one Family Welfare
Assistant (DGFP) and one Community Health-care Provider (CHCP) from
the project. All provide similar services. When one is preoccupied with
domiciliary services, the other staff take responsibility for providing
services at the facility, which include health, family planning and nutrition
services.

Besides community clinics, the primary infrastructure includes

467 hospitals at upazila-level and below with a bed capacity of 18 880
(Table 4.1) (MOHFW 2013).There are also 1275 union subcentres and
87 Union Health and Family Welfare Centres (UHFWC) which provide
outpatient services only. Besides these, there are five 10-bed (in number)

84
and 18 20-bed hospitals at the union level under the DGHS. DGFP runs
3827 Union Health and Family Welfare Centers, of which 1500 have been
upgraded to provide primary and outdoor care (Bangladesh Health Sector
Profile, 2010). At the union level, 24 Mother and Child Welfare Centers
(MCWC) mainly offer outdoor services, with a few providing Emergency
Obstetrical Care (EmOC) services (MOHFW 2012).

Table 4.1 Distribution of beds in the public sector at upazila (sub-

district) level and below
2007 2010 2013
Type of facility
hosp bed hosp bed hosp bed
Upazila Health Complex 413 15 741 424 15 877 436 18 290
50 bed hospital 153 7650 156 7800 268 13 400
30/31 bed hospital 260 8091 254 7874 151 4670
10 bed hospital - - 11 110 11 110
Union hospital 17 340 27 410 31 490
20 bed hospital 35 700 14 280 18 360
10 bed hospital - - 13 130 13 130
Total 430 16 781 451 16 287 467 18 780
Trauma Centre (20 bed) - - 5 100 5 100
Source: Bangladesh Health Bulletins 2007, 2010, 2013

Secondary and tertiary level facilities

This category of hospitals comprises general hospitals, district hospitals,
medical college hospitals, specialty hospitals, and other hospitals. At
the district level, DGHS operates 53 district hospitals, nine general
hospitals, three leprosy hospitals, three communicable disease hospitals,
13 chest disease/TB hospitals, 43 chest/TB clinics and 23 school health
clinics (MOHFW, 2012). The district and general hospitals offer primary
and secondary care through outdoors, indoors (outpatient and inpatient
services) and emergencies. Leprosy, communicable diseases and chest
disease/TB hospitals provide specialized services through outdoors and
indoors. Chest/TB and school health clinics provide outdoor services
only. The DGFP at the district level operates 60 MCWCs (mostly 10 beds
although some are upgraded to 20 beds). In these facilities, outdoor and
indoor services are provided along with EmOC services (MOHFW, 2012).

At the national level, DGHS has 17 medical college hospitals under its
jurisdiction; these hospitals also offer dental (20 beds), homeopathic
and ayurvedic services (each with 100 beds) (MOHFW, 2012). In addition,
DGHS operates eight super-specialized teaching hospitals covering chest

85
diseases, traumatology, CVDs, ophthalmology, cancer, kidney/urology,
neuromedicine and mental health. All of these facilities are located in
Dhaka, with the exception of the mental health hospital in Pabna. The
DGFP operates two 100-bed hospitals, both in Dhaka, providing outdoor,
indoor and EmOC services.

The Bangabandhu Sheikh Mujib Medical University (BSMMU) has been

the leading postgraduate medical institution in Bangladesh since 1998;
it was later made autonomous by the Ministry of Health and Family
Welfare(Bangladesh Health Sector Profile, 2010).Later, two other
specialized hospitals of the Ministry – Institute for Child and Maternal
Health (ICMH) and National Institute for Kidney Diseases and Urology
(NIKDU) –also received autonomy.

The distribution of beds in the respective secondary- and tertiary-level

hospitals by year is shown in Table 4.2. As can be seen, there has been
a steady increase in both number of hospitals and total number of beds.
In the process, there have been realignments, upgrading and opening
of new specialized hospitals such as trauma centres at the upazila level
and specialized centres for COPD/bronchial asthma and burn at the
secondary/tertiary level.

Table 4.2 Distribution of beds in the secondary and tertiary hospitals

by year
2007 2010 2013
Type of facility
hosp bed hosp bed hosp bed
District hospital 49 4950 53 7650 53 7850
General hospital 13 2950 9 1250 11 1350
Infectious disease hospital 5 180 5 180 5 180
Medical/dental /alternative 16 8280 17 10 005 22 11 960
medicine college hospital
Specialized hospital affiliated 7 1914 7 2114 7 2300
with post-graduate institutes
Specialized hospital (other) 1 500 2 500 2 750
Chest disease/TB hospital 11 550 12 546 13 816
Leprosy hospital 3 130 3 130 3 130
Specialized centres --- --- 3 150 3 200
Other hospital 3 525 6 305 6 305
BSMMU (Medical U) --- --- --- --- 1 1212
Total 108 19 979 117 126 27 053
Source: Bangladesh Health Bulletins 2007, 2010, 2013

86
Private sector hospitals and beds
There has been rapid increase in for-profit private sector health care
facilities in the country commensurate with successive governments’
open-door economic policy since the 1990s. The country now boasts
of state-of-the art (by south Asian standards) hospitals such as Apollo
Hospital and Square Hospital. However, the cost of treatment in such
facilities is beyond the financial capacity of even the middle-class
populations. There are also hospitals and clinics and diagnostics which
are of modest standard and less costly.

Currently, there are 2983 registered private hospitals and clinics in the
country providing about 45 485 beds (MOHFW, 2013). Only a few among
these have free beds for the poor and disadvantaged. Besides the
registered ones, there are a substantial number of clinics and hospitals
which are not registered with the regulatory bodies, and do not fulfil the
minimum standards of operation.

Thus, the total number of functional beds (public and private) in the
country is around 91 000.

Population bed ratio

The number of hospital beds indicates resources available for delivering
care to patients admitted to hospitals. In Bangladesh there is less than
one bed per 1000 population, which indicates inadequate resource for
delivering hospital services (OECD/World Health Organization, 2012).
A more recent estimate reported by the government is that on average
there is one bed for every 1699 people which is quite inadequate (MOHFW,
2013). Figure 4.1 shows the most recent data on population-to-bed ratio
in government medical college hospitals and secondary/tertiary hospitals
according to the seven administrative divisions of the country (MOHFW,
2013). As can be seen, Khulna has the highest population–bed ratio
(33 069) for a medical college hospital while Chittagong in the south-east
of the country has the highest population–bed ratio (8054) for secondary
and tertiary care hospitals. Meanwhile, the capital Dhaka has the lowest
ratio (4174). The average length of stay in hospitals is three days (OECD/
World Health Organization, 2012) and there is optimum use of beds (100%
or more) in secondary and tertiary hospitals compared to the PHC-
level hospitals (Table 4.3), indicating inadequate hospital resources at a
relatively high cost (BRAC, 2012).

87
Figure 4.1 Population per bed in public sector (medical college and
secondary and tertiary care) hospitals in different divisions
of Bangladesh in 2012

Medical college hospitals Secondary and other tertiary

care hospitals
33 069
19 842

18 563

12 696
11 599
11 092
9091

8054
8772

4174
7300
6698
6962
4956

5780
5657
Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Rangpur
Sylhet
Average

Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Rangpur
Sylhet
Average
Source: Bangladesh Health Bulletin 2013

Table 4.3 Distribution of utilization (bed occupancy) of public hospitals,

2010
Upazila Health Complex Secondary and tertiary level hospitals All
10–50 bed 100–150 bed 200–250 bed hospitals

Percentage Percentage
Division Hospitals Hospitals
of hospitals 100% or of hospitals
with 100% with 100%
Total with 100% Total higher Total with 100%
or higher or higher
or higher Bor* or higher
Bor** Bor*
Bor* Bor*

Barisal 33 4 12.1 4 1 1 0 20.0%

Chittagong 82 5 5.9 9 6 3 2 66.7%

Dhaka 103 13 12.6 11 6 3 0 42.9%

Khulna 50 9 18.0 8 5 2 2 70.0%

Rajshahi 111 21 18.9 11 9 2 1 76.9%

Sylhet 31 0 0.0 3 2 0 0 66.7%

Total 413 52 12.6 46 29 11 5 59.6%

Source: Bangladesh Health Watch, 2011

4.1.3 Medical equipment

In the public sector, the Central Medical Store is responsible for
procurement and supply of medical and surgical equipment and products
including drugs. The public sector has provisions for all basic medical
and diagnostic facilities (laboratory, radiography, ultrasonogram, etc.)

88
including specialized diagnostic facilities in tertiary care hospitals (e.g. CT
scans). The private sector, and the recently emerging high-cost hospitals
and clinics in particular, have state-of-the-art diagnostic equipment and
facilities.

The public sector health facilities in Bangladesh are poorly equipped with
medical devices, instruments and supplies (World Bank, 2012). Many of
the lower-level facilities lack basic instruments such as clocks or height
measures. Greater than 50% of the surveyed MCWCs (n=50) did not
have child height measurement scales and 255 of the surveyed district
hospitals (n=40) did not have a clock with second hand and lacked minor
surgical tools. About half of the community clinics (n=758) did not have
blood pressure measuring devices or thermometers. In the surveyed
UHCs, out of 34 basic laboratory items, 19 items were available in less
than 60% of the facilities. Around 83% of the surveyed UHCs (n=80) and
62% of the MCWCs have ambulances which are functioning. Forty-seven
percent of the district hospitals (DH), 41% of the UHCs and 25% of the
MCWCs reportedly restricted the use of ambulances due to funding
shortfalls. From the same survey, data reveal that 65% of the DHs and
52% of the UHCs have functioning X-ray machines, 61% of the DHs and
57% of the UHCs have functioning ultrasonograms, and 86% of the DHs
and 83% of the UHCs have functioning ECG machines (World Bank, 2012).

4.1.4 Information technology

The health system of Bangladesh is rapidly adopting technology to its
information and management systems. Under the HPNSDP (2011–2016),
the Health Information System (HIS) and e-Health is implemented
through an operation plan (MOHFW, 2012). The HIS Management
Information System (MIS) collects data electronically from all facilities
from national to upazila-level. Expansion of internet access to union-level
facilities and community clinics has started and soon will be within the
HIS net. The HIS is being used for generation of various databases to aid
management decision-making.

Under e-Health, mobile phone-based services and telemedicine is

provided. All the UHCs and district hospitals have a dedicated mobile
phone number which connects to a call centre accessible round the clock
for everyone in the catchment area. Those living in the catchment area
can call and a doctor on duty answers and gives necessary medical advice
free of charge. Gradually, this service will be extended to community
clinics.

89
Launched in July 2011, telemedicine service is now available from
nine hospitals (three UHCs, three district hospitals and three tertiary
hospitals) and uses high-quality video conferencing devices. It has thus
expanded the opportunity of medical consultation to rural areas often
not served by specialist doctors. By 2013, telemedicine services will be
expanded to several thousands of community clinics and to facilitate this,
internet-ready mini-laptops are being distributed to the clinics.

Currently, a pilot project named MOVE-IT is in place to build a unified

electronic information system to register all pregnancies, births, deaths,
cause of death, non-fatal health events and coverage of priority services
for maternal and child health harnessing the power of mobile and IT. This
is being implemented by the Government in partnership with an NGO and
an IT company under funding from the WHO Health Metrics Network.

4.2 Human resources

WHO defines health workers as “all people engaged in actions whose
primary intent is to enhance health”. In the context of low-income
countries like Bangladesh, health workers include professionals
(doctors, nurses and midwives, dentists, public health professionals),
allied professionals (medical assistants, physiotherapist, pharmacists,
dietitians, etc.) and health-care providers in the informal sector who
operate “outside the purview of regulation, registration, or oversight
by the government or other institutions” (Ahmed, Hossain et al., 2009).
Thus, the heterogeneity of the health workforce at different levels of
administrative units is a fact of life in Bangladesh, like all transitional
societies.

At the community level, there are all kinds of informal providers –

traditional birth attendants, practitioners of traditional medicine and
faith healers, village doctors, drug vendors/retailers and self-educated
homeopaths – along with some semi-qualified allopathic providers such
as community health workers/providers (Table 4.4). Given the shortage of
professional health-care providers, they have become the major providers
of health care to the vast majority of the population, especially in rural
areas. Qualified health professionals become available from union level
(the lowest administrative unit comprising several villages) and above. At
the apex of the pyramid are the district and medical college hospitals and
specialized tertiary hospitals where various specialists are available and
only a fraction of the population has access to these due to geographic,
socio-cultural and financial barriers.

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Table 4.4 Informal health-care providers at PHC level in Bangladesh
Type of services
Provider Training Health sector
provided
Faith healer (Ojha/ Not applicable Non-secular; based on Private
pir/fakir) religious belief
Traditional healer Mostly self-trained, but some Ayurvedic, based Private
(Kabiraj) may have training from Govt. or on diet, herbs
private colleges of traditional and exercise etc.
medicine Sometimes also
combine allopathic
medicine such as
antibiotics and steroids
etc.
Traditional healer Self-trained, combines Combination of Private
(totka) ayurvedic, unani (traditional ayurvedic, unani and
muslim medicine originating faith healing
from Greece) and shamanistic
systems; also use allopathic
medicine
Village doctors/ Few have one year training Allopathic Private
Rural medical from Govt. Organizations which
practitioners stopped in 1982; majority have
(RMPs); in Bangla, three to six months training
Palli Chikitsok from unregistered private
organizations
Homeopath Mostly self-educated, but Homeopathic Private
some possess recognized
qualification from Govt. or
private Homeopathy Colleges
Drug vendor/drug No formal training in Allopathic; in addition Private
seller; also village dispensing; none of them to dispensing, they
‘quack’ are trained in diagnosis also diagnose and treat
and treatment; some
learn treatment through
apprenticeship or working in
drug stores (‘quack’)
Traditional birth No training or short training on Assisting normal Private
attendants safe and clean delivery by Govt./ delivery
private organizations/NGOs
Community health Training on basic curative care Allopathic: curative Public/private/
workers (health/ for common illnesses and and preventive/ health nonprofit NGOs
family welfare preventive health by Govt./ promotion
Assistant, NGO private/NGO organizations of
CHWs etc.) varying duration

Source: (Ahmed, 2005)

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4.2.1 Health workforce trends
The health system in Bangladesh is characterized by a massive shortage
of skilled health workers with twice as many doctors as nurses, clustered
disproportionately in urban areas while rural facilities are overburdened,
understaffed and insufficiently equipped. It is one of the 57 countries
identified by WHO as having critical shortage of health workforce (WHO,
2006). The recent report of WHO suwggests that there are 0.3 doctors and
0.3 nurses per 1000 population and cumulatively less than 23 doctors,
nurses and midwives per 10 000 population. Facilities as well as human
resources are planned on geographical considerations rather than the
size of population of a given area.

The size of the professional health workforce is consistently increasing

over time, but not according to requirements (Figure 4.2). At present there
are 64 434 registered doctors, 6034 registered dentists, 30 516 registered
nurses, (MOHFW, 2013) and 27 000 nurse-midwives (MOHFW, 2012).
These are cumulative figures, and though there is a provision for updating
the register every five years, this is hardly done on a regular basis.
Attrition occurs from professional mobility and “brain drain”, failure of
rural retention, death and retirement. Some leakage occurs in the form of
drop-out (becoming inactive in the profession), change of profession, and
migration. Thus, the number of currently available doctors in the country
is 46 951; no updated data is available for other categories of providers.

Figure 4.2 Bangladesh Medical and Dental Council (BMDC) registered

health workforce in 1997, 2007 and 2012
58 977

70 000

60 000
45 273

Doctors
50 000
Dentists
30 418

40 000
27 000
26 608

Nurses
21 715
19 354

30 000 Midwives
15 408
13 211

20 000
4986
2945

10 000
536

0
1997 2007 2012

Source: Bangladesh Health Bulletins 1997, 2007, 2012

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The recent trend of feminization of the health workforce (especially
doctors) in Bangladesh is especially serious because it is difficult to
post women in remote rural and hard-to-reach areas due to lack of
infrastructure and other socio-cultural reasons. Many female doctors,
nurses, medical technologists and para-professionals choose to remain
as housewives after marriage and become inactive in profession for
limited time or permanently.

Shortages also exist among other cadres such as medical assistants and
health technologists. This results in many sanctioned posts lying vacant
in the public sector. In case of doctors, dentists and nurses, the vacancy
exceeds more than one fifth of the sanctioned posts (MOHFW, 2013). In
case of public sector recruitment, the average lead-time is two years
from requisition to completion of selection. Thus, if the Ministry makes
a request to the Public Service Commission (PSC) for certain number of
physicians due to vacancies, PSC can only supply these after two years by
which time the Ministry has already incurred further vacancies. Similarly,
though the local authority (like head of hospitals or civil surgeon) is
authorized to recruit class III and IV employees, they need to seek
permission from DGHS, which usually cuts 20% of the request almost
routinely. Thus, 20% of vacancies always remain in the public sector
health services, mostly in rural areas.

Doctors in private sector

According to an estimate in 2003, around 50% of the doctors, 42% of the
nurses and 65% of the paramedics work in the private sector exclusively,
besides those public sector employees who also practice privately after
office hours. The involvement of the health workforce in the private sector
is increasing, as revealed by an estimated 62% of the medical doctors
working in the private sector in 2013 (MOHFW, 2013). No such current
data is available for the other health professionals.

Density of health workforce

Figure 4.3 presents the density (per 10 000 population) of different types
of health-care providers from a study on health workforce in the formal
and informal sectors. There are about eight formally qualified HCPs
(doctors, nurses, dentists) per 10 000 population (5% of the currently
active health-care providers) in Bangladesh. It has now around five
physicians and two nurses per 10 000 populations, the doctor-nurse ratio
being 0.4 (Ahmed, Hossain et al., 2011).

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Figure 4.3 Density of health-care providers per 10 000 populations

70 64.2
60
50
40
33.2
30
20
12.5 11.4 9.6
10 7.7
5.6
1 0.9
0
Physicians, dentists, nurses

Traditional healers

Traditional birth attendants

Paraprofessionals

Village doctors

Sellers of allopathic medicine

Community health workers

Homeopaths

Other
Source: Bangladesh Health Bulletins 1997, 2007, 2012

Distribution of health workforce

The existing health workforce in Bangladesh is very inequitably
distributed as demonstrated amply from a recent study (Ahmed,
Hossain et al., 2011). All significant health institutions are located in the
capital city which shows great centralization, while health workers are
concentrated in urban secondary and tertiary hospitals, although 70% of
the population lives in rural areas (Country Case study) (GHWA, 2008).
The overwhelming urban bias of the distribution of qualified professionals
remains a persistent phenomenon (Figure 4.4). They are mainly
concentrated in the urban areas, and disproportionately in Dhaka
division including the capital city. On the other hand, unqualified/semi-
qualified allopathic practitioners such as village doctors and Community
Health Workers (CHWs) are mainly concentrated in rural areas. Drug
shop attendants are evenly distributed. There are also the usual stock
of traditional healers and trained/traditional birth attendants in rural
areas. A comprehensive HRH strategy is currently being developed by
the Human Resource Development Unit of Ministry of Health & Family
Welfare, Bangladesh Secretariat (WHO, 2014).

94
Figure 4.4 Rural-urban distribution of health-care providers by type
(per 10 000 populations)

Homeopaths
Traditional Medicine
TBA/TTBA
Drug store salespeople
Village doctors
CHWs
Allopathic
Dentists
Nurses
Physicians
Others

0% 10% 20% 30% 40% 50% 60%

urban rural

Source: Bangladesh Health Watch, 2007

Health workforce gaps, projected workforce needs and current production

Currently, the health workforce is skewed towards doctors with a ratio
of doctors to nurses to technologists of 1:0.4:0.24. According to the WHO
recommended ratio of 1:3:5, Bangladesh has a staggering shortage of
over 90 000 doctors, 273 000 nurses and 455 000 technologists (Table 4.5).
The Ministry has a target of achieving a ratio of 1:1:1 in the foreseeable
future.

Table 4.5 Projected workforce per 10 000 populations based on WHO

recommended skill mix ratio and MOHFW targeted skill mix
ratio using 2007 data
Workforce
MOHFW WHO
MOHFW Workforce MOHFW projection
Health-care projected recommended
2007 ratios workforce using
provider skill mix skills mix
estimates 2007 projection WHO
ratios ratios
ratios
Doctor 38 537 1 1 1 91 000 91 000
Nurse 15 415 .4 1 3 91 000 273 000
Technologist 9249 0.24 1 5 91 000 455 000

Source: World Bank 2010

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4.2.2 Professional mobility of health workers
While there is already a shortage of qualified doctors in the country, of
even more concern is the fact that the migration of skilled workforce
is occurring on a continuous basis. According to one estimate, there
were 1794 registered Bangladeshi doctors working in the United States,
Canada, United Kingdom, Australia, New Zealand and Saudi Arabia in
March 2001 (Peters and Kayne, 2003). This is a gross underestimate
because data is not available for other Middle Eastern countries and
India. No current data is available. It is estimated that on an average,
200 doctors from the public sector move abroad every year (Adkoli, 2006).
Medical technologists and some nurses also migrate annually, but no
reliable data are available.

4.2.3 Training of health workers

The basic undergraduate degrees such as Bachelor of Medicine and
Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS) and
Diploma of Nursing are awarded by medical and dental colleges and
nursing schools respectively. A brief description of the different cadres is
given below:

Doctors: Basic allopathic medicine is the mainstream of medical

education. It is a five-year degree offered as MBBS after 12 years of
schooling. After passing the final professional examination, one year
of internship is a prerequisite to get formal registration to work as a
practicing physician.

Nursing: Nursing as a profession in Bangladesh is not as prestigious

as the medical profession due to various socioeconomic, cultural and
religious factors. Currently, the basic nursing course comprises a three-
year diploma course after 12 years of schooling. Midwifery was offered
as a separate training programme (12 to 18 months) until the late 1970s.
Later it was incorporated within nursing training, with one year of
midwifery training at the last year of the Diploma in Nursing. Recently,
considering the deficiency of this cadre, a separate programme for
midwifery was reintroduced in 2011 as a three-year course.

Dental surgeons: A four-year graduate course is offered by public and

(mainly) private sector dental colleges to produce dental surgeons.

Public health professionals: The first institution established was the

Institute of Public Health Nutrition (IPHN) in 1974. This was followed

96
by the establishment of Institute of Epidemiology, Disease Control and
Research in 1976 and the National Institute of Preventive and Social
Medicine (NIPSOM) in 1978. The latter formally introduced the Diploma in
Public Health (DPH) and Diploma in Community Medicine (DCM) courses
which ultimately evolved into Master of Public Health (MPH) courses.

Medical assistants: Introduced in 1976, they are trained to provide basic

primary care including prescribing and referral in assistance with a
doctor and even in the absence of a doctor to provide services at UHC/
UHFWCs. It is a three-year diploma course after 10 years of schooling.

Medical technologists: These include various disciplines such as

laboratory, radiology, physiotherapy, sanitary inspection, dentistry,
pharmacy, and radiotherapy. There are both diploma and Bachelor
courses. As of December 2011, 22 institutes offer BSc courses in different
disciplines such as Physiotherapy, Laboratory Medicine, Dentistry,
Occupational Therapy, Speech Therapy, Optometry and Pharmacy.
Two NGOs and a private hospital offer different technical courses
in ophthalmology including optometry, refraction, and training for
ophthalmic assistants and ophthalmic nursing assistants. The National
Institute of Cardiovascular Diseases and Hospital (NICVDH) offers a
Cathlab technologist course with 10 seats.

Family Welfare Visitors (FWVs): The National Institute of Population

Research and Training (NIPORT) and Directorate General of Family
Planning (DGFP) offer an 18-month FWV course as in-service training
to selected women, who after passing are posted as FWVs, mostly at the
UHFWCs under DGFP.

Community-based skilled birth attendants (CSBAs): To facilitate

attendance of births by skilled health personnel, the Ministry of Health
and Family Welfare started a programme in March 2003 to produce
community-based skilled birth attendants by providing six months
training to accredited female field workers. However, many NGOs such
as BRAC and projects like UNDP’s Chittagong Hill Tracts Development
Facility trained their workers as CSBAs at other institutions including the
Institute of Child and Mother Health, and Ad-din Hospital at Jessore.

Community paramedics: Two-year Community Paramedic courses

are offered exclusively by the private sector, for which institutes are
accredited by NIPORT and Bangladesh Nursing Council.

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The annual production capacity of health workforce is shown in Table 4.6
below. With the exception of nursing, there are more seats available for
doctors, medical technologists, and medical assistants in the private
sector than in the public sector. These numbers have increased to some
extent recently. However, compared to the existing gaps, the current
combined capacity to produce health workforce is inadequate.

Table 4.6 Annual production capacity of health workforce including

private sector as of 2013
Number of seats for
Number of institutes
HRH categories admission
Total Public Private Total Public Private
Physicians
Post graduate 33 23 10 2260 2091 169
Medical college 87 23 64 7712 2862 4850
Dental college 27 9 18 1597 532 1065
Sub-total for physicians 147 55 92 11 569 5485 6084
Medical assistants 111 8 103 6821 716 6821
Nurses and allied HRH
Nursing (Diploma) 91 44 47 4540 2630 1910
Nursing (B.Sc) 36 13 23 2845 1285 775
Midwifery 12 - 12 320 - 320
Community skilled birth 47 45 2 NA NA NA
attendant
Specialised nursing 4 - 4 80 - 80
Sub-total for nurses and 190 102 88 7785 3915 3085
allied HRH
Medical technologists
Inst. of health technology 90 8 82 12 650 2419 10 231
(Diploma)
Inst. of health technology 18 3 15 1425 265 1160
(B.Sc)
Sub-total for medical 104 11 97 14 075 2684 11 391
technologists
Source: Author’s calculation from Bangladesh Health Bulletin 2013

4.2.4 Alternate medical care providers

In the National Health Policy 2000, Ayurvedic, Unani and Homeopathy
were added as an alternative education system along with the
mainstream medical education so as to produce alternative medical
practitioners. Two types of courses are offered: graduate with five years

98
of study and 12 months of internship (BUMS and BAMS), or diploma with
four years of study and six months of internship (Diploma in UMS and
AMS)(MOHFW, 2011). The different institutions teaching and training in
alternative medicine is shown in Table 4.7 below. The annual intake of these
institutions currently stands at about 400 students.

Table 4.7 Academic institutions for teaching and training alternative

medicine in Bangladesh
Name of Duration Duration of No. of
Total Govt. Private Degree offered
institution of course internship seats
Govt. Unani 1 1 0 5 years 1 year BUMS (Bachelor 50
and Ayurvedic of Unani Medicine
Medical College and Surgery);
BAMS (Bachelor of
Ayurvedic Medicine
and Surgery)
Homeopathic 2 1 1 5 years 1 year BHMS (Bachelor 50
Medical College of Homeopathic
Medicine and
Surgery)
Tibbia College / 12 1 11 4 years 6 months DUMS (Diploma of 25*
Unani Diploma Unani Medicine and
College Surgery)
Ayurvedic 8 0 8 4 years 6 months DAMS (Diploma of na
Diploma Ayurvedic Medicine
College and Surgery)
Homeopathic 41 0 41 4 years 6 months DHMS (Diploma na
Diploma of Homeopathic
College Medicine and
Surgery)
Total 64 3 61
*only in government institutions, na - not available
Source: Asia Pacific Observatory on Health Systems and Policies

4.2.5 Doctor’s career paths

Doctors
The career prospects of general physicians in the public sector are
not good. Within the health cadre are teaching and administration
subcadres who have different entry requirements and pathways for career
development. In the teaching subcadre, postgraduate qualification is a
prerequisite which limits their number to start with, and as such, they enjoy
the opportunity of speedy promotion since there are more posts at upper
levels. But in the administration subcadre, a postgraduate qualification
is not required and since the base of this subcadre is large and posts at

99
the upper level are limited in numbers, the opportunity for promotion is
very limited. The majority of the doctors working in the administration
subcadre obtain their first promotion almost at the end of career and
retire before moving to more higher posts. These two distinct promotional
pathways place both sides in unequal competition and create tension.
Since there are shortages of health cadre officials at higher levels like
Director, Army Medical Corps officers on deputation come to serve in
those positions. Since they belong to the army and not the regular civil
health administration, conflicts also arise between these deputed army
officers and their civilian counterparts or superiors.

In the case of doctors, there are postgraduate courses on preclinical,

paraclinical and clinical subjects. In these subjects, doctors have
the option to acquire further specialization in two different ways–
postgraduate courses and fellowships. A doctor can be specialized in a
subject in either way, for example he/she can have a MS in Ophthalmology
or be a fellow of ophthalmology.

Formal postgraduate courses offered in different institutions which

include a two-year Diploma, a five-year Masters (Masters in Surgery/
Masters in Medicine), a three-year MPhil, or an 18-month MPH Master of
Transfusion Medicine or Master of Medicine (MMED). At first there was
only one institution (Institute of Postgraduate Medicine and Research
(IPGMR), now Bangabandhu Sheikh Mujib Medical University (BSSMU))
offering postgraduate courses for doctors, but since the late 1990s the
old medical colleges started offering these courses (Faiz, 2007). Recently,
some private medical colleges and institutions have also started offering
these courses. In December 2011, 2237 seats for postgraduate courses
were available in the country (Table 4.8).

Table 4.8 No. of seats for postgraduate courses offered by different

institutions (Health Bulletin 2013)
Name of
MS MD M.Phil Diploma MPH MTM MMED Total
institutions
Medical University 140 150 70 106 - 10 - 476
(BSSMU)
22 Government 312 360 242 478 185 - 15 1592
institutions
10 Private 21 38 15 95 - - - 169
institutions
Grand total 473 548 327 679 185 10 15 2237
Source: Asia Pacific Observatory on Health Systems and Policies

100
Fellowship (FCPS) and membership (MCPS) are offered to the doctors
through four years of training by an autonomous authority, the
Bangladesh College of Physicians and Surgeons (BCPS). Table 4.9 shows
the number of awards given by year and fellowship/membership. These
options create more opportunities for individual career paths and total
production of specialized doctors. On the other hand, different degrees
in the same profession may create confusion in the service sector rules
regarding recruitment and promotion, for example.

Table 4.9 No. of fellowship and membership awardees by year and

category (Health Bulletin 2012)
FCPS MCPS
2007 2008 2009 2010 2011 2007 2008 2009 2010 2011
Total 172 216 239 288 320 108 79 93 125 118
Source: Asia Pacific Observatory on Health Systems and Policies

4.2.5 Other health workers’ career path

Nurses
After passing the diploma, nurses can undergo a two-year post-basic
BSc nursing course as in-service training. In 2004, a Bachelor of Science
in Nursing was introduced as a four-year graduate course. However, the
numbers of BSc nurses are low and out of 174 sanctioned posts of Class I
nurses, only one is filled as of June 2013 (MOHFW, 2013). Specialized
nursing courses like cardiac nursing, rehabilitation and pediatric nursing
and junior nursing (midwifery) are offered by institutions in the private
sector.

4.2.6 Dual practice

Dual practice by physicians in the public sector is a common behaviour
in Bangladesh. About 80% of government physicians, particularly at
secondary and tertiary level hospitals, commonly run private chambers
after office hours (Gruen, Anwar et al., 2002).The main reason physicians
carry out dual practice in the health sector is to supplement their income
derived from public service. The rate of absenteeism is high among
public doctors and especially those known to have a private practice and
engaged in dual practice to double their income (Gruen, Anwar et al.,
2002; Chaudhury, Hammer et al., 2006). There is no regulation of such
dual practice, except for a few large private hospitals where private
practice after hospital hours is restricted.

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5 Provision of services

Chapter summary
Health services are delivered by both the public and non-public sectors
in Bangladesh. In the public sector, the Ministry of Health and Family
Welfare is the main agency providing public health services, including
promotive and preventive services. The public health services include
programmes for the control of TB, now covering all upazilas with the
Directly Observed Treatment Strategy (DOTS); the National Leprosy
Elimination Programme, which reduced prevalence rates to 0.24/10 000
by 2010; the Malaria and Parasitic Disease Control Programme which
targets approximately 11 million people in high-risk areas; Kala-azar
control which has now expanded to cover 27 districts; and the HIV/AIDS
programme which has managed to keep the incidence of HIV below 1%
among high-risk populations. These programmes are supported by
National Public Health Institutes, while health promotion programmes
are organized by the health promotion sections of both DGHS and DGFP.

Primary and ambulatory care is delivered through the public network

of facilities, particularly through the community-based health-care
programme delivered by community clinics; and by the private formal
and informal and NGO providers. In urban areas, patients tend to use
the outpatient units of the major urban hospitals for ambulatory care.
Secondary and inpatient care is provided through public facilities at
upazila, district, medical colleges and specialized urban hospitals, as well
as private hospitals mainly in urban areas. There is no structured referral
system, so that patients with minor ailments may also present directly to
hospitals for treatment.

Due to epidemiological and demographic change, Bangladesh is facing

the double burden of communicable and noncommunicable disease
including the emergence and re-emergence of other diseases (avian flu,
dengue, etc.). Moreover, with recent incidents in garment factories, the
focus is shifting towards the occupational health and safety of workers in
the ready-made garment sector. The public health programmes need to

102
be revisited and redesigned to effectively address emerging challenges.
Bangladesh has made significant progress in the development of its
domestic pharmaceutical sector, with the introduction of the National
Drug Policy (NDP) in 1982. Domestic manufacturers now provide 75% of
total drug sales, and are expanding to develop an export market. Within
the public sector, the Central Medical Stores procures and distributes
drugs to public sector hospitals and facilities where they are provided
free of charge. However, outside the public sector, there is a chaotic
market of some 64 000 licensed pharmacies and 70 000 unlicensed drug
stores, selling all types of medicines without requiring prescriptions.
Polypharmacy and dispensing by the prescriber are also common in the
private sector and constrains the rational use of medicines.

5.1 Public health

Provision of public health services, including emerging and
noncommunicable diseases, is primarily the responsibility of the
Ministry of Health and Family Welfare provided through a sector wide
approach implemented by the Directorate General of Health Services
and Directorate General of Family Planning. The SWAp provides service
coordination, curative care, urban health, NCD/CD care, and more
through its Essential Services Delivery7 Operational Plan (ESD OP)
(MOHFW, 2011). However, with rapid urbanization, addressing health
issues in urban areas is a mounting challenge. Provision of public health
services in the urban areas is a prerogative of the Ministry of Local
Government, Rural Development and Cooperatives, while the Ministry of
Health and Family Welfare provides the technical oversight and logistics.
In order to improve health service delivery, coordination between the
two ministries needs to be strengthened. Though there is an Operational
Plan focusing on NCDs, preventive care as well as treatment of NCDs is
limited. There has been some achievement in reducing MMR and IMR,
but Bangladesh lags in addressing nutrition. The percentage as well as
the absolute number of malnourished women and children in Bangladesh
is on a declining trend, but the figures remain high. Drowning, one of the
major causes of under-five mortality today, is a growing concern. Arsenic
in groundwater, the main source of safe drinking water has emerged as
a major public health problem. Based on these changing trends, looming

7 The ESD OP covers primary health-care services in Bangladesh which include: health education,
nutrition, adequate and safe water sanitation, maternal and child health, immunization,
prevention and control of endemic diseases, treatment of common ailments and injuries, and
provision of essential drugs (ESD OP, 2011).

103
challenges, double burden and the emergence/re-emergence of diseases,
the public health programmes need to be reviewed and updated to
incorporate new programmes and phase out older ones which are less
effective.

Disease surveillance and notification

Two key organizations, Institute of Epidemiology, Disease Control and
Research (IEDCR) and International Centre for Diarrhoeal Disease
Research, Bangladesh (icddr,b) support disease surveillance. The
surveillance systems cover priority communicable diseases, sentinel
surveillance for influenza-like illnesses, emergency outbreak
investigations and more. After diagnosis, WHO along with the Government
is notified as per the International Health Regulations, as Bangladesh
is IHR-compliant. A hospital-based influenza surveillance system is
functional in 12 hospitals across the country.

Occupational health
As a developing country, Bangladesh is moving fast towards
industrialization. However, the physical and organizational infrastructure
is yet to meet safety standards for occupational health and the human
rights of employees. New, emerging industries like shipbreaking,
shipbuilding, ready-made garments and construction are highly risky
and offer unsafe work environments. According to a survey in 2010,
1310 employees were killed and 899 injured in the year to June 2010 in
various work-related incidents, of whom 456 workers were killed and
356 critically injured in workplace incidents (e.g. falls, electrocution,
suffocation, fire, explosion) due to unsafe work environments
(Occupational Safety, Health and Environment Foundation Bangladesh,
2010).

There are over 4000 Ready Made Garments (RMG) factories, employing
more than four million workers generating billions of dollars in exports
(Yardley J, 2011). The rapidly-growing ready-made garment sector
is especially vulnerable and accidents such as building collapse and
fire have become almost a regular occurrence. In November 2011,
111 workers died in the Tajrin fire incident (AMRC, 2013). In one of the
largest industrial accidents, the collapse of a multistoried building
housing several ready-made garment units killed a staggering 1143
workers and injured thousands in April 2013 (Odhikar, 2013).

104
The shipbreaking industry is another hazardous industry which is a
source of livelihood for around 500 000 people directly or indirectly,
and a source for 50% of the country’s production of steel (World Bank,
2010). However, the infrastructure including mechanization is very
poor in Bangladesh. The hazardous waste and associated occupational
health hazards pose a significant national (and global) concern. The
working conditions have been very poor with very limited use of personal
protective measures. Workers’ right to union membership is absent and
the health and safety of workers compromised. In 2013 alone, 20 deaths
were reported in the sector (FIDH, 2013).

The country has not yet ratified key international labor standards on
occupational safety and health (OSH) policy such as the Promotional
Framework for Occupational Safety and Health Convention 2006 (No.
187) and the Occupational Safety and Health Convention 1981 (No.155)
(ILO: OSH Country Profile Bangladesh). However, the recently amended
Bangladesh Labor Act 2013 requires that safety committees be created
in factories with 50 workers or more, and that safety welfare officers be
posted in workplaces with more than 500 employees. It stipulates the
establishment of health centres in workplaces with over 5000 employees.
The Department of Inspection for Factories and Establishments (DIFE)
under the Ministry of Labor and Employment (DIFE web) is responsible for
enforcing labor laws. It also provides information and advice to employers
and workers concerning the most effective means of complying with the
legal provisions.

Communicable Disease Control Programs

TB: Detection rates have increased, yet Bangladesh continues to rank
the sixth-worst on the list of highest burden countries for TB in 2012
(WHO, 2013). While treatment success rates have increased, due
to urbanization there has been an increase in the slum population
(an increase in the population density) and that has led to the rise in
the spread of TB. Furthermore, another major problem is the spread of
MDR- TB, which requires further attention.

In order to control and eliminate TB, the Government has created

a separate Operational Plan under the health sector programme
(MOHFW, 2012), the National Tuberculosis Control Programme (NTP).
The NTP adopted the Directly Observed Treatment Strategy in November
1993 and since then has expanded to cover all upazilas; by 2007, the
geographical coverage was 100% (MOHFW, 2011). Bangladesh is on track

105
to achieving the sixth MDG, with TB deaths declining from 76 to 43 per
100 000 (MOHFW, 2011). A joint reassessment by WHO and the NTP will
be undertaken following the completion of the prevalence survey planned
for 2014 (WHO, 2013).

There are seven divisional chest disease hospitals and 44 chest clinics
throughout the country that provide diagnosis and treatment services.
Besides these facilities, the Upazila Health Complexes also diagnose and
treat TB patients.

Bangladesh received the GFATM grants in Round-6 and Round-9 and the
programme is now being managed by the Government in collaboration
with the BRAC-led 21-member NGO consortium. Long-term momentum
needs to be maintained to control the disease on a sustainable basis,
particularly keeping in mind the emergence of MDR-TB (GFATM, 2012).

The Ministry of Health and Family Welfare, with the support of USAID,
launched the Community-based Programmatic Management of
Multidrug-Resistant Tuberculosis (MDR-TB) Programme. There are
around 6000 new MDR-TB cases each year. Eight GeneXpert machines
have been procured for high-volume chest disease clinics nationwide.
With the machines, diagnosis of MDR-TB is completed in two hours
and patients can be started on treatment the same day. Upazila health
workers are trained under this approach to manage patient care in their
communities (USAID, 2012).

Leprosy: Countrywide expansion of the leprosy programme has resulted

in a remarkable reduction of the prevalence of leprosy. The National
Leprosy Elimination Program (NLEP) consolidates its efforts to achieve
subnational (district-level) elimination and to sustain elimination status.
The NLEP further works to reduce the prevalence at national level and to
achieve grade 2 deformities among new cases of less than 5% (MOHFW,
2011). Countrywide expansion of multi-drug therapy at all upazila
hospitals, integration of leprosy services into the general health services,
establishing model partnerships with NGOs, effective collaboration with
some key groups like village doctors, religious leaders, Bangladesh
Scouts and implementation of some focused activities like Special Action
Projects for the Elimination of Leprosy, Leprosy Elimination Campaign,
have helped towards the elimination of leprosy (MOHFW, 2011).
Prevalence reached 0.24/10 000 population at the end of 2010. There are
only two districts with a prevalence of more than 1/10 000 population in
2011 (PMMU, 2013).

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Malaria: Malaria is endemic in 13 districts of the north-eastern border
belt, including Chittagong Hill Tracts (CHT) and about 11 million people
live in malaria high-risk areas (MOHFW, 2011). Presently, malaria control
activities are carried out through the Communicable Disease Control
(CDC) OP under DGHS. The Malaria and Parasitic Disease Control unit is
responsible for the planning, implementation, monitoring and evaluation
of the activities related to malaria control at the national, district and
upazila levels (WHO, 2012). Access to diagnosis by microscopy is available
up to the subdistrict level; however, this service is not available around
the clock. Delays in reporting of positive cases need to be minimized
to facilitate early initiation of treatment and the quality of microscopic
diagnosis needs further improvement. Rapid Diagnostic Testing (RDT) has
been introduced on a small scale in the country (WHO, 2012).

The Government’s target is to reduce malaria morbidity and mortality by

60% of the baseline of 2008 by 2016 (MOHFW, 2011). Preventive services
for malaria control include an integrated and strengthened surveillance
system, selective vector control, promotion of insecticide-treated
mosquito nets, epidemic preparedness and community participation.
These activities need to be implemented and effectively monitored
(MOHFW, 2011).

Bangladesh has secured GFATM funds for malaria control and

implementation is ongoing. The Ministry of Health and Family Welfare
works closely with a consortium of 21 NGOs, led by BRAC, to establish a
network of community-level programmes that focus on the use of RDT
and microscopy, effective treatment of confirmed cases, providing ITNs
to people who live in the endemic areas, and implementing behaviour
change and community mobilization programmes. Community Health
Workers (CHWs) identify malaria symptoms, conduct blood tests using
the RDT and provide treatment at the community level (BRAC, 2011). The
impact of these efforts is monitored through an established surveillance
and reporting mechanism from communities to the central level (GFATM,
2012).

A growing concern for Bangladesh is cross-border migration and the

spread of new cases (Coker, Hunter et al., 2011). Moreover, security,
geographical topography and remoteness issues, particularly in CHT
areas, render implementation of the programme difficult. More effective
regional collaboration is needed to control the disease.

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Kala-azar: Kala-azar has re-emerged since the cessation of spraying
operations. Since then, this has become a neglected tropical disease;
attention and resource allocation has been inadequate. At least
20 million people in more than 27 districts are at risk, with the single
district of Mymensingh accounting for more than half of all cases in
Bangladesh. Similar to malaria, the Kala-azar Control Programme is
the responsibility of the CDC OP. Both active and passive case detection
and treatment, and disease and vector surveillance need to be further
strengthened. Elimination is the goal of the current sector programme
(with a prevalence of less than one case per 10 000 population in endemic
areas by 2016) (MOHFW, 2011). Diagnosis needs to be strengthened
through provision of microscopy, RDT and building the capacity of the
staff. Under service provision, quality assurance of diagnosis needs to be
strengthened for all vector-borne diseases in Bangladesh.

HIV: HIV prevalence is low and at present the epidemic remains

concentrated among injecting drug users (IDUs) in a particular location.
While HIV prevalence among men having sex with men and female
sex workers has remained below 1%, unsafe practices among IDUs,
particularly needle sharing, have caused a sharp increase in the number
of people infected. Serosurveillance in 2005 showed that the incidence
of HIV in IDUs was 4.9%, except for a small pocket in central Dhaka
where it has reached 9%. Since Bangladesh is a low-prevalence country,
interventions have not targeted the general population; however, low
condom use and poor comprehensive knowledge of HIV/AIDS among
youths (16% in 2006), increase the risk factors for contracting HIV/AIDS.
The National Strategic Plan for HIV and AIDS guides the provision of
services and is currently undergoing a midterm review (UNAIDS, 2012).
The National AIDS and STD Programme (NASP) leads on HIV/AIDS control
activities in Bangladesh, which are implemented mostly by NGOs – many
of which are contracted through the sector programme; comprehensive
service packages are directed to the most at-risk populations (including
the provision of condoms, diagnosis and treatment of STIs, voluntary
counselling and testing and behavioural change communication);
scaling up ART treatment and care; and conducting regular serological
surveillance (MOHFW, 2011).

Public health institutes

Several specialist agencies under the Ministry of Health and Family
Welfare and some nonprofit private sector organizations are engaged
in public health research and development, including knowledge

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management. In the public sector these include the National Institute
of Preventive and Social Medicine (NIPSOM), Institute of Epidemiology,
Disease Control and Research (IEDCR), Institute of Public Health (IPH),
National Institute of Population Research and Training (NIPORT),
Bangladesh Medical Research Council (BMRC), Centre for Medical
Education (CME), Institute for Child and Maternal Health (ICMH), and
the DGHS Research and Development Unit. Autonomous bodies like the
BSMMU and other medical colleges are also involved in research and
development.

In the private sector, the lead research agencies include icddr,b,

James P Grant School of Public Health, BRAC University and the
Bangladesh Institute of Research and Rehabilitation in Diabetes,
Endocrine and Metabolic Disorders (BIRDEM). There is close
collaboration between some national institutes and private research
institutions, such as icddr,b and IEDCR. Government also provides some
support to some of private institutions, for example BIRDEM and icddr,b.

Promotive and preventive programmes

There are many ongoing promotional and preventive activities undertaken
by the public and private sectors and NGOs. These activities range
from family health, maternal and child health immunization, nutrition,
to CDs (TB, malaria, leprosy), NCDs (diabetes, cancer, CVDs), and
secondary prevention programmes (breast and cervical cancer). Most
of the programmes have promotional components which are provided
through various means: posters, leaflets, TV and radio drama series and
“infomercials”, uthanboithaks (courtyard meetings), personal interaction,
home visits and mobile vans (caravan). Promotive and preventive services
are discussed in detail in Section 5.3 under “Primary/ambulatory care”.

5.2 Patient pathways

In Bangladesh, there is no structured referral system. Usually, the
patients choose the most convenient provider or facility, based on
availability, accessibility and affordability. Generally the first point of
contact is either a pharmacy or a village doctor or the community health
worker (either government or NGO field functionary) who visits them.
In case of serious ailments, people go directly to public facilities for
secondary and tertiary care. Affluent individuals choose the qualified
private providers/facilities. There is no restriction on patients with
minor ailments seeking care from specialists. In urban areas, people
living in the vicinity of secondary or tertiary hospitals seek primary care

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from these facilities. Under the sector programme, there is discussion
of establishing a structured referral system, which will start from the
lowest level of the community clinics up to the tertiary-level facilities
at the national level (MOHFW, 2010). Patient referrals do not take place
routinely, rather on an ad-hoc basis, especially for emergency cases. The
structure of the referral network is fragmented, and it needs to be made
more comprehensive.

5.3 Primary/ambulatory care

Ambulatory care consists of primary and specialized care (outpatient
services). Primary care is delivered by a range of providers from the
public sector (health and other ministries), NGOs, and the private for-
profit sector. In the public sector, primary care is delivered at different
tiers of Ministry of Health and Family Welfare facilities – services are
provided from the lowest level of the community clinic to tertiary-level
facilities. There are 12 394 functional community clinics providing
primary and outdoor care. The community clinics are a flagship
programme of the government (under the Community Based Health-
care (CBHC) OP providing primary health care at the community level
in Maternal, Neonatal, and Child Health, Reproductive Health (RH)
and Family Planning (FP), IMCI, Nutrition and some CD/NCD services
(MOHFW, 2012). The services are provided by Community Health-care
Providers,Family Welfare Assistants, and Health Assistants (DGHS, 2011).

In urban areas, due to the lack of primary health facilities, secondary and
tertiary facilities are the individual’s first point of contact. Besides these
facilities, there are a small number of public urban dispensaries providing
primary care. The NGOs and for-profit private sector provide primary and
specialized ambulatory care. Many NGOs provide these services in their
health centres and hospitals, such as satellite clinics and static centers.
For example, the USAID-funded network of NGOs provides primary care
nationwide through its Smiling Sun clinics. In selected urban areas, NGOs
contracted by the Urban Primary Health-care Project provide primary
care, including comprehensive reproductive health care. Marie Stopes has
a wide network providing a range of reproductive health services all over
the country.

5.3.1 Promotive
Promotive health service activities are geared for improving the level of
knowledge, attitude and practices in relation to health, family planning,
and nutrition. A wide range of health promotion activities is undertaken

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by both the public and the non-public sectors. Activities under the public
sector are carried out by several ministries, departments, institutions, in
addition to the Ministry of Health and Family Welfare and its directorates.
The Ministry has dedicated health promotion channels through both
DGHS with its Bureau of Health Education (BHE) and DGFP through
its Information, Education and Motivation (IEM) unit. The BHE and IEM
structure extends to the districts with designated officials and staff at
each level.

The majority of Ministry of Health and Family Welfare health programmes

have adopted a behavioural change communication approach to health
promotion. Some communicable disease prevention programs like TB,
malaria, HIV/AIDS, Kala-azar, diarrhoea and filariasis have adopted an
advocacy, social mobilization and communication approach to stimulate
informed demand.

It is widely recognized that NGOs play a significant role in advocacy,

communication and social mobilization services and bring about
behavioural change through extensive health promotion services in areas
like maternal and child health, population control, and communicable
diseases. Many for-profit enterprises, as a part of their CSR activities,
are also involved in promotion of health and wellbeing (e.g. promotion
of hand-washing by Unilever). The services now need to strengthen the
focus on activities to prevent the spread of CDs and the rise of NCDs by
encouraging healthy lifestyles, healthy diet and food practices.

5.3.2 Preventive
Primary and secondary preventive initiatives are undertaken by both the
public and non-public sectors; however, the public sector plays a more
dominant role. Initiatives focus on disease prevention programmes and
outpatient care (e.g. screening and medicine). In order to address child
illnesses and child health, the Government has undertaken several
activities including: EPI, Integrated Management of Childhood Illnesses
and nutrition corners (Planning Wing, 2013), ORT corners and ARI
control (MOHFW, 2010). An achievement of Bangladesh to this extent
is the extensive use of ORT and zinc tablets for diarrhoea prevention in
children, helping to reduce diarrhoea rates. The Government adopted
the Integrated Management of Childhood Illnesses (IMCI) strategy
in 1998. The NGO-private sector partnership between icddr,b and a
pharmaceutical company was instrumental in the development of the
Baby Zinc Formula.

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Bangladesh has achieved immunization equity in all aspects. However,
in the case of antenatal care, inequity prevails (for example, antenatal
care from a medically-trained provider for the lowest wealth quintile is
31% compared to the highest quintile at 75%) (NIPORT, 2013). Meanwhile,
under preventive care, child health measures and CDs (HIV, TB, malaria)
have been emphasized to a greater extent. However, similar investments
have not been made in other programmes, such as NCDs.

5.3.3 Chronic disease

NCDs in Bangladesh were not considered a public health priority until
2007 when they were included in the HNPSP (Alam, Robinson et al.,
2013). The Government has taken several critical policy decisions related
to NCDs such as signing and ratifying the Framework Convention on
Tobacco Control, endorsing several national strategies related to NCDs
including undertaking national prevention and surveillance, developing
the first comprehensive strategic plan of surveillance and prevention of
NCDs 2007–2010, undertaking the national risk factor survey in 2010 and
recently establishing a separate operational plan for NCDs under one line
director in the DGHS (Alam, Robinson et al., 2013). Several issues have
been hindering the implementation of strategic plans for NCDs including
lack of clear lines of responsibility, absence of dedicated financing, and
competing priorities (World Bank, 2011).

Nonetheless, as the result of the first national NCD survey, care for NCDs
has been initiated, with DGHS establishing NCD “corners” in selected
Upazilla Health Complexes in parallel with the existing services already
in place. Dedicated to providing services for cardiovascular diseases,
diabetes and chronic respiratory diseases (asthma and COPD) and
screening for certain cancers, this initiative serves as a key change in
service delivery for NCDs in Bangladesh. Each NCD corner is planned to
have dedicated staff and equipment, and has been piloted in three UHCs
(Alam, Robinson et al., 2013).

In general, however, care for NCDs is provided through health service

delivery in public sector which has not yet integrated NCD prevention and
treatment (Alam, Robinson et al., 2013). According to the World Bank,
health workers in the primary health-care system in Bangladesh are
not yet trained in NCD treatment (World Bank, 2011). Furthermore, the
number of trained personnel for secondary and tertiary care services
is inadequate, the biochemical investigations required for accurate
diagnosis are currently only available on a fee-for-service basis, and the

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provision of basic drugs for treatment is limited and sporadic at best (Alam,
Robinson et al., 2013). In addition, even though Bangladesh has a national
essential drugs policy and a list of essential drugs to be used in the public
health services system, drugs for treating NCDs are not included in the
list (World Bank, 2011). Currently, financing for NCD treatment is heavily
dependent on OOP payments, which restricts access for many citizens
(Alam, Robinson et al., 2013).

5.4 Inpatient care

The secondary and tertiary (specialized and teaching hospitals) facilities
provide specialized ambulatory care for different specialties like
cardiology, nephrology, orthopedics, endocrinology, neurology, cancer and
ophthalmology at the different levels.

The primary, secondary and tertiary facilities all provide inpatient care. In
the public sector, there are 583 hospitals with 41 655 beds offering inpatient
care. Earlier, UHCs were the first primary-level facilities providing services.
Recently, in some of the unions, Union Health Family Welfare Centers have
been upgraded to 10-bed hospitals providing inpatient care, especially
institutional deliveries (MOHFW, 2012). Further attention needs to be
directed towards building capacity of the lower-level facilities, which provide
these services to the rural areas.

The secondary-level facilities offering inpatient care include district

hospitals and Maternal and Child Welfare Centres. Medical college hospitals
and specialized hospitals are tertiary-level facilities. Tertiary curative care is
mostly provided at the national and divisional levels through large hospitals
affiliated with medical schools. The BSMMU has over 1200 beds providing
general and specialist hospital services through 14 departments.

Some international hospital networks operate in the country (e.g. Apollo

Hospital) and there are some which have affiliations (such as United
Hospital). Private medical colleges provide clinical services as part of
their clinical training for their students. Private health care facilities
are governed by the Medical Practice Private Clinics and Laboratories
(Regulation) Ordinance 1982 (amended in 1984). In the late 1990s, there was
a rapid increase in private hospitals, clinics, and medical colleges, not only
in Bangladesh but throughout the subcontinent. However, accessibility is
limited to the better-off and particularly those in urban areas.

Many NGOs like Gonosasthaya Kendra and Ad-din operate secondary care
hospitals. Bangladesh Diabetes Association runs a network of hospitals

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under its National Health Network. Many of these facilities provide
secondary care in addition to primary care. In Dhaka, the Diabetes
Association runs a cardiac hospital providing super specialist services.
Various branches of the Bangladesh National Society for the Blind
operate eye hospitals in many parts of the country. The Society of Hearing
Impaired Children operates a super specialized ear-nose-throat hospital.
The Centre for Rehabilitation of the Paralyzed is well known for its
rehabilitation services and operates in limited places.

5.5 Emergency care

Emergency care is delivered at different levels, from the subdistrict UHCs
to the tertiary public sector facilities. Large hospitals in the nonprofit
and for-profit sectors also provide emergency care (among them Square,
Apollo, Lab-Aid, Holy Family, Kumudini, GK and Ad-din).

Emergency transport services (ambulance) are available in public sector

facilities. There is no centralized system geared for accessing ambulance
services. Individual facilities need to be approached to access the service.
There are also some for-profit private enterprises that provide emergency
transport services. However, the public sector ambulance services can
be ill-equipped, out of order, and sometimes used for other purposes.
Table 5.1 illustrates that the availability and use of emergency transport
services are adversely affected due to lack of funding.

Big hospitals in the nonprofit and for-profit private sector provide

emergency ambulance services. Ad-din has a fleet of small ambulances
mainly for the transport of pregnant women within Dhaka City. Some
hospitals such as Square and Appllo also offer air ambulance services.
Nonprofit organizations such as Anjuman Mofidul Islam and Markajul
Islam provide free emergency transport for patients and also for dead
bodies.

Table 5.1 Availability and functional status of ambulance (2011)

Percent of health facilities reporting the items by facility-type Year 2011
DHs UHCs MCWC
Has ambulance 100% 93.6% 70.7%
Ambulance functional 97.5% 83.5% 61.7%
Lack of funding restricts the use of 47.5% 41.0% 24.1%
ambulance
Source: BHFS 2011

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5.6 Pharmaceutical care
5.6.1 Pharmaceutical production and supply
The National Drug Policy 1982 was instrumental in improving the
supply of quality essential drugs at an affordable price, especially in
the early years (Islam, 1999). This was made possible by allowing local
pharmaceuticals to buy raw materials from international competitive
markets and establishing a transparent mechanism for fixing drug
prices (Ahmed 2004). The Essential Drug Company Ltd. was set up by
the Government to supply the bulk of public sector demand (>80%).
Bangladesh became the first low-income country to develop an
indigenous pharmaceutical industry, thanks to NDP 1982 (Hogerzeil,
2004). It has grown to account for a market share of more than 75%
of total drug sales compared to 25% before the policy was enacted.
The subsequent surge in manufacturing capacity is evident in the near
exponential growth in annual drug sales to US$ 1.25 billion in 2011, a
more than 100-fold growth over 30 years (Ali M, 2008).

The burgeoning pharmaceutical sector has cemented its achievement

by successfully exporting its products to countries of Asia, Africa,
Latin America and Europe (from 37 countries in 2004 to 84 in 2011)
(Shawon, 2011). The expansion of the pharmaceutical sector is further
facilitated by the unique opportunity to capitalize on the exemption
of patent regulations under WTO/TRIPS until January 1, 2016. The
pharmaceutical industry now contributes about 1% of the country’s
total GDP and is the third largest contributor of government revenue
(Saad, 2012).

Bangladesh is now fulfilling 95% of its demand from indigenous sources

(Shawon, 2011; Saad, 2012). It now imports some essential lifesaving
drugs and other high-quality drugs not manufactured in the country
such as cancer drugs, vaccines and insulin, but the situation is changing
(see below). Also, 80% of the active pharmaceutical ingredients (API) are
imported, and currently 21 companies are producing 41 types of APIs.
The government is in the process of establishing an API park which is
expected to cut the cost of APIs by 20% (Shawon, 2011;Saad, 2012).

Market share of different companies

The pharmaceutical market in Bangladesh is highly concentrated and
limited to a few big indigenous companies. At present, out of the top
10 pharmaceutical companies, eight are based in Bangladesh. The top
10 have 68% of the market share and the top 20 have 78%, while the

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top 10 multinational companies have only 9% of market share (Shawon,
2011). The market leader, indigenous company Square Pharmaceuticals,
alone has 19%+ of the market. Currently, there are 265 allopathic drug
manufacturing companies in the country, of which 30 are considered
large-scale units that dominate the market (Begum, 2007). The number
of registered items (in brand names) exceeds 8000 (DGDA, 2011). Besides
the allopathic pharmaceutical companies, there are 204 Ayurvedic,
266 Unani, 79 homeopathic and 25 herbal companies (DGDA, 2011).

Vaccines, contraceptives and other products

The Government carries out free vaccination for children under-five and
women through its EPI. It has to buy US$ 20 million worth of vaccines
per year besides the support from GAVI. Fortunately, this state of
affairs is coming to an end. In January 2012, one of the top domestic
manufacturers, Incepta, opened the first vaccine plant in the country with
an annual capacity of 18 million vaccine doses (Hasib, 2012). The company
also launched production of insulin.

Until 1998, all types of contraceptives including condoms were supplied

by donors free of charge. Later, with technical assistance from USAID,
the Ministry of Health and Family Welfare developed the capacity to
procure these products from international markets. The contraceptives
are marketed through the Social Marketing Company which grew
out of a pilot project of USAID-funded Social Marketing Sustainability
Programme. Currently, several brands of contraceptive pills and condoms
are marketed through the company. Major proportions (>80%) are
imported but some brands of contraceptive pills are procured from the
local manufacturers, and there is a public sector condom manufacturing
plant under the government-owned Essential Drugs Company to produce
condoms for the local market. Out of 3 billion condoms required annually,
the company is currently supplying 250 million.

5.6.2 Distribution of drugs

Central Medical Stores distributes drugs to public sector hospitals and
facilities where the consumers receive them free of charge (WHO, 1985).
The pharmacies in the public sector facilities are run by the Diploma
pharmacists (Grade B pharmacists who have completed a three-year
course following 10 years of schooling). Graduate pharmacists (Grade
A pharmacists) are mainly employed in the burgeoning pharmaceutical
industry, and partly in academia.

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Outside the public sector, retail distribution is chaotic in the absence of
any regulatory mechanism. According to the Bangladesh Chemist and
Druggist Samity (BCDS), there are about 64 000 licensed pharmacies (of
which 14 000 are members of the Samity or “association”) and around
70 000 unlicensed drugstores in the country involved in selling drugs
over the counter (Zahedee, 2009). In reality, there are no “prescription-
only”drugs in Bangladesh. Anybody can buy any medicine in any amount
including addictive drugs without prescriptions from these drugstores.
Most of the sales people do not have training in dispensing of drugs,
let alone diagnosis and treatment, yet this does not stop them from
doing these things. According to law, persons dispensing drugs at the
drugstores (community pharmacies) should have at least a short training
of twelve weeks duration (Grade C pharmacists) before they are able to
apply for a Pharmacy license. This certificate course is conducted by the
Bangladesh Pharmaceutical Society (BPS) in cooperation with the BCDS
through 45 tutorial centres (Mazid and Rashid, 2011). The content, form,
and utility of this training remain a matter of grave concern (Amzad,
2013).

As these drugstore sales people have no other channel of information

from the formal sectors open to them, they are easy prey for the
aggressive marketing strategies of the pharmaceutical companies
(Applbaum, 2006). Irrational use of drugs such as overprescribing, multi-
drug prescribing, use of unnecessary expensive drugs and overuse of
antibiotics and injections are the most common problems found with
these retailers (Ahmed and Hossain, 2007). These shops are also the main
channels through which the counterfeit, substandard and expired drugs
are marketed (Star Report, 2003).

5.6.3 Availability and affordability of drugs at PHC level, and rational use of
drugs
Availability of essential drugs is an important factor to prevent bypass
of PHC facilities by the community for accessing health-care services
(SIDA, 2001). Despite the decades since NDP was implemented, evidence
exists of frequent and persistent unavailability of essential drugs,
especially in the government health facilities where they are provided
free of charge (Omer and Cockcroft, 2003). Irrational use of drugs such
as overprescribing, multi-drug prescribing, use of unnecessary expensive
drugs and overuse of antibiotics and injections is prevalent (Guyon,
Barman et al., 1994; Islam, 1999). A recent survey on essential drugs at
Upazila Health Complexes found the availability of essential drugs for

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common illnesses to be poor. When the service users have to go to the
market to procure drugs not available in the UHCs, affordability is also
compromised due to the widely differing prices by brands (Ahmed and
Islam, 2012). The study also found polypharmacy on the rise, as well
as use of antibiotics in inappropriate indications and doses. This is not
surprising, especially in rural Bangladesh where the provider/prescriber
and the dispenser are very often the same person (village doctors,
salespeople at drug shops), thus giving rise to conflicts of interest
(Axon, 1994). To maximize profit, they often prescribe drugs in stock
whether they are needed or not, especially the costly ones like the brand
antibiotics. Added to this are the aggressive marketing strategies of the
pharmaceutical companies, especially in case of the unqualified/semi-
qualified providers who do not have any other channel of information from
the formal sectors open to them. However, other qualified providers are
not exempt from this pressure.

5.6.4 Generic prescription

The habit of writing generic prescriptions is almost non-existent in
Bangladesh although marketing of drugs in generic names does occur
in the public and private sectors. The list of essential medicines needed
for this is not available in around half of the UHCs and urban clinics
(Ahmed and Islam, 2012). A study on the prescribing practices of private
practitioners in Bangladesh found medicines prescribed in generic names
in only 0.2% of prescriptions written (Begum, 2012). In another study from
a tertiary public sector hospital in Dhaka, only 1.33% of the prescriptions
had medicines prescribed in generic names (Alam, Parveen et al., 2011).
To improve this situation, concerted efforts are necessary to train and
motivate doctors and allied health professionals about the benefits of
generic prescription and prescribing from essential drug lists which may
lead to cost savings, especially for poor patients.

5.7 Rehabilitation/intermediate care

Rehabilitative services are limited in availability due to the scope of care.
Rehabilitative care can be grouped into three categories: recovery from
injury like accidents (hip replacement); illnesses/disease (neurological,
stroke) and substance abuse. Most of the services are concentrated
in urban areas, particularly in metropolitan regions. NGOs are the
main providers of rehabilitative services, followed by the public sector.
Currently, the for-profit sector is also expanding in this field of care.

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The National Institute of Traumatology and Orthopedic Rehabilitation
(NITOR) hospital along with a few trauma centres located in different
parts of the country provide rehabilitative care in the public sector. NITOR
is a 500-bed tertiary level centre which receives referral patients from all
over Bangladesh. The Centre for the Rehabilitation of the Paralyzed is an
NGO providing curative and rehabilitative services for injuries, orthopedic
conditions and strokes. There are very few treatment and rehabilitation
facilities which deal with substance abuse. In the public sector, there is
only one detoxification center with 40 beds in Dhaka. Some NGOs run
rehabilitative centers for substance users, like Caritas and Dhaka Ahsania
Mission. In the for-profit sector, there are some centres with inadequate
facilities for rehabilitative services. These facilities are too costly for
middle-class and poor families.

5.8 Long-term care

There is no long-term care facility in Bangladesh as yet. An unpublished
report suggests that there are about six registered aged care homes
in different parts of the country, but senior citizens need to be mobile
as well as capable of taking care of themselves in order to live there.
The homes do not get government subsidies and are run on the profit
generated from the residents. The Government has recently allocated
BDT 8.91 billion in 2011–2012 for providing old age allowances for senior
citizens, and people with physical infirmities, handicaps and partial
handicaps are given priority (Department of Social Services, 2014).

5.9 Services for informal carers

Elderly people in Bangladesh are generally taken care by their immediate
family, such as sons or daughters, and get long-term care by family in
case of debilitating old age. The majority of care for the elderly, disabled
and chronically ill is provided by family members, and this can be a
significant factor in reducing opportunities to earn income for families,
and contributing to keeping them in poverty. There is currently no
government support for informal carers, and very little support in terms
of respite care or domiciliary care for those providing care in the home.
However, in October 2013 the parliament has passed the 2013 Parents’
Care Act, an unprecedented law mandating children help their elderly
parents financially if they live separately. Under the law in effect, children
must give parents who live apart from them a monthly income as a
subsistence allowance or violators face a three-month sentence or a fine
(US$ 1,280) (Chowdhury KR 2014).

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5.10 Palliative care
Palliative services are very limited in availability. There are only a few
private entities providing these services. Recently, the BSMMU started
offering palliative care. Two memorial trusts (ASHIC Foundation for
Childhood Cancer and Mosabbir Cancer Care Center) in the nonprofit
private sector also provide palliative care to children with cancer.

5.11 Mental health care

There is widespread stigma against people with mental illness in
Bangladesh, with myths and superstitions prevalent around the cause
and outcome of mental illness. These phenomena result in delayed
care-seeking, neglect and abuse (Firoz, Karim et al., 2006). In 2003–2005
a nationwide survey in Bangladesh among 13 080 people aged ≥18
years found that 16% of adult population suffer from some kind of
mental disorder, the prevalence being higher among women (19%)
than men (12.9%) (Firoz, Karim et al., 2006). Antipsychotics, anxiolytics,
antidepressants, mood stabilizers and antiepileptic drugs are included
in the list of essential medicines in Bangladesh. However, psychotropic
drugs are not widely available. Few patients visiting Government facilities
are provided with these.

There are only a few outpatient mental health facilities (n=50) and no
community-based follow-up care or day treatment facilities in the
country. There is only one dedicated mental hospital in Bangladesh which
has 500 beds, where the patient stay is 137 days on average. The National
Institute of Mental Health also runs a 150-bed hospital in Dhaka. There
are also 15 beds in forensic inpatient units, and 3900 beds in residential
facilities (e.g. homes for the destitute, inpatient detoxification centres,
and homes for people with mental disability). Quite a few substance abuse
treatment and rehabilitation facilities are privately run and not mentioned
in any official register. Most mental health facilities are clustered in urban
areas, especially in metropolitan cities. The absence of a specific mental
health authority makes it difficult to monitor and evaluate the mental
health services systematically.

In 2006, Bangladesh approved a mental health policy, strategy and plan

as part of the policy for surveillance and prevention of NCDs. The policy
recommended community-based mental health as the main approach
to be followed for addressing mental health issues (WHO and Ministry
of Health and Family Welfare, 2007). Mental health in Bangladesh is

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legally restricted by the outdated Indian Lunacy Act 1912. To remedy this
situation, a mental health act has been drafted and is currently awaiting
enactment.

Challenges in providing mental health care

Lack of human resources and inadequate training facilities pose a serious
challenge to mental health care in Bangladesh. A limited number of
mental health specialists are available and the density of mental health
professionals in public and private sectors combined is 0.49 per 100 000.
Psychiatrists and psychologists occasionally need to work together.
However, coordination among the various mental health professionals is
challenging due to institutional structures and limitations. Facilities for
mental health training are insufficient with provision for only 4% of the
medical doctors and 2% of the nurses. Most primary health care facilities
are heavily dependent on physicians, who make very few referrals to
mental health specialists.

Budget allocation for mental health is minimal. In 2005, less than 5% of

the total government health budget (approximately US$ 1.4 million) was
spent on mental health services. A major proportion of the expenditures
were devoted to the mental hospital (67%) with limited allocation for
community-based mental health care. Social insurance schemes do not
provide coverage for mental disorders (WHO and Ministry of Health and
Family Welfare, 2007). Mental health is yet to be included in the initiatives
for universal health coverage.

Integration of mental health services in primary health care

To address these problems, joint initiatives by the Bangladesh
Government and WHO resulted in development of a blueprint for
community-based mental health services (WHO-South-East Asian
Regional Office,2007). In 2011, the National Institute of Mental Health
(NIMH) provided the justification, advantages and feasible ways of
providing mental health services through primary health care. This
integration was proposed as a viable way of closing the treatment gap to
ensure effective, affordable and acceptable mental health services. The
consensus was to develop trained non-specialist workers, referral and
back-referral with occasional shared models of care in model upazilas
in the context of a limited number of specialist mental health service
providers and the absence of separate community mental health centres
in Bangladesh (NIMH & DGHS, 2011).

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Recent initiatives
In the past, there have been some research, policy, training and advocacy
initiatives in mental health that look promising in spearheading the
mental health agenda. In 2009, a pilot study on paramedic-conducted
mental health counselling for abused women in rural Bangladesh
revealed promising results warranting the scale-up of such community-
based mental health services (Naved, Rimi et al., 2009). In 2013, the
Government was active in preparing a final draft of a mental health act
that has been submitted to the health ministry and in the process of
review by the law ministry. It is hoped that the draft act will be submitted
to the Parliament and approved soon.

In 2013, a course in leadership for mental health system development

has been launched for the first time in Bangladesh by the James P
Grant School of Public Health at the BRAC Institute of Global Health
to create leadership in the field of public mental health (Movement for
Global Mental Health, 2013). This initiative was followed by the formation
of an informal mental health network comprised of psychiatrists,
psychologists, lawyers, activists, patient rights groups, NGOs, academic
institutions and interested individuals. It remains to be seen how such
academic and informal network initiatives can contribute to advancement
in policy and implementation. For the first time, a recently formed NGO,
Innovations for Well-being, is making efforts to provide nationwide
training on first aid in mental health. In the wake of the recent human
tragedy of a building collapse that killed more than 1000 people,
the National Institute of Mental Health and the Clinical Psychology
department in Dhaka University as well as BRAC, the biggest local NGO,
and many other NGOs and private organizations were actively involved in
providing emergency relief and planned for longer-term mental health
services to the victims and their families (BRAC, 2013; WHO, 2013).

5.12 Dental care

Dental services are provided by both public and private sectors,
concentrated in urban areas. Government provides for the position of a
dental surgeon at upazila-level facilities but most of the positions remain
vacant. It is difficult to retain dental practitioners in rural areas.

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5.13 Complementary and Alternative Medicine (CAM) and
Traditional Medicine
Alternative medical care includes homeopathic, Unani, and Ayurvedic
medical services, predominant mostly in the rural areas. The government
provides services through the district and upazila level facilities – medical
officers, herbal assistants and compounders provide alternative medical
care in the outdoor departments (DGHS, 2011; PMMU, 2013). Services are
also offered by private providers. While the Government has established
a few alternative medical institutes in the country, they are largely in the
private sector. Alternative medical practices need to be more effectively
and more complementarily integrated into health systems (aligning
with the allopathic services, further developing the capacity of service
providers, ensuring quality, and improving education and job standards,
for example).

5.14 Health services for specific populations

The Ministry of Health and Family Welfare provides limited health-care
services for special populations, such as drug addicts. The majority of
health services for HIV/AIDS patients, street dwellers and sex workers are
provided by private organizations at a limited scale. There are both public
and private rehabilitation centers for treating drug addicts in Bangladesh.
So far, there is at least one public treatment centre in Dhaka, Chittagong,
Rajshahi and Khulna including three additional treatment centres in
Jessore, Rajshahi and Camilla Central Jail. There are 68 private centres
registered by the Department of Narcotics Control under the Ministry of
Home Affairs for treatment and rehabilitation of addiction (Ministry of
Home Affairs, 2014).

In 2002, icddr,b opened the first voluntary counselling and treatment

(VCT) centre, Jagori, in order to provide the full range of confidential and
voluntary counselling and testing with quality control in Bangladesh.
Jagori also provides primary health care, including management of
sexually transmitted infections; referrals to other specialists, such as
antenatal care, skin specialists, clinical psychologists, and management
of post-exposure prophylaxis are all available. Jagori works closely with
two HIV-positive support groups in Bangladesh, Ashar Alo Society and
Mukto Akash, and several other organizations that run more than 50
testing centres around the country. Jagori services have been expanded to
five key cities including Dhaka, Sylhet, Chittagong, Jessore and Rangpur.
In 2013 the Ministry of Health and Family Welfare planned to introduce

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free health services for HIV/AIDS patients in public hospitals through
five medical college hospitals in Dhaka, Chittagong, Khulna, Sylhet and
Rajshahi. The Ministry plans to sign an agreement with three NGOs,
Ashar Alo Society, Mukto Akash and CAAP (Confidential Approach to AIDS
Prevention) which will be responsible for monitoring and supervising the
service (Uzzal M, 2013;icddr,b, 2014).

There are no formal health services for the Hijra or gay community. A
few NGOs provide limited health-care services for brothel-based sex
workers. A small number of NGOs provide health services for the urban
homeless (apart from sex workers) and there are 18 registered red light
areas in Bangladesh. So far, there is no formal service available to street
dwellers apart from the Essential Services Package provided through the
Government and NGOs in rural and urban areas (icddr,b, 2014).

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6 Principal health reforms

Chapter summary
Recent health reforms in Bangladesh commenced with the Health and
Population Sector Strategy developed by the Government and donors in
1997. This strategy advocated a number of institutional and governance
reforms, notably the shift from a project basis towards a coordinated
sectoral programme. These reforms were then implemented through a
series of five-year sectoral programmes, commencing with the HPSP
of 1998–2003. Key reforms included: pooling of donor funds in a SWAp,
provision of selected primary health-care services under an Essential
Services Package to the poor, introduction of one-stop services through
community clinics, and unification as well as bifurcation of health and
family planning wings of the Ministry of Health and Family Welfare. Under
the latest five-year programme, the HNPSDP, health sector activities
have been grouped into 38 operational plans implemented by 38 Line
Directors. While the SWAp has improved coordination and alignment
among multiple donor projects, there remains fragmentation within the
vertical programmes of the Ministry, continuation of a number of vertical
programmes funded outside the SWAp, and a lack of a comprehensive
ministerial plan.

Other key reforms include: the establishment of community clinics

to replace domiciliary visits; their withdrawal when coverage of key
programmes fell, and then re-instatement together with domiciliary
programmes by the new government; unification of the DGHS and
DGFP in 2000, and then subsequent re-separation in the face of poor
performance by FP officers; attempts at decentralization of health
services to the upazila level, although with limited delegated authority;
and the recent maternal health voucher scheme.

Recently, in recognition that the high levels of OOP expenditure form

a barrier to utilization, a Health-care Financing Strategy (2012–2032)
has been developed to provide direction in achieving universal health
coverage. The strategy puts emphasis on prepayment mechanisms

125
with scope of risk-pooling and separate mechanisms are suggested for
people in different economic sectors (formal sector, informal sector
and people in poverty). Taxes, social health insurance contribution and
community-based health insurance schemes have been recommended.
Over its 20-year implementation period (2012–2032), the strategy aims at
reduction of OOPP from 64% to 32% of total health expenditure, increase
in government expenditure from 26% to 30%, increase in social protection
from less than 1% to 32%, and reduced dependence on external funds
from 8% to 5%.

6.1 Analysis of recent major reforms in Bangladesh

Over the last decade, the health sector has undergone some major
reforms leading to a breakthrough towards attaining greater equity and
efficiency in resource use. The National Health Policy formulated in 2000
formalized some massive institutional reforms that the health sector had
been going through in the 1990s under the influence of external donors.
In 1996 the World Bank and other consortium members indicated to
the Government that they would not proceed with further credits until
a comprehensive, sector wide strategy had been adopted (Vaughan,
Karim et al., 2000). This also included substantive structural and
organizational reforms by the Ministry of Health and Family Welfare (Buse
and Gwin, 1998). Accordingly, the HPSS approved in 1997 showed the
health sector a new direction towards efficiency and cost-effectiveness
through advocating certain institutional and governance reforms. The
HPSS later fed into the 2000 National Health Policy. As a result, these
documents advocated for a common set of institutional reform strategies.

Reflecting these strategies, in 1998, the Health and Population Sector

Programme was launched. HPSP (1998–2003) emerged as a major reform
programme that initiated certain major boosters to the health sector,
many of which have been carried forward by the latter programmes
including a SWAp for management, provision of selected primary health-
care services under Essential Services Package to the poor, introduction
of one-stop services through community clinics, and unification as well as
splitting of health and family planning wings of the Ministry of Health and
Family Welfare. The next five-year health programme, HNPSP 2003–2010,
adopted a few more reform measures, including a maternal voucher
programme to reduce maternal mortality. Major health reforms since
2000 and their impacts on the health system are presented in Table 6.1.

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Table 6.1 Recent reforms and the accompanying changes in the health
system
Policy/ Changes in the health
Impact on the health system
Programmes system
Health Policy Basic services are provided ESP is implemented as a cost effective way
14 August, through a package called of providing primary care services with some
2000 Essential Service Package (ESP) pitfalls. Urban areas have been kept outside
to make health services cost the ESP intervention.
effective.
All the basic services under Initially Community Clinics failed to produce
ESP delivered through one-stop the desired result due to noncooperation
service centres at the thana of service providers due to their conflict of
(THCs), Union (UHFWC) and interests and because of the unwillingness
partially at the village level of the community to accept the withdrawal
Community Clinics replacing of domiciliary service. Above all, change
domiciliary services. of political regime also led to the
underperformance of Community Clinics.
Unification of health and family Unification did not produce positive results
planning wings of the ministry as it was done without considering the
of Health at the thana level and institutional constraints. Deep-rooted
below instead of top-to-bottom differences between different cadres of
unification. personnel have posed serious constraints to
adequate service provisions.
Transition from a project driven SWAp has helped create a common funding
approach to a Sector-Wide pool for donors, reduced duplication, and
Approach (SWAp) has taken brought about greater control over funds
place. by the government. Uniform financial
accounting procedure has been developed
In planning, the newly and implemented. Significant progress has
introduced SWAp enfolded all been made in standardizing and unifying
the relevant programmes as a disbursement procedures and reducing
single entity rather than having transaction costs associated with managing
separate plans for individual multiple donor funds.
projects.
Despite these achievements some structural
In implementation, all sources of issues still act as the barriers to the full
funding, including GOB, donors, implementation of SWAp.
and households were considered
as sectoral resources as a
whole.

Source: Asia Pacific Observatory on Health Systems and Policies

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Table 6.1 Recent reforms and the accompanying changes in the health
system (cont.)

Policy/ Changes in the health

Impact on the health system
Programmes system
The HNPSP DSF has been implemented in Voucher scheme has been able to produce a
(2003–2010) the form of maternal health very positive result.
voucher scheme. The scheme
is implemented with provisions The program coverage is expanding from
for antenatal and birthing care initial 10 upazilas in 2007 to 46 upazilas in
at home and in public or private 2012. Performance data at the output level
sector facilities. It also provides also continue to improve. Safe delivery rate is
for transport and maternity care now at impressive 89% amongst the voucher
in 46 poorest upazilas. recipients who constitute approximately 50%
of the pregnant women in the target upazilas.
More strikingly, the maternal mortality rate
among the voucher-holder women is 12 per
100 000 live births, in sharp contrast with the
national rate of 194 per 100 000 live births
(DGHS 2011).
Health and family planning Implementation of the philosophy of integrated
wings have again been planning through SWAp is facing difficulty.
bifurcated Duplications, overlapping continue to exist.
Domiciliary services have been Currently, with the reinstatement of
reinstated and CCs have been domiciliary services, and other upgrading
revitalized attempts, CCs have been able to create
enthusiasm among the villagers. Rate of CC
utilization has been increased in recent years.
Decentralization of health Centralized procurement of logistics for all
services has been implemented programs result in delays in providing supplies
partially through delegation and logistics. This often prevents the newly
of some administrative and constructed health facilities from functioning
budgetary authority to the local properly.
level.

Source: Asia Pacific Observatory on Health Systems and Policies

6.1.1 Introduction of Sector Wide Approach

HPSP introduced a transition from a project approach to a sector-wide
approach of management through which all health sector projects were
planned and managed in an integrated manner instead of as vertical
initiatives. Accordingly, the SWAp was introduced in 1998 through
HPSP (1998–2003) and the subsequent health programmes have made
commitments to continue to follow this approach. World Bank (2009)
notes, “SWAps represent a shift in the focus, relationship and behaviour
of donors and governments. They involve high levels of donor and country
coordination for the achievement of program goals, and can be financed

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through parallel financing, pooled financing, general budget support, or a
combination”.

According to the SWAp, under the HNPSDP, the health sector activities
have been grouped into 38 programmes with 38 operational plans to
be implemented by 38 Line Directors with policy and administrative
guidance from the Ministry of Health and Family Welfare. It has helped
create a common funding pool for donors, reduced duplication, and
brought about greater control over funds by the Government. All
institutions in the health sector operate on the same planning and budget
cycle. Development partners that are pooling resources (known as the
“Pooled Development Partners”) provide sector-wide support by making
contributions to a foreign exchange account held by the Government at
the Central Bank. Together with the Government’s contributions, those
funds are made available to the implementing agencies or spending units
through state budgetary channels (IRT, 2009).

SWAp has produced impressive results. Regarding the impact of SWAp,

the Ministry of Health and Family Welfare (2011) states,“SWAp has
created opportunity for coordination, harmonization and alignment
of multiple donor funded projects and resources. Uniform financial
accounting procedure has been developed and implemented. Significant
progress was made in standardizing and unifying disbursement
procedures and reducing transaction costs associated with managing
multiple donor funds”. Despite these achievements, SWAp has still been
facing challenges in its full implementation.

Fragmented structure: Although SWAp aims to eliminate vertical

structures, the health sector itself is characterized by a vertical
organizational structure (DGHS, DGFP, DNS, NNP, DDA, NIPORT), most of
which are operating parallel systems for human resources, procurement,
monitoring and financial reporting (IRT, 2009). Coordination among these
institutions is very weak.

Ill-defined sectoral boundary: The boundary of the health sector is

not clearly defined. There are 32 operational plans under the Ministry
of Health and Family Welfare and a number of projects included in the
sector. The Ministry is implementing several parallel projects included
in its Annual Development Plan (ADP), which are outside the SWAp
programme. The boundaries of the sector extend beyond the mandate of
the Ministry.

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Urban health is being managed by the Ministry of Local Government
while a number of infrastructure projects still remain outside the
purview of the HNPSDP or the SWAp. In addition to this, a number of
vertical programmes like TB, Malaria, and HIV/AIDS as well as numerous
NGO programmes are being implemented under separate financing
arrangements. This hampers sector-wide monitoring and evaluation
(IRT, 2009). A true SWAp would encompass both urban and rural health
services provided by any ministries including the Ministry of Health and
Family Welfare, Ministry of Local Government, Ministry of Chittagong Hill
Tracts, Ministry of Home Affairs, as well as the buy-in and participation
from other players, including the Ministry of Finance. Moreover, private
sector and NGO expenditures constituting a large share of health budget
remains outside the purview of SWAp.

Lack of a comprehensive ministerial planning and managerial guideline:

SWAp is not working well even in aid coordination towards increased aid
effectiveness. A common account has been opened into which all donors
earmark funds to the Ministry but the Ministry often lacks adequate
and timely information on all earmarked funds for planning purposes.
Explaining the reasons, the ITR (2008) states,

“The coordination framework is weak, and does not inhibit

development partners or MOHFW from pursuing agendas outside the
HNPSP, sometimes sharing information, but other times not…parallel
funding is still not harmonized, while the pool fund is only partially
harmonized with [Government] procedures.”

On the other hand, although substantial progress has been made in the
standardization of procurement procedures, no common guidelines have
yet been developed for managing technical assistance. The procurement
of technical assistance is, thus, still done under development partner-
specific guidelines (MOHFW, 2008). Due to the bifurcated structure in the
Ministry, adequate and timely monitoring of sector performance is yet
to take a sustainable shape for using routine information for decision-
making (MOHFW, 2011).

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 Box 6.1 Strategic interventions and supportive actions proposed by the Health-
care Financing Strategy.

1. Design and implement Social Health Protection Scheme

• determine institutional arrangements for Social Health Protection Scheme
• design and implement Health Equity Fund/National Health Security Office
• implement SSK for Below Poverty Line (BPL) population
• Design social health protection scheme for above BPL (formal and informal)

2. Strengthen financing and provision of public health-care services

• implement needs- and performance- based allocation
• scale up/reinforce Result-Based Financing (MHVS)
• retain user fees at point of collection

3. Strengthen national capacity

• support information exchange platform/knowledge hub/resources pool
• develop the capacity to design and manage the social health protection scheme
• strengthen financial management and accountability
• improve monitoring and evaluation
• introduce mechanisms to support the production of additional key staff (nurses,
paramedics and medical technicians)

Source: Asia Pacific Observatory on Health Systems and Policies

6.1.2 Selected primary health-care services under the Essential Service

Package
To achieve the greatest health impact per taka spent and to serve the
most vulnerable groups like women, children and the poor, an ESP
containing five basic maternal, child and public health services has been
introduced to be delivered from one single service point, called “one-stop
shopping”. The objective of introducing the ESP was to facilitate access
to multiple health services for clients, for example enabling multiple
family members to be seen during a single health facility visit. One-stop
services (close-to-client) were provided in three tiers of facility: Thana
Health Complexes at the thana level, Union Health and Family Welfare
Centres at the union level and the community clinics at the village level.
To achieve equity and efficiency in resource distribution, an ESP was
designed to allocate 60–65% of the total health-care resources to the
primary level (upazila and below) (Bangladesh Health Watch, 2012). ESP
is being implemented as a cost-effective way of providing primary care
services. It has some pitfalls. The Sixth Five Year Plan (2011–15) notes
that the ESP was mainly directed towards rural areas, leaving a major gap
in primary health-care coverage of the urban poor. Moreover, there is still
no system in place to monitor health-related inequalities.
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6.1.3 Establishment of community clinics, withdrawal of domiciliary
services and their reinstatement
Until the introduction of HPSP in 1998 domiciliary health and family
planning services were a very popular source of care for the rural
illiterate poor women. Deeming domiciliary services not to be cost-
effective (since the health workers did not have any office at the village
level and their household visits did not guarantee meeting patients), it
was thought that having a facility at the village level would make financial
sense. Accordingly, the 1998 HPSP introduced a change from the previous
household-level service to facility-level service by setting up community
clinics in villages to provide one-stop services. During 1998–2001, under
the leadership of the Awami League Government, 10 723 community
clinics at a ratio of one for every 6000 population were established
against the planned 1:18 000. Establishment of community clinics was
also considered a step toward bringing primary health services closer to
the people. Community clinics are managed as a partnership between
Government and the community. Two Government health workers provide
ESP services at the clinics with 30 items of necessary medicines, but
the clinic is managed by a 9–13 member body of local people, called
the Community Group. Community responsibilities include day-to-day
maintenance, cleanliness, security and local fund generation.

Thus a major strategic shift in the service delivery pattern –from

household domiciliary to facility-based services – was introduced. Such
policy change was not based on an assessment of the needs of the
population. As a result, it had a tremendously negative impact on the
performance of health and family planning programmes. The sectoral
achievement during the HPSP period was quite disappointing. The total
fertility rate remained stagnant (3.3) for the entire period. Contraceptive
prevalence rates saw a slight increase from 49.2% in 1997 to 53.8% in
2003 while maternal and infant mortality rates did not see any significant
fall. Such a lacklustre performance was due to the non-receptiveness
both of the service providers at the local level and the recipients. From
the recipient side, rural women, who were so long accustomed to receive
domiciliary services, were not ready to visit facilities to obtain the required
services. On the other hand, service providers also had many conflicts of
interest, as will be discussed in the next subsection. This conflict caused
noncooperation from the provider side and ultimately the new facility
failed to provide services as desired.

However, when the Bangladesh Nationalist Party assumed power in

2001, the community clinics were closed before producing any positive

132
results and domiciliary services were reinstated. However, the Awami
League returned to power in 2009 and took initiatives to revitalize the
community clinics as the top priority in the health sector. Accordingly,
community clinics have been upgraded and alongside them, domiciliary
services continue to function. Upgrading included making the existing
community clinics functional, construction of 2876 new clinics,
appointing one Community Health-care Provider for each clinic,
and upgrading them with modern information technology to store,
process and transmit health related data from the catchment areas.
The increasing rate of utilization of community clinics in recent years
(2009–2011) as projected in the Bangladesh Health Bulletin 2012 is a
manifestation of the success of community clinics to be able to create
an impact over the health system (DGHS, 2012).

6.1.4 Unification of Health and Family Planning wings of the Ministry of

Health and the U-turn
Both wings of the health ministry – Health and Family Planning –
implement programmes related to Maternal and Child Health, which
often causes overlapping and duplication. In order to provide health
and family planning services in a package under the ESP and to ensure
efficiency gains, attempts were undertaken to integrate Health and
Family Planning wings. Integration was far from smooth even during
the Awami League regime that introduced it, due to bureaucratic
politics. Fearing resistance from higher-level bureaucrats, integration
was planned to take place in stages. By early 2000, the two wings were
unified at the upazila level and below as the upper-level officials (from
district to Directorate level) of the two wings who were of comparable
official status, did not want to compromise their positions. On the
other hand, integration at upazila level and below was made possible
because the upazila-level family planning officials were already of a
lower official status than the upazila health officials and therefore, it
was easier to bring them under their supervision (Osman FA, 2004).
Nonetheless, the upazila-level family planning officials resented the
integration. They did not want to be accountable to the upazila health
officials as it curtailed their authority to manage family planning
services (Hossain and Osman, 2007). Ultimately, the deteriorating
morale of family planning officers led to disruption of family planning
service delivery and stagnation in the reducing the total fertility rate
and increasing the contraceptive prevalence rate. The association of
the Awami League with the integration process and the performance

133
failures were used by the next Government led by Bangladesh Nationalist
Party as grounds for policy reversal. After continuing confusion for a long
time, in 2007, with the introduction of HNPSP (2007–2011), the previously
bifurcated Health and Family Planning wings of the Ministry faced a
U-turn.

Health services have been integrated at the community level without

considering the institutional constraints. Although this has been an
attractive proposition, deep-rooted differences between different
cadres of personnel have posed serious challenges to adequate service
provision. These policy changes have had considerable negative effects on
health, particularly among the ultra-poor. However, the U-turn and return
to the bifurcation of the two wings would perpetuate inefficiencies and
overlapping of the health programmes.

6.1.5 Decentralization of health services

To address inefficiencies, decentralization of health administration has
long been proposed, with little follow-up. The HPSP (1998–2003) strongly
advocated for a decentralized health system with emphasis on greater
delegation of responsibility for financial management to thana/upazila
level and greater autonomy to hospital management. The subsequent
HNPSP (2007–2011) elaborated the decentralization issue by specifying
(i) decentralized planning and budgeting; (ii) setting of local priorities
in consultation with local communities; and (iii) the development of
an Upazila Health System, managed by Upazila Health Management
Committees as an expansion of the primary health-care system.

These have been implemented with little delegation of power from

the centre to the concerned organizations. For instance, centralized
procurement of logistics for all programmes results in delays. This
often prevents the newly-constructed health facilities from functioning
properly. Formation of Upazila Health Management Committees has
remained mere rhetoric. Having decentralized the Upazila Health
System through strengthening the Upazila Health Complexes, the Union
Health and Family Welfare Centers/Sub-Centers still lack adequate
human resources, drugs and other medical aids. The ongoing HPNSDP
(2011–16) has also committed to the introduction of a decentralized
Upazila Health System. The programme emphasizes nationwide coverage
of the ESP through the Upazila Health System. This requires a large
investment in facilities, staff, and logistics as well as delegation of
tasks and responsibilities from central, division and district levels to the

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upazilas, unions and wards. Given the uncertainties of introducing
a decentralized administrative system in the larger political and
administrative context of the country, the possibility of implementing a
decentralized health system in Bangladesh remains elusive.

6.1.6 Maternal Health Voucher Scheme

To address the problem of poor utilization of heath facility services
by the poor mothers, the Government introduced a demand-side
financing scheme in 2007 to attempt to influence health seeking
behaviour. Demand-side financing involves channelling a part of
the Government subsidy for health services directly to households,
allowing them to purchase health services themselves or through an
agency (Bhatia, Yesudian et al., 2006). In line with the reform agenda
of the Health Sector Programmes, WHO and the Ministry agreed in
2004 to pilot the innovative Maternal Health Voucher Scheme in order
to improve access to and use of quality maternal health services.
The scheme was formally inaugurated in 2007. This scheme aims
to increase utilization of health services by the poor by subsidizing
medicines, tests and transport to the health facility, as access is
greatly discouraged due to high OOP costs. Currently, the programme
is being implemented in 502 unions of 46 upazilas in 38 districts
(DGHS, 2011). Under the programme, eligibility for getting vouchers
is a defined poverty criterion, validated by the local government
representative. A voucher entitles its holder to specific free health
services, such as antenatal and postnatal care, safe delivery, treatment
of complications including caesarean section, transportation costs,
and laboratory tests. Private and NGO care providers, once certified
under the scheme, are reimbursed for vouchers. If delivery is attended
by skilled staff, voucher-holders get cash benefits or nutritious food
and giftboxes.

The programme is gradually expanding its coverage from the initial

10 upazilas in 2007 to 46 upazilas currently. Performance data at
the output level continue to improve. The safe delivery rate is now
at an impressive 89% among the voucher recipients who constitute
approximately 50% of the pregnant women in the target upazilas.
Participation of non-public health-care providers (NGO and private
facilities) is also increasing. An Economic Evaluation Report released
in January 2011 says that the scheme is very successful with an
“unprecedented positive impact in increasing utilization of maternal

135
services from designated public and private providers in a short period of
time”. In addition to the increased rate of safe delivery, the facility delivery
rate also increased to 40%. The utilization rate of antenatal care services
continued to improve. Strikingly, the maternal mortality rate among the
voucher-holder women is 12 per 100 000 live births, in sharp contrast
with the national rate of 194 per 100 000 live births (DGHS, 2011).

Despite these achievements, mistargeting has been found to be common

in the selection of beneficiaries. Though the programme is designed
to provide subsidy for maternal health care for up to two children, lack
of reliable data and an inadequate monitoring system leads to adverse
selection of beneficiaries (BRAC, 2012). Moreover, the incentives for
pregnant mothers have also in some cases created adverse impacts on
the family planning programme.

6.1.7 Health care financing reform

Against the backdrop of high OOPPs, low government spending on health
and poor budget execution, the Ministry of Health and Family Welfare
in 2012 adopted a health-care financing strategy, Expanding Social
Protection for Health: Towards Universal Coverage Health-care Financing
Strategy 2012–2032 (HEU, 2013). The first ever Health-care Financing
Strategy attempts to address three major challenges: (i) inadequate
health financing; (ii) inequity in health financing and utilization, and (iii)
inefficient use of existing resources. To address these challenges and to
increase financial risk protection for the entire population, it determines
three strategic objectives: (i) generate more resources for effective health
services; (ii) improve equity and increase health-care access, especially
for the poor and vulnerable; and (iii) enhance efficiency in resource
allocation and utilization. Over the proposed 20-year implementation
period, the strategy aims at reducing OOPP from 64% to 32% of THE,
increasing government expenditure from 26% to 30% of THE and
increasing population coverage by prepayment schemes (tax-financed
and social health protection schemes) to 100% by 2032. The Health-care
Financing Strategy envisages increasing budgetary allocation for health to
15% by 2032, which is in alignment with the Sixth Five Year Plan’s target
of increasing the health budget to 12% by 2015 (HEU, 2013).

The strategy will be implemented in three phases, short, medium and

long-term. The short term will be up to the end of HPNSDP, i.e. 2016.
In this phase, SSK (the Shasthyo Shuroksha Kormasuchisocial health
protection scheme) pilot rolls out, and a National Health Security Office

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and other key elements of the social health protection scheme will
be designed. The medium term will be up to 2021 when the activities
launched during the preceding phase (SSK, National Health Security
Office and social health protection programmes) will be appropriately
scaled up. The long-term will end in 2032. In the long-term, building
upon the achievements of the short and medium terms of sequenced
implementation of the strategic interventions proposed, Bangladesh will
move towards achieving universal health coverage. In order to increase
access, tax-funded primary and preventive care and services will remain
free for all groups of the population and must be strengthened for
improving efficiency and effectiveness.

The Health Care Financing Strategy will start with populations below the
poverty line and the formal sector and eventually will cover the informal
sector. The strategy intends to cover all formal and informal sectors
and those under the poverty line under a common scheme. The Ministry
of Health and Family Welfare needs to focus on designing a common
scheme for all segments of population (formal and informal, poor and
non-poor) from the start to avoid fragmentation in pooling and also to
avoid creating any interest groups that will resist equitable expansion
of coverage, considering problems faced in other countries such as
Thailand (Health Insurance System Research Office, 2012). Another issue
is Bangladesh’s large informal sector. Any contribution-based scheme for
such a large sector will be immensely difficult to implement. Keeping this
in mind, the strategy may need to be revisited.

The Health-care Financing Strategy proposed a substantial change in

the current payment system from direct payment (i.e. OOP) made at
the service point to paying for services through prepaid risk-pooled
schemes. This involves determining a suitable institutional arrangement
to manage social health protection schemes for different groups. Besides
institutional arrangements, financial management and procurement
capacity need to be significantly improved to implement the proposed
schemes. All these require substantial Government efforts, resources and
an effective change management process for successful implementation
of the strategy (IRT, 2013).

The Health-care Financing Strategy proposes a range of interventions

to mobilize resources for the health sector. However, it does not provide
estimates of additional funds each intervention is expected to generate.
The short term will end in 2016. A number of activities need to be carried

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out in this phase. The pilot to cover the population in poverty is yet to
start. A number of activities are in the development stage. For example, a
social health protection scheme for the formal sector is being designed,
the required law has been drafted and a communication strategy
prepared.

The Health-care Financing Strategy is yet to be translated into a realistic

and feasible investment plan in order to equip the health ministry to
negotiate with the Ministry of Finance for reprioritization of health within
the Government budget. Furthermore, the full impact of the Health-
care Financing Strategy will depend on actions that fall under the
other building blocks: human resource development and management,
quality of health-care services, disbursement of budgetary allocations,
information technology, governance and stewardship.

Mobilizing additional resources for Health-care Financing Strategy

implementation
In a World Bank assessment of the vulnerability of different countries,
the overall fiscal capacity of those countries was also assessed based
on respective countries’ debt–GDP ratio, fiscal deficit, current account
balance, international reserves, and reversible capital flows. Bangladesh
is classified as a country that has some fiscal capacity (Cord, Verhoeven,
Blomquist and Rijkers, 2009). It is important to examine possible options
for raising additional resources and quantify the possible contribution
from each option in order to estimate implement the Health-care
Financing Strategy in a limited fiscal capacity setting.

Generating health-specific resources

Health-specific resources such as earmarked taxes and introduction
of mandatory health insurance can generate additional resources for
health. According to a recent study, additional resources of US$ 287.5
million will be generated if tobacco taxes are raised from current level
to the WHO/WB-suggested level (Barkat, Chowdhury et al., 2012). Excise
taxes in Bangladesh account for just over half the retail cigarette prices
on average and total taxes on cigarettes account for almost two thirds of
retail prices. WHO and World Bank recommend raising them to two thirds
and four fifths of the retail prices respectively. Low taxes made cigarette
prices in Bangladesh the lowest in the region (Tekabe and Tandon, 2013).
Bangladesh may raise the taxes to the level recommended by WHO and
the World Bank and earmark the additional revenue generated from this
for the health sector.

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Mobilizing external resources
Historically, the health sector has depended on external resources.
External assistance in absolute terms more than doubled between the
first and third SWAp while as a share in total sector programme budget,
it fluctuated. While the first sector programme, HPSP, received 24% of
its financing from external sources, the corresponding figures for the
second sector programme, HNPSP and the third sector programme,
HPNSDP were 27% and 24% respectively8. It is to be noted that the share
of external assistance comprising loans and grants in the total national
budget is much less than that in the health budget. According to the
budget document 2013–2014, foreign loans and grants account for 9.4%
of the total national budget. However, given the global downturn the
prospect of increased external resources is limited.

Efficiency gains
Increasing budgeted amounts for health may not be enough for
generating fiscal space if the resources are not spent efficiently. Even
without increasing the budget amount, fiscal space might be generated
by increasing the efficiency of health systems. A recent study on Ministry
of Health and Family Welfare facility efficiency found that the facilities
expanded service delivery during 1997–2010 even though in real terms
the facility budget remained static (Rannan-Eliya RP et al., 2012). This led
to substantial reductions in real unit costs which declined to one half to
one third of the levels in 1997. This means financing of expanded service
delivery was done through efficiency gains.

Several studies indicated areas where efficiency improvement is

essential. According to a recent report (PMMU, 2013), the Bangladesh
Medical Equipment Survey 2012 found that between 2008 and 2012, the
average time between signing of a contract and the goods to be received
by the hospital fell from 29 months to 19.6 months; and the proportion
of equipment lying idle declined from 57% to 46%. This shows significant
improvement within four years. The main reasons for not utilizing
equipment include the lack of a comprehensive equipment planning and
an absence of adequate maintenance (PMMU, 2013). There is substantial
room for improvement.

Another area is absenteeism among the medical staff at the Ministry

facilities. Studies found high absenteeism among doctors and nurses at

8 Sources include Project Appraisal Documents (PAD) and Program Implementation Plans (PIP) of
HPSP, HNPSP and HPNSDP

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facilities at upazila level and below (FMRP, 2005). However, a recent study
reported significantly lower absenteeism (7.4%) among physicians and
non-physicians at the facilities at upazila level and below (World Bank,
2012). At the upazila level, absenteeism among physicians (10%) is double
the absenteeism among non-physicians (5%).

Ambulances are in working condition in most of the district (97%) and

upazila (83%) hospitals. However, lack of funding restricts use of the
ambulance in 47% and 41% of hospitals at the district and upazila level
respectively.

Ministry facilities lack adequate supply of essential drugs. The

Bangladesh Health Facility Survey 2011 found that 27% the hospitals at
the district level and below have 75% of the 37 listed essential drugs.
Rannan-Eliya et al. (2012) report that during 1997–2010 in nominal terms,
the overall facility budget tripled while the facility budget for medicines
increased seven-fold. This may have had a positive impact on expansion
of service delivery during the same period. To strengthen the delivery of
a quality health-care system, drug supply should be improved. Improving
the availability of essential drugs at Ministry facilities would increase
utilization of services and lower unit costs.

Better coordination in budgeting, planning and implementation at

all levels will lead to efficiency gains. At present, resource allocation
to facilities is infrastructure- and human resource-driven without
considering needs of the facilities or the population they serve.
Introducing needs-based resource allocation will improve efficiency
in resource allocation as well as in utilization. Moreover, salaries for
personnel dominate the public spending at facilities, particularly at
the upazila level and below (Rannan-Eliya RP et al., 2012). Increasing
discretionary elements of public spending at the facility level may lead to
some efficiency gains.

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6.2 Future developments
Despite various reforms undertaken to make services cost-effective
and efficient, that have shown many positive results, Bangladesh has
yet to attain universal health coverage. It is imperative for the country
to undertake necessary steps for achieving universal health coverage in
the near future. The key challenges to financing for universal coverage
in Bangladesh are the high and potentially impoverishing OOP spending
on health; the poor quality of service delivery in the public sector; a
large and mostly unregulated private sector that dominates provision of
care; and the increasing burden of NCDs requiring costly individual care
(Bangladesh Health Watch, 2012). Thus cost sharing is a major issue in
attaining universal health care.

In recent times, it is recognized that some form of insurance involving

risk-pooling and prepayments could be an effective mechanism to
ensure universal health coverage (WHO, 2010). The recently revised 2012
National Health Policy has also termed health services as an individual
right and to help exercise this right, the policy advocates health insurance
for formal sector employees and the introduction of health cards for the
poor and disadvantaged.

The inaugural Health-care Financing Strategy, now approved by

the Minister of Health and Family Welfare, provides a framework
for developing and advancing health financing during 2012–2032
(MOHFW, 2012).The strategy is aligned with the vision of the HPNSDP
2011–2016, universal health coverage as defined by WHO, and the 2011
National Health Policy. The strategy puts emphasis on prepayment
mechanisms with scope of risk-pooling and separate mechanisms
are suggested for people in different economic sectors (formal sector,
informal sector and people in poverty). Taxes, social health insurance
contribution, community-based health insurance schemes etc. have been
recommended. In addition to the gains noted above,the strategy aims
to reduce dependence on external funds from 8% to 5%. It also targets
reduced inefficiency in resource utilization in terms of no unspent budget
which is currently 5%. The strategy is developed for achieving universal
health coverage in Bangladesh by providing financial risk protection to all
people in the country.

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7 Assessment of the health system

Chapter summary
The stated objectives in the 2011 National Health Policy are:
(i) strengthening primary health and emergency care for all; (ii) expanding
availability of client-centred, equity-focused and high-quality health-
care services; and (iii) motivating people to seek care based on rights for
health.

In terms of financial protection and equity in financing, Bangladesh is

not performing well, as evidenced by the high and increasing proportion
of health financed by OOP, from 57% in 1997 to 64% in 2007. While
theoretically all Bangladeshi citizens have the right to receive health care
according to need, low government investment in public facilities, some
user charges and payments for medicines, and high use of the private
sector have resulted in significant inequity in access to services. Current
reforms such as community clinics and maternal care vouchers provide
access to only limited services; meanwhile, the proposal for health
insurance for formal sector workers will not address the majority of
workers in the informal and rural sector.

In relation to user experience and equity of access, the general public

perception of the public health system is poor, with complaints of long
waiting times, absenteeism, poor behaviour of providers, and exclusion of
some marginalized groups. Access to care demonstrates much high rates
of utilization of public and private services by the wealthier quintiles, but
some improvement in equity in access over the last decade.

Despite these issues, population health outcomes have shown marked

improvement, with falls in maternal, infant and under-five mortality rates,
and significant reductions in total fertility rate. In comparison with MDG
targets, infant and under-five mortality and total fertility are on track to
reach the 2015 targets; maternal mortality and prevalence of underweight

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are not on track to reach targets despite significant reductions, while
targets for HIV, malaria and TB and still potentially achievable.

These outcomes have been achieved by improvements in coverage

with key interventions, such as delivery in a health facility, childhood
immunization, management of diarrhoea with ORS, and treatment
success rates for TB. However, the provision and coverage of services for
the growing burden of NCDs is only just beginning.

However, quality of care in both public and private services is poor, with
little assessment of the quality of provider care, low levels of professional
knowledge, and poor application. These problems are compounded by
poor accountability, with high levels of absenteeism, corruption and poor
performance by public and private providers.

7.1 Stated objectives of the health system

In the revised and updated 2011 National Health Policy, the specific goals
of the health system are delineated as: (i) ensure primary health and
emergency care for all; (ii) expand availability of client-centred, equity-
focused and quality health care; and (iii) motivate people to seek health
services for control and prevention of diseases based on rights for health.
To achieve these, objectives such as taking health services to the doorstep
of the population (e.g., one community clinic for every 6000 people within
a limited radius), reducing maternal, neonatal and child mortality and
morbidity, achieving replacement level fertility by 2021, and reducing
gender and equity gaps in health-care provision have been established.

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Table 7.1 Health indicators and their targets
Baseline
Key health indicators Current position Target 2015
positions
Infant mortality rate (IMR) 153 (1970s) 65 (2004) On track to 31
/ 1000 live births
Neonatal mortality / 1000 52 (1993) 41 (2004) Off track to 22
live births
Under-five mortality 151 (1990/1) 88 (2004) On track to 48
(U5MR) / 1000 live births
Maternal mortality / 574 (1990/1 ) 194 (BMMS 2010) Off track to 147
100 000 live births
Prevalence of underweight 67 (1990) 36 (BDHS 2011) Off track to 33
children (6 to 59 months)
% U5 stunted (24–59 54.6 (BDHS 1996) 41 (BDHS 2011) Off track to 25
months)
Total fertility rate 6.3 (BFS 1975) 2.3 (BDHS 2011) On track to 2.2
Prevalence of HIV / 100 000 0.005 (1990/1) <.001 On track - halting
Prevalence of malaria / 43 (1990/1) 59 (2008) On track - halting
100 000
Prevalence of TB / 100 000 264 (1990/1) 225 (2007) On track - halting
Source: Asia Pacific Observatory on Health Systems and Policies

Historically, a number of policy approaches such as the national five-

year plans, donor-led health and population projects, two national
health policies and the national health workforce strategies guided
the development of health sector in realizing the above goals.
Through these policies and strategies, several important changes
occurred: a strategic shift from urban-based to rural-based and
from curative to preventive health services, adoption of primary
health care as a strategy to ensure health for all, development of a
grassroots and mid-level health workforce to address shortages, and
expansion of postgraduate medical education to build up a critical
mass of professionals specialized in different disciplines. However,
policy implementation has a mixed track record. Some of the policy
commitments have been implemented while some have been partially
implemented or neglected. For example, despite policy promises for
offering a special package of incentives for doctors serving in the rural
areas, no such package has yet been offered in practice due mainly to
bureaucratic reluctance.

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7.2 Financial protection and equity in financing
7.2.1 Financial protection
While theoretically there is universal coverage (all Bangladeshi citizens
have the right to receive health care according to need), the increasingly
high OOP (from 57% in 1997 to 64% in 2007) is largely the result of
limitations on availability of services (height) due to low investment in
staff, equipment and medicines in the public sector, and consequent
use of the private sector, coupled with limitations on depth (some user
charges, especially purchase of medicines on supplies not available in
public sector facilities). The high levels of OOP payment combined with
informal payments for health services in public sector facilities are
impoverishing millions of households annually and is the most regressive
method of health financing.

The current heavy reliance on OOP – accounting for 64% of THE, with
two thirds of OOP being spent on medicines (HEU, 2010) –the high
incidence of catastrophic payment and impoverishment due to OOP (Van
Doorslaer, O’Donnell et al., 2007), are the major challenges that need to
be addressed in order to ensure financial risk protection (Rannan-Eliya
RP et al., 2012).

The incidence of catastrophic payment in Bangladesh is the highest in

the Asia Pacific region, as is the burden of OOP on households. About
5% incur catastrophic OOP payments, using the threshold of 25% of
monthly household consumption expenditure. Using the threshold of
25% of household non-food expenditure, about 15% of households incur
catastrophic health expenditure (Van Doorslaer, O’Donnell et al., 2007). A
more recent estimate found that 7% of households spend more than 25%
of their monthly non-food expenditure on health care as OOP (Rannan-
Eliya RP et al., 2012). The same study estimated that in a given month,
the proportion of population falling below the international $1 poverty
line due to OOP on health care decreased from 4% in 2000 to 3.1% in 2005
and 0.7% in 2010. Besides catastrophic expenditure, illness shocks have
troubling economic consequences such as lost earnings (Van Doorslaer,
O’Donnell et al., 2007).

The better-off section of the population spend more on health care

(O’Donnell, Van Doorslaer et al., 2008). The richest 40% spend 60% of
OOP. These findings imply that the richest could pay for the required
medical care, while the poorest were not able to do so and often forego
needed health care (Rannan-Eliya RP et al., 2012).

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Current policies largely focus on providing protection for identified high-
risk groups such as the pilots in the use of vouchers for delivery care,
exemptions from payment for the poor, and requirements for provision
of free care to the poor for private sector hospitals. These are likely to
have limited impact on the high OOP, and could be subject to abuse or
poor targeting.

7.2.2 Equity in financing

Financing of health expenditure is mainly tax-based, besides
contributions from development partners. As noted in Section 3.3.2,
the current tax system is progressive, with the highest burden for the
richest quintile. However, the high reliance on OOP is very regressive,
with a relatively higher contribution by the poor than the rich, and this
leads to catastrophic expenditure resulting in poverty.

Reduction of OOP and protection of the poor from catastrophic

expenditure will require some form of prepayment and pooled
resources. The concept of health insurance is still in a nascent stage in
Bangladesh, with some pilots of community health insurance by NGOs,
contributions from public sector employees, and contributory schemes
for formal private sector employees.

Introduction of a broader “prepayment” national insurance scheme

faces a number of issues including identifying adequate fiscal space,
appropriate payment mechanisms that limit overuse and supplier
induced demand, regulation of use of pharmaceuticals, and community
acceptance and willingness to contribute to an insurance scheme.

Equity in OOP
While the richest 40% spend 60% of OOP O’Donnell, Van Doorslaer
et al. (2008) also found inpatient hospital care to be pro-wealthy for
both public and private sectors. Overall hospital outpatient services
have small pro-wealthy bias although private sector outpatient care is
slightly pro-poor. Non-hospital care is also slightly pro-poor (O’Donnell,
Van Doorslaer et al., 2008). The richest quintile receives more than
30% of the total subsidy (O’Donnell, Van Doorslaer et al., 2008). Use
of traditional providers was higher among the poor (6–8%) and was
even higher in the case of children (Rannan-Eliya RP et al., 2012). Drug
outlets are the dominant heath provider (MOHFW, 2010).The overall
utilization of health care had been inequitable in all three rounds (2000,
2005, 2010) of the Household Income and Expenditure Survey. These

146
findings suggest that the poor rely on unqualified, low-quality private
sector providers (O’Donnell, Van Doorslaer et al., 2008).

The equity divide in health financing and access to needed health

services is major challenge to universal health coverage achievement.
Its heavy reliance on OOP accounting for 64% of THE, two thirds of OOP
being spent on medicines, high incidence of catastrophic payments and
impoverishment due to OOP are the major challenges that need to be
addressed in order to ensure financial risk protection. Besides health
financing and financial risk protection issues, Bangladesh also faces
challenges related to access. Access barriers such as lack of information
or awareness, cost, distance and quality are well documented by various
studies. In order to achieve universal health care, Bangladesh must tackle
both sets of challenges.

7.3 User experience and equity of access to health care

7.3.1 User experience
People’s perception of public sector health services in Bangladesh
is not good (Cockcroft, Andersson et al., 2007). Besides their main
complaint about the non-responsiveness of the health systems and
health-care providers, complaints of long waiting times, absenteeism
and misbehaviour of the providers, exclusion of marginalized groups
(e.g. destitute, eunuchs), lack of privacy, and lack of explanation of health
issues and management to the clients are frequently made. The daily
newspapers frequently report malpractice by doctors and dissatisfaction
with respect to the quality of services.

In a study exploring the other side of the story, health-care providers

unanimously mentioned lack of infrastructure (physical and human) and
supplies as the sole reason behind poor attitudes toward clients and poor
services delivered (Cockcroft, Milne et al., 2011).The doctors in addition
mentioned unfair treatment by an administration which fails to recognize
good work and reward it through incentives such as promotion.

7.3.2 Equity of access to health care

Access to care is constrained by lack of awareness about the availability
of the services; financial (e.g. user fees), geographic (e.g. distance to
the facility), and socio-cultural barriers (e.g. gender); and also negative
perceptions regarding quality of the care provided.

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Access to primary care is less constrained by geographic barriers, with
public sector services well distributed. However, perceptions of low
quality and frequent absenteeism lead many to use informal private
sector providers such as “village doctors” or to directly purchase from
pharmacies.

Higher-level care and diagnostic facilities are concentrated in urban

areas, especially the capital city Dhaka. Difficulties in attracting and
retaining some categories of staff (specialist doctors, nurses) limit the
provision of facility care in some areas (e.g.the north-east is not as well
catered for as the south-west) (DGHS, 2013). Access also demonstrates
disparities by SES quintile, with higher access/use of services for
higher quintiles for most key services (delivery by skilled attendant,
facility delivery). Policies addressing disparities in distribution of health
workforce have been poorly applied (e.g. incentives are not yet agreed),
and posting systems and regulations have largely evaded reform.

7.4 Health outcomes, health service outcomes and quality

of care
7.4.1 Population health outcomes
Bangladesh has achieved substantial gains in the field of health since
independence in 1971. As documented in Section 1.4, life expectancy
has increased from 45 to 68 years (1971–2011) and the total fertility
rate decreased from 6.3 to 2.3 (1975–2011), the maternal mortality ratio
decreased from 322 to 194 per 100 000 live births (2001–2010) and the
infant mortality rate fell from 87 to 43 per 1000 live births (1994–2011).

However, most of these improvements have occurred in relation to

communicable and maternal and child health conditions, with overall
little reduction in mortality and morbidity from NCDs, and increases in
mortality rates from CVD and some cancers (see Section 1.4).

The recent Lancet series explored the paradox of improvement in

population health outcomes, alongside a poorly performing health
system. The papers identified improvements in SES determinants
(education, poverty reduction, food supply), effective delivery of vertical
programme interventions (ORS, immunization, family planning) and use
of NGOs to obtain community mobilization, as key factors (Chowdhury,
Bhuiya et al., 2013).

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Key indicators of access and utilization of public health programmes
demonstrate increases over the last decade, which are likely to have
contributed significantly to the falls in mortality and increases in life
expectancy. Examples include:

• The percentage of pregnant women receiving four antenatal visits

increased from 17% to 26%, delivery attended by medically trained
provider increased from 16% to 32% and postnatal care by a medically
trained provider within 48 hours of delivery increased from 16% to 27%
(NIPORT, Measure Evaluation et al., 2012).
• The percentage of fully immunized children under one year of age
increased from <60% in 2000 to 80%+ in 2011. Similarly, exclusive
breastfeeding also increased steadily, from 46% in 1993–1994 to 64%
in 2011 among infants under six months as a result of the intensive
Infant and Young Child Feeding campaign in recent years.
• The percentage of children under five receiving ORS for episodes of
diarrhoea increased from 58% in 1993–1994, to 81% in 2007–2011. The
proportion of children with symptoms of acute respiratory infection
who were taken to a health facility or trained provider reached 35% in
the period 2006–2010 (NIPORT, Mitra Associates et al., 2011).
• Detection of cases of TB increased from 21% of estimated cases in
1994 to 73% in 2007, with treatment success rates for new smear
positive cases rising from 73% in 1994 to 92% in 2007 under the DOTS
programme.
7.4.2 Health service outcomes and quality of care
However, much less is known of the outcomes and quality of care
provided for chronic and noncommunicable diseases. As noted in
Chapter 1, NCDs are responsible for half of annual mortality (Bleich,
Koehlmoos et al., 2011) and account for 61% of the disease burden in
terms of disability adjusted life years loss (World Bank, 2011).

A nationwide survey on mental health reported that around 16.1% of the

adult population suffers from some sort of mental illness (Firoz, Karim
et al., 2006). The level of awareness of and medical care sought for
mental illnesses is very low. Much stigma is attached to mental illnesses.
Thus, morbidity from psychiatric illnesses remains an under-recognized
public health problem in Bangladesh. The Government acknowledges
mental illness as an issue in need of attention, yet the scope and scale
of interventions is very limited. Services are provided by both the public
and private sector, but they are limited to the urban areas. In Bangladesh,

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mental health service provision is limited to psychiatry only. There is
dearth of counselling services.

Evidence also exists on the poor quality of care by the informal providers.
The informal sector providers’ main routes of entry into the profession are
apprenticeship and inheritance and/or a short training of a few weeks to a
few months’ duration from semi-formal, unregulated private institutions.
As such, their professional knowledge base is not at a level necessary
for providing basic curative services with minimum acceptable quality of
care (Ahmed and Hossain, 2007, Ahmed, Hossain et al., 2009). However,
CHWs trained by formal government institutions or NGOs were found to
be better than other informal allopathic providers (e.g. village doctors
and salespeople at drug retail outlets) in providing some specific services
such as DOTS and treatment for child acute respiratory infections,
including rational use of drugs (Ahmed and Hossain, 2007; Chowdhury,
Hossain et al., 2009). Their services have also been found to be cost-
effective (Islam, Wakai et al., 2002).

The regulations relating to registration and control of private medical

care providers are often not enforced effectively, leading to the uneven
quality of service and inappropriate physical facilities. Apart from BMDC
registration requirements, there is little assessment of the quality of
physician care in Bangladesh, whether in the public or private sector.
Findings from a few small-scale studies indicate that there is significant
room to improve the technical quality of care provided (Arifeen, Bryce
et al., 2005; Chowdhury, Hossain et al., 2009;Hasan, 2012).

Like BMDC, the Bangladesh Nursing Council regulates the activities

of nursing professionals. Interestingly, studies show that nurses in
Bangladesh spend only a tiny fraction of their duty times on patient care,
sometime as low as 5% in government hospitals (Hadley and Roques,
2007; Zaman S, 2009). The main reasons behind this are stigmatization
and low status of the profession, the nursing activities being in direct
conflict with societal norms in areas such as “night duty, contact with
strangers, and involvement in dirty work”. The situation is a little better in
the private and NGO sectors.

On the other hand, poor quality of services is another important reason

for not achieving universal health coverage in Bangladesh. Poor quality
service is strongly associated with low utilization of services, especially
by the poor. Major problems affecting utilization are lack of sufficient
drugs, staff shortages (especially in remote facilities), poor prioritization

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of spending, and pervasive problems of management and coordination.
All these are the indicative of poor governance. Improving the quality
of service will require significant reform to increase the health budget,
ensuring the provision of drugs, decentralizing health services for faster
service, reducing fragmentation and increasing accountability to users.

Increased delegation of management and financial responsibility to

upazila level will help improve the quality of services to a large extent.
Establishment of an Upazila Health System of preventive and curative
health services, including specific disease control programmes,
accountable to the Upazila Health Management Committee would help
foster quality service at the local level. Introduction of Upazila Health
Systems would require increased investment as well as true delegation of
authority at the upazila level.

7.4.3 Equity of Outcomes

Though there have been commendable gains in health outcomes recently,
gross inequity remains. For example, differential levels of early childhood
mortality were observed according to socioeconomic status (NIPORT,
Mitra Associates et al., 2011). Neonatal mortality, infant mortality and
under-five mortality in the highest wealth quintile households (23, 29, 37
respectively per 1000 live births) were much less than among the lowest
wealth quintile households (34, 50, 64 respectively per 1000 live births).
Similarly, vaccination coverage (BCG, measles and three doses each of
DPT and Polio) among children from highest quintile households was 93%
compared to 77% among lowest quintile households.

The same trend of SES differentials was observed in case of child

nutritional status (NIPORT, Mitra Associates et al., 2011). Children of
lowest quintile households were proportionately more stunted (54%
compared to 26% for highest wealth quintile households), underweight
(50% compared to 21% for highest quintile households) and wasted (17%
compared to 12% for highest quintile households).

Fifty one percent and 64% of the pregnant women from highest wealth
quintile households were assisted during delivery by a qualified
doctor and a medically trained provider respectively, compared to
only 5% and 11% respectively in the case of lowest wealth quintile
households(Bangladesh Demographic and Health Survey, 2011). Only
10% of pregnant women from lowest wealth quintile households were
delivered in a health facility compared to 60% for the other group

151
of women. The percentage of C-section delivery was 3% and 41%
respectively for the lowest and highest wealth quintile households.

7.5 Health system efficiency

7.5.1 Allocative efficiency
Public sector hospitals are financed from revenue and development
budget. Resources are allocated based upon a fixed number of beds
and not disease burden, size of the population, or community need.
Historically, public sector allocation of resources has been biased to the
secondary and tertiary facilities, at the expense of primary health-care
facilities. As such, PHC-level facilities received disproportionately low
allocations compared to the secondary and tertiary hospitals. Recently,
with the introduction of SWAps, some reversal in this trend has begun.
Evidence shows that it has been successful in expanding funding for
primary health-care services through the Essential Services Package and
allocating these resources to subdistrict level and below, which are used
by the rural poor (Ensor, Dave-Sen et al., 2002)

7.5.2 Technical efficiency

Due to various gaps in physical infrastructure and human resources,
people’s perception of the services provided at public sector health
facilities is poor and as such, they mostly resort to unqualified informal
providers (Cockcroft, Andersson et al., 2007). According to the providers,
lack of supplies and inadequate infrastructure is one of the major causes
of inefficient services provided by these facilities (Cockcroft, Milne et al.
2011).

Though the NDP of 1982 has revolutionized the pharmaceutical sector

and made Bangladesh self-sufficient in essential medicines, good
manufacturing practice is not followed by all pharmaceutical companies.
Incomplete regulation by DGDA means the market is flooded with expired,
counterfeit and low-quality drugs. Health-care providers do not prescribe
drugs in brand names and are prey to the aggressive marketing policies
of the pharmaceutical companies.

Besides shortages, the health system is affected by a poor skill

mix. Instead of the ideal WHO recommended ratio of 1:3:5 (doctors:
nurses: technologists), it has currently a ratio of doctors to nurses to
technologists of 1:0.4:0.24. According to the WHO standard, Bangladesh
has a staggering shortage of over 90 000 doctors, 273 000 nurses and

152
455 000 technologists. There is no probability of reversing the current
ratio in favour of nurses and technologists under current strategies for
the foreseeable future.

7.6 Transparency and accountability

None of the mechanisms, in effect, has proved to be efficient in ensuring
accountability. In fact, the existing structure and management of health
organization does not facilitate health system accountability. This
has been reflected in the high absenteeism of doctors in rural areas,
corruption, poor service quality, and above all, the poor performance of
service providers. Weak accountability is the outcome of some prevalent
aspects of management: an inaccurate job description, performance-
evaluation based on subjective criteria, a nonfunctioning system of
reward and punishment and weak monitoring systems. Among health
service providers from medical doctors to health workers, none has well-
defined chain of accountability (Hossain and Osman, 2007). Ineffective
accountability causing high absenteeism among doctors in rural areas, a
supply side barrier, is evident in recent studies (Chaudhury and Hammer,
2003; FMRP 2003) and represents a major challenge for service provision.

There exists no meaningful system for monitoring the activities of

doctors, nurses and staff of the health facilities. Lack of accountability
and monitoring facilitate increased corruption and the suffering of
those accessing care. A household study conducted by Transparency
International Bangladesh (TIB) in 2007 reveals that 44.1% of the
households seeking health care were somehow victimized by corruption
(TIB, 2010). Corruption mostly takes the form of informal payments
(bribes) for outpatient tickets, purchasing the admission form for
inpatient service and the external sale of medicines that are the property
of public hospitals. All of these are demonstrative of non-transparent and
unaccountable health sector governance.

The Ministry of Health and Family Welfare oversees overall planning as

well as implementation functions, with deconcentration of some power to
the local level. Various bodies regulate the services and their standards,
but true regulatory power lies with the Ministry, which severely undercuts
the quality of health governance. Various structural and financial
limitations of the regulatory institutions have intensified this weakness
further. The accountability of providers, on the other hand, remains
very poor, as noted with the high absenteeism of doctors in rural areas,
corruption and poor service quality.

153
8 Conclusions

8.1 Key findings

Bangladesh has made enormous progress in health in recent years,
surpassing its neighbors in raising life expectancy, and reducing fertility
and the mortality of mothers and infants. But maternal and neonatal
mortality is still quite high, there are emerging and re-emerging
infectious diseases (e.g., dengue, swine and bird flu), mass arsenicosis
is a lingering concern, an emerging burden of NCDs, an epidemic of
road accidents, miserable health and sanitation conditions in the urban
slums, and fallouts from the effect of climate change on health. Through
the sixth Five Year Plan, the country implemented all health reforms
with a very low national health budget and the health status of the nation
remained generally poor despite various donor-supported vertical
programmes. A number of factors played important roles in hindering
expected improvement in the overall health status of the country.

• the complexity of the mixed health systems and poor governance;

• inadequacy of health resources and impact on quality of care;
• inadequate and uneven health service coverage;
• health-care financing through catastrophic OOPP by households; and
• inequitable access to health services hindering universal health
coverage

8.2 The complexity of the mixed health systems and poor

governance
The health system of Bangladesh is organized through multiple actors
performing diverse roles and functions through a mixed system of
medical practices. There are four key actors: Government, private sector,
NGOs and donor agencies. The Ministry of Health and Family Welfare
provides services through different executing and regulatory authorities
primarily in rural areas, and health services in urban areas are
delivered through Ministry of Local Government, Rural Development and
Cooperatives in partnership with NGOs and the private sector without the
oversight of the Ministry of Health and Family Welfare. Thus the Ministry

154
has been empowered to act as the central body for regulating a wide
range of health agencies, including medical professions and institutions,
and it has no authority to regulate services delivered by the private sector,
leading to domination by that sector in urban areas.

The existing structure and management of health organizations fails

to make the health system accountable to its stakeholders, leading to
high absenteeism rates among doctors, corruption, poor service quality,
poor performance of service providers, inaccurate job descriptions,
absence of a well-defined chain of accountability and other challenges
for the health sector. Despite nontransparent and unaccountable health
sector governance, Bangladesh has achieved MDG 4 by reducing child
death ahead of the 2015 target, and rapidly improving in other indicators
including maternal death, immunization coverage, and survival from
infectious diseases including malaria and tuberculosis, and diarrhoea.
However, these outcomes have been achieved by overall improvements
in SES determinants (education, poverty reduction, food supply), and
effective delivery of vertical programme interventions through NGOs.
Therefore, the Ministry of Health and Family Welfare would need to
improve its coordination with other ministries and NGOs that are directly
and indirectly involved with health services to maintain these successes.

8.3 Inadequacy of health resources and impact on quality of

care
Bangladesh has an extensive health infrastructure in the public and
private sectors, but is not equipped with adequate human and other
resources such as drugs, instruments and supplies. Despite a very
fast-growing private sector, the number of existing hospital beds is not
adequate to meet current demand. There is a critical shortage of trained
health providers and an inappropriate skill mix, thus the country remains
at a ratio of doctors to nurses much lower than the WHO recommended
ratio of 1:3:5. The trained medical doctors are being rapidly absorbed by
the private sector, albeit there is less than one doctor per 3000 population
and a constant rate of 20% vacancies among public sector health service
posts, suggesting an alarming shortage of doctors to provide adequate
services.

It is also alarming that due to a critical shortage of qualified health-

care providers and the costs of medical care, a large proportion of
poor patients seek treatment from informal providers who are mostly
untrained. Since the informal providers are not a part of the mainstream

155
health system, their quality is not monitored and thus the overall situation
forces the poor to compromise on quality of health care. On the top of the
human resource crisis, the unavailability of basic medical and diagnostic
facilities in public hospitals, such as clocks, height scales, thermometers
and blood pressure measuring cuffs indicate the poor capacity of the
public sector to offer minimum health services. Mobilizing the private
sector to produce more health workers and bring informal health-care
providers within the mainstream health systems may facilitate reducing
the gap in human resources more quickly. There is an urgent need for
more investment of public funds and stronger local accountability to
improve the quality of public services, as well as improved regulation and
monitoring of services provided by the private sector.

8.4 Inadequate and disproportionate health service

coverage
The Government provides comprehensive health services delivered
by both the public and the non-public sectors through the Ministry of
Health and Family Welfare and the Ministry of Local Government, Rural
Development and Cooperatives. There are well-functioning disease
surveillance and notification systems for early detection and control of
priority communicable diseases. A number of vertical programmes have
been implemented successfully and made a positive impact on health,
particularly child survival. The role of NGOs in social mobilization for
behavioural change through extensive mass promotion services has
supplemented the inadequacy of human resources in public sector.
However, some of the successful programmes could not derive optimal
benefit for the target population, such as control of child death from
pneumonia or neonatal sepsis, undernutrition of children under five
and spread of MDR-TB. More importantly, the double burden of disease
that the country has faced due to the health transition has not been
addressed by the service delivery system. The Government has made
little investment in the fight against NCDs. Very few specialized facilities,
mostly located in the capital city, meet the service demand of NCDs and
none of the public facilities have trained staff or the drugs necessary to
treat NCDs at district and subdistrict health facilities.

Due to lack of linkages and coordination across ministries delivering

health services, vertical programmes and specialized services adopted
by the Ministry of Health and Family Welfare do not necessarily get
translated to urban health systems. Further, the inability of the formal
sector to provide essential health services has resulted in a widespread

156
increase in informal providers as an alternative source of care in both
urban and rural areas, particularly for the poor. In order to improve
health service delivery, the coordination between the two ministries
needs to be strengthened and public health programmes should be
revisited to effectively address the challenges based on emerging trends.
Regulation of informal providers for service quality and establishing a
well-structured referral system between outpatient and tertiary health
facilities may reduce the dependence of the patients on convenient
services offered by informal providers. The current health system is not
prepared to address emerging health issues such as population ageing
and NCDs, emerging and re-emerging infectious diseases, poor maternal
and child nutrition, injuries related to road traffic accidents, drowning,
violence, occupational health, mental health, palliative care, or long-
term health-care services for elderly population. Further investment in
NCD services and other emerging health issues should be incorporated
into health service delivery by both the Ministry of Health and Family
Welfare and the Ministry of Local Government, Rural Development and
Cooperatives in order to expanding service coverage across all segments
of the population.

8.5 Health-care financing through catastrophic OOPP by

households
Health services in Bangladesh are predominantly financed by households’
out-of-pocket payments comprising 64% of THE. Incidence of catastrophic
payment in Bangladesh is the highest in the Asia Pacific region. Currently
Bangladesh spends US$ 26.60 per capita and the pace of growth is faster
than per capita GDP, suggesting that people are bound to spend more on
health than domestic products. The bulk of this health spending goes to
qualified medical providers as direct payment, and a smaller proportion
to alternate medical practitioners, being spent mostly on medicines.
The high levels of OOP payment combined with informal payments for
health services at public sector facilities are impoverishing millions of
households annually. Financial risk protection remains a major challenge.

Although public expenditure on medicines and medical goods increased

significantly, patients need to purchase medicines prescribed by providers
at public facilities, even though they are supposed to be supplied free of
cost. While public spending on public health and prevention has almost
doubled in absolute terms, the share of spending on hospital care for
inpatient and outpatient care remains very low, and the health sector
budget has been further reduced from 7% to less than 5% of the total

157
government budget in 2013, despite a fast-growing population and the
emergence of new health issues. It is a paradox that despite a low total
health expenditure, Bangladesh has obtained good value for health
compared to other countries in the region, taking the maternal and child
mortality outcome indicator as a yardstick. Clearly, Government savings
on health spending can be attributed to the greater contribution of
households to health spending, leading to more catastrophic OOPPs by
households and poverty. Finding an affordable health financing strategy
for the poor in the near future is imperative for sustaining the success of
the Government in the health sector.

8.6 Inequitable access to health services hindering

universal health coverage
The National Health Policy mandates strengthening primary health and
emergency care for all people and a number of reforms for extending
services targeting the poor are in place. As such, the current reform has
supported establishing one community clinic for every 6000 people in
rural areas, facilitating access to care as well as treatment at no cost
irrespective of the socioeconomic status of a household. Meanwhile, in
the urban areas, non-state providers have been contracted to deliver
primary health care at the lowest administrative urban units limited
to the city corporation and municipality areas. They charge fees for
services, although with provision of free services for the poor certified
by the contracting agency. This leads to inequity in service provision and
payment mechanisms between urban and rural areas.

Most of the primary health facilities provide basic health care and thus
do not have the capacity to support inpatient care or emergency medical
care. Although there is no well-structured referral system in place,
there is a triage approach in rural health set up by establishing primary
health care at the lowest administrative unit, and secondary and tertiary
care at the subdistrict and district level respectively. However, there is
only one secondary facility per subdistrict and one tertiary facility per
district for 70% of the population living in rural areas, and no specialized
public or private institution. On the other hand, all significant public
and private institutions, including most medical colleges, hospitals,
clinics, laboratories, drug stores, are established in the capital city or at
the division level and thus the rural population are inherently deprived
of specialist services in general. Even within urban areas there is a
disproportionate population–bed ratio, with the lowest ratio in the capital
city given a higher population density than other cities.

158
Although the NGO sector has contributed significantly to promotive,
curative and preventive health services in Bangladesh, most of the NGO-
based health service institutions are located in urban areas, and rural
people mostly depend on unqualified informal providers. However, in
the absence of a prescription policy, households end up spending much
more at drug outlets due to overprescribing, multidrug prescribing and
prescribing of expensive drugs by these unregulated and untrained
informal providers mostly in the rural areas due to limited options and
availability. Such disparity in the distribution of health service facilities
and access to qualified providers has created geographic inequity in
access to quality care and prevents the majority of the population from
the benefits of health services.

There is also inequity in the budgetary allocation for health. The health
ministry has the lowest sanction of all ministries historically and the
local bodies do not play any formal role in determining the supplies,
thus ultimate allocative decisions are made centrally on the basis of the
previous year’s actual expenditure, availability of resources and the policy
focus of the government, with no reflection of health demand at the local
level. With an unrealistic heath budget and inadequate allocation in every
sector under a very low Government health budget, households are forced
to pay substantially from their own budgets – and of course the poor pay a
larger proportion of their income than the rich.

8.7 Remaining challenges

However, despite all challenges discussed above, the Ministry of Health
and Family Welfare will need to tackle more challenges and adopt timely
appropriate strategies in order to sustain its hard-earned success. The
first challenge will be to establish strong coordination for developing
long-term self-sustaining health plans with increasing focus on primary
health care and prevention strategies for both acute and long-term
care. It will require supraministerial decision-making to establish
linkages between urban health services and the health ministry, referral
systems, deployment of adequately-qualified providers, and a unified
and affordable financing mechanism for health services in order to
reduce high OOP payments. It will be also important to evaluate some of
the current vertical programmes that demonstrate few positive health
outcomes such as HIV/AIDS, mental health and urban primary health-
care, in order to strengthen the health system.

159
The health system has been facing enormous challenges in catering
to the health needs of more than 150 million people and this challenge
will be even greater in future, with the country on the verge of rapid
population growth, particularly due to faster growth in urban areas
and slow progress in implementing current strategies for achieving
universal health coverage. Rapid capacity building to promote prevention,
particularly to halt the epidemic of NCDs will be essential, but poses
a great challenge for the health system. Since the majority of people
depend on informal sector providers, deployment of the large health
cadre following regulation and improving the quality of care, may help
reduce the gap of trained community based health work force, such as
Community Health-care providers who have been assigned to community
clinics. However, it will require the Ministry of Health and Family Welfare
to bring informal sector providers under the mainstream health systems
and monitor their services under a national policy, which will need strong
political will and support from the recognized health-care authorities in
the country. Bangladesh needs a realistic plan for an affordable payment
mechanism for health in order to reduce catastrophic out-of-pocket
payments for health and to develop parallel strategies for investing more
in health.

It is an impressive move that the Health-care Financing Strategy

(2012– 2032) has been developed to provide direction in achieving
universal health coverage. The current strategy puts emphasis on
prepayment mechanisms with scope of risk-pooling and different
mechanisms are suggested for people in different economic sectors, be it
the formal or informal sector, or people in poverty. Mechanisms include
taxes, social health insurance contributions and community-based health
insurance schemes. However, the concept of health insurance is still
in a nascent stage in Bangladesh and prepayment for health will not
be a popular idea unless irregularities in the payment mechanisms are
minimized and access to quality health care is optimized for best value for
money. Further challenges that will remain for the Government include:
the equitable expansion of basic health services across all socioeconomic
and geographic boundaries as a prerequisite of establishing the new
strategy, and bringing adult wage earners, particularly the wealthy, into
the programme to widen the financial protection of the poor.

160
8.8 Future prospects
Bangladesh has set an extraordinary example of gaining good health at
very low cost and has been projected as a role model for other developing
countries in the region. While gains in health have been fully credited
to the Ministry of Health and Family Welfare, it is the progress of other
ministries relevant to public health that has catalyzed the success of
overall health agenda of the Government. It is a paradox that despite
an accountability vacuum regarding health and little coordination by
the Ministry of Health and Family Welfare with other sectors, a number
of vertical health programmes, particularly in preventive care, such as
immunization, control of diarrhoea, tuberculosis, and other emerging
infectious diseases, have been sustained over a long period and brought
positive health outcomes. Mobilizing the huge informal health cadres
outside the official allopathic system would be a useful strategy for
strengthening human resources in health, especially in the remote
and hard-to-reach areas of the country, and achieving universal health
coverage.

Bangladesh has successfully applied IT to its information and

management systems to ensure they are easily accessible for
performance assessment of specific programmes at least up to
subdistrict level. Internet access has been established up to union-level
facilities and the community clinics will soon be included in the HIS net
for the generation of various databases aiding management decision-
making. Under e-Health, all the UHCs and district hospitals have mobile
phone-based services for providing necessary medical advice free of
charge. Telemedicine service is now available in eight hospitals through
high-quality video-conferencing devices and this has expanded to several
thousands of community clinics. This expands the opportunity for
providing medical consultation to rural areas where there is no access
to specialist doctors. The pilot project MOVE-IT has opened the prospect
of building a unified electronic information system to register all vital
statistics and improve coverage of priority maternal and child health
services.

The Urban Primary Health-care Service Delivery Programme has set

another promising fee-based model. Although the service is hosted by a
non-health ministry and coverage remain slow, this model demonstrates
a positive transition in patient behaviour from free health care to fee-
for- services. This is also a successful model that has demonstrated
that non-state providers engaged in supporting public health services

161
under and private heath sector can be brought under regulation of
the Government. Further evaluation of the UPHCSDP to tease out
weaknesses would help in identifying a strategy to strengthen primary
health care in both urban and rural areas for gradually reducing
Bangladesh’s dependence on donors for primary health care by
generating revenue in health. Further exploration of scope for linking
the UPHCSDP model to community-based health insurance maybe an
innovative approach for reducing catastrophic out-of-pocket payments
and establishing a sustainable health-care delivery system. Overall, the
Bangladesh health system is at a crossroad and investment in health
would contribute to the improvement of the health of the population and
fulfil the Government mission to achieve universal health coverage within
the foreseeable future.

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9.2 Further reading

Balabanova, D., M. McKee and A. Mills (2011). Good health at low
cost 25 years on. What makes a successful health system? London,
London School of Hygiene & Tropical Medicine (http://ghlc.lshtm.ac.uk/
files/2011/10/GHLC-book.pdf)

9.3 Useful websites

Ministry of Health and Family Welfare Government of the People’s
Republic of Bangladesh

http://www.mohfw.gov.bd/

9.4 HiT methodology and production process

HiTs are produced by country experts in collaboration with an external
editor and the Secretariat of the Asia Pacific Observatory based in the
WHO Regional Office for the Western Pacific in Manila, the Philippines.
HiTs are based on a template developed by the European Observatory on
Health Systems and Policies that, revised periodically, provides detailed
guidelines and specific questions, definitions, suggestions for data
sources and examples needed to compile reviews. While the template
offers a comprehensive set of questions, it is intended to be used in a
flexible way to allow authors and editors to adapt it to their particular
national context. The template has been adapted for use in the Asia
Pacific region and is available online at: http://www.WHO.who.int/asia_
pacific_observatory/hits/template/en/

Authors draw on multiple data sources for the compilation of HiTs,

ranging from national statistics, national and regional policy documents
to published literature. Data are drawn from information collected
by national statistical bureaux and health ministries. Furthermore,
international data sources may be incorporated, such as the World
Development Indicators of the World Bank.

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In addition to the information and data provided by the country experts,
WHO supplies quantitative data in the form of a set of standard
comparative figures for each country, drawing on the Western Pacific
Country Health Information Profiles (CHIPs) and the WHO Statistical
Information System (WHOSIS). HiT authors are encouraged to discuss the
data in the text in detail, including the standard figures prepared by the
Observatory staff, especially if there are concerns about discrepancies
between the data available from different sources.

The quality of HiTs is of real importance since they inform policy-making

and meta-analysis. HiTs are subject to wide consultation throughout the
writing and editing process, which involves multiple iterations. They are
then subject to:
• A rigorous review process consisting of three stages. Initially, the
text of the HiT is checked, reviewed and approved by the Asia Pacific
Observatory Secretariat. It is then sent for review to at least three
independent experts, and their comments and amendments are
incorporated into the text, and modifications are made accordingly. The
text is then submitted to the relevant ministry of health, or appropriate
authority, and policy-makers within those bodies to check for factual
errors.
• There are further efforts to ensure quality while the report is finalized
that focus on copy-editing and proofreading.
• HiTs are disseminated (hard copies, electronic publication, translations
and launches). The editor supports the authors throughout the
production process and, in close consultation with the authors, ensures
that all stages of the process are taken forward as effectively as
possible.

9.5 About the authors

Syed Masud Ahmed is the Director of the Centre of Excellence for
Universal Health Coverage (www.coe-uhc.org), a joint venture of Centre
of Equity and Health System, icddr,b and James P. Grant School of Public
Health at BRAC University. He has also been a Professor at the School
since 2011. Before joining current position in July 2013, he was the
Senior Research Coordinator at the Research and Evaluation Division
of BRAC in Bangladesh. He was a visiting fellow (David E. Bell Fellow)
in Population and International Health at Harvard Center for Population
and Development Studies during 1997. Dr Ahmed was awarded a Ph
D from Karolinska Institutet University, Sweden in 2005. His research

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interests include studying the impact of microcredit-based development
interventions on the health and wellbeing of the poor, and exploring
the mechanisms of such impact; health equity and improving the
health system’s ability to reach the poorest-of-the poor; and human
resources for health. Dr Ahmed has published extensively in national
and international peer-reviewed journals including Lancet and authored
book chapters, monographs and working papers. He has travelled
extensively and presented papers in international seminars, conferences
and workshops. He was also a peer reviewer for renowned public health
journals such as Bulletin of WHO, World Development, Social Science and
Medicine, Health Policy and Planning, Tropical Medicine and International
Health,and BMC Public Health. He has a blog at http://syedmasudahmed.
blogspot.com,titled“Bangladesh Health Scenario”.

Bushra Binte Alam has been managing the health agenda of the World
Bank in Bangladesh by supporting the implementation of one of the
largest health sector programmes since 2009. Having graduated in
medicine and completing postgraduate studies at the London School
of Hygiene & Tropical Medicine in Virology along with an M. Phil in
Preventive and Social Medicine, she has more than 25 years of experience
of working in the health sector. She has worked for the Government of
Bangladesh for more than 15 years and has worked in different capacities
in various international organizations including UNFPA and DFID.

She was one of the authors who had designed the UN-MNH (maternal
health programme), which is now being implemented in Bangladesh
jointly by the three UN agencies. She was also involved with the design
of two consecutive health sector programmes (HNPSP and HPNSDP).
She supported the finalization of the Joint-UN Maternal and Neonatal
Health Program (Saving the Lives of the Mothers and Newborn) in the
Philippines. Her areas of expertise include health systems strengthening,
maternal and neonatal health, HIV&AIDS and policy and strategy
formulation for the health sector.

Iqbal Anwar is a maternal health and health systems expert. Currently

he is working as a scientist at icddr,b. Before joining icddr,b in 2001, he
worked with the Ministry of Health and Family Welfare at different tiers
of the national health system as service provider, 1st line manager,
human resource development officer, EIS medical officer and operations
research expert. Dr Anwar is now involved in a number of research
protocols in the field of maternal, neonatal and child health with

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special focus on quality of care, inequity in health and research policy
communication.

Tahmina Begum is a health and development economist with 19 years

of professional experience. She graduated from the Department of
Economics at the University of Dhaka and obtained M. Sc. in Economics
of Education from the Institute of Education (IOE), University of London
UK. Currently she is an independent consultant of World Bank, GIZ,
and Health Economics Unit (HEU) of the Ministry of Health and Family
Welfare. Ms Begum was involved in a number of HEU research that
include dual job holding of doctors, unofficial fees, costing of public
health facilities, private sector health facilities, public and OOP spending
on MNCH, resource allocation formula and others. She led a number of
public expenditure reviews of the health sector conducted by HEU and
published extensively in peer reviewed journals.

Rumana Huque joined University of Dhaka in 2000 as a lecturer. Currently,

she is employed as an Associate Professor in Department of Economics,
University of Dhaka. She teaches Health Economics. She completed
BSS (Honours) and MSS in Economics from the University of Dhaka,
Bangladesh, an MA in Health Management, Planning and Policy from
University of Leeds, UK in 2002, and earned a Ph D from the University of
Leeds in 2010. She specializes in health systems and health economics
with a special focus on health-care financing, resource allocation and
budgeting, and economic evaluation.

Jahangir AM Khan is a health economist and the Head/Coordinator of

Health Economics and Financing Research Group at icddr,b and Associate
Professor of James P. Grant School of Public Health at BRAC University
in Dhaka. He has published research articles in the areas of health
insurance, costs of health interventions, economics of social protection
programmes due to sickness and disability in welfare states. Dr Khan
appeared as a focal person for developing the first ever health-care
financing strategies of Bangladesh and is currently an evaluate member
of the Evaluation Committee of National Health Accounts of Bangladesh
related proposals, organized by the Ministry of Health and Family Welfare.
Prior to his engagement in icddr,b, Dr Khan worked at Karolinska
Institute of Sweden as a faculty and still is an adjunct researcher there.

Herfina Nababan currently works as an international research fellow

in icddr,b and James P. Grant School of Public Health, Bangladesh. She
is a medical graduate from the Faculty of Medicine, Universitas Pelita

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Harapan, Indonesia in 2007 and obtained her Master of Health Science
from the Global Health Policy Department, Graduate School of Medicine,
University of Tokyo, Japan in 2012. For the period of 2008–2010 she
worked as a teaching assistant in the Microbiology and Infectious Disease
Department, Faculty of Medicine, Universitas Pelita Harapan, Indonesia.

Ferdous Arfina Osman is a Professor of Public Administration at Dhaka

University. She gained her doctoral degree in 1999 in Public Policy
and Administration from the University of Manchester, UK under the
Commonwealth Scholarship Plan. Dr Osman has published extensively
in academic journals at home and abroad on issues and areas relevant to
public policy and governance. Her major research foci are public policy,
health policy, governance and public management.

Co-authors
Arshee Rahman currently works with the World Bank as a consultant
on the health sector programme, providing research and operational
support. She previously worked with REACH Initiative, a joint UN initiative
of FAO, UNICEF, WFP and WHO on renewing efforts towards preventing
child hunger and undernutrition. Arshee completed her Master’s in
Public Health from the James P. Grant School of Public Health of BRAC
University, and her Bachelor’s in Anthropology and Law & Society from
York University (Canada).

Kuhel Islam completed Masters in Public Health (MPH) from James P.

Grant School of Public Health, BRAC University. He earned his Bachelor’s
degree, Biology majoring in Molecular Genetics from University of
Victoria, British Columbia, Canada. He then moved to Saudi Arabia to take
up the position of a Junior Researcher in the Department of Comparative
Medicine at King Faisal Specialist Hospital and Research Center, Riyadh.
He was involved in a project for molecular typing and gene extraction of
the mycobacterium tuberculosis. He later joined as a Microbiologist and
Laboratory Coordinator at the International Organization for Migration in
Dhaka. He worked in a Ministry of Health, UK project for TB screening of
applicants going to UK for long-term stays. He was trained in Thailand
in laboratory sputum culture procedure and in lab data management
systems.

Rashidul Alam Mahumud is a Senior Research Officer at icddr,b. He is a

statistician by training from Rajshahi University. He worked as a Senior
Lecturer at the School of Business in the Department of Statistics in

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Asian University of Bangladesh. Mr Mahumud has published a number of
articles in peer-reviewed journals.

Kawkab Mahmud is a Senior Research Associate in the Centre for

Universal Health Coverage (UHC), James P Grant School of Public
health, BRAC University. She started her career as a Medical officer in
tertiary level health care hospital and research institute (BIRDEM), Dhaka
Bangladesh. She joined the School of Public Health as a Coordinator of
research project and also contributing as a Teaching Fellow of relevant
module of Masters of Public Health Programme. Dr. Kawkab’s research
works involve clinical studies and cross country research projects on
human resource for health issues. Dr. Kawkab completed her MBBS
degree from University of Dhaka, Bangladesh and MPH from the
University of Melborne, Australia.

Shabnam Mostari, works as a Senior Research Associate at the James

P. Grant School of Public Health at BRAC University, Bangladesh. She
did her Master’s in Public Health (MPH) from North South University
Bangladesh. She got research grants from Maternal Health Task Force
at the Harvard School of Public Health and DFID. Her research interests
include maternal health, universal health coverage with minimal
economic compromise.

Dr. Nasima Selim, Senior Lecturer, James P Grant School of Public

Health (JPGSPH), BRAC University is currently pursuing PhD studies at
the Institute of Social and Cultural Anthropology at Freie Universitaet (FU)
Berlin, Germany. At JPGPSH, she teaches “Anthropological Approaches
to Public Health and Qualitative Research Methods”. Dr. Selim was co-
investigator in three mixed-method, multi-country research projects
at JPGSPH: (1) “Health Professional Education Situation Analysis of
Bangladesh” (2012); (2) “Violence against marginalized women in
Bangladesh” (2010); and, (3) “Globalization as a social determinant of
health: Influences on patterns of food consumption among young people
in Asian Universities”(2009). Dr. Selim studied medicine and public
health in Bangladesh (Sir Salimullah Medical College and JPGSPH
respectively), interdisciplinary social sciences at the Centre for Studies in
Social Sciences, (CSSSC) Calcutta, India, and medical anthropology at the
University of Amsterdam, the Netherlands. Her research interests include
social determinants of health, public mental health, health professional
education, qualitative research and mixed methods. She is especially

185
interested in the interface of public health and social sciences focusing on
the intersection of medicine and religion in terms of alternative healing,
self-care and meditation practices. She co-edited several monographs
and published in peer-reviewed journals on mental health on well-being
techniques, violence against women, and topics related to public health
and medical anthropology. She was a peer reviewer for the Community
Mental Health Journal, Journal of Mental Health, and Religion and
Culture. Dr. Selim is a founding member of the Bangladesh Mental Health
Network.

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 The Asia Pacific Observatory on Health
Systems and Policies (the APO) is a
collaborative partnership of interested
governments, international agencies,
foundations, and researchers that promotes
evidence-informed health system policy
regionally and in all countries in the Asia
Pacific region. The APO collaboratively
identifies priority health system issues
across the Asia Pacific region; develops and
synthesizes relevant research to support
and inform countries’ evidence-based policy
development; and builds country and
regional health systems research and
evidence-informed policy capacity.

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