As Bangladesh navigates a period of significant reforms aimed at national progress, the public healthcare system stands out as a crucial pillar requiring urgent and focused attention. Beset by deep-rooted systemic challenges that hinder its ability to deliver equitable and quality services to all citizens, public healthcare in Bangladesh is a critical area that demands profound re-evaluation and strategic intervention. On the occasion of World Health Day, we had the opportunity to speak with Dr. Shams El Arifeen, a leading research director at the icddr,b with a long and distinguished career focused on improving health outcomes, about the pressing challenges our healthcare system currently faces and the essential steps that can be taken towards meaningful reform.
Considering the public healthcare system specifically, what do you see as the most significant systemic challenges in delivering quality health services to the population of Bangladesh?
Well! The key challenge really boils down to our inability to decide on our long-term direction. Are we going to continue with the current model, which is heavily dominated by a largely unregulated private sector? Interestingly, while you might expect better services from private providers, national health facility surveys consistently show their readiness isn’t any better than comparable public facilities. Over the years, we have had strategies and numerous stakeholder consultations, but the bottom line is a lack of decisive action. Meanwhile, our out-of-pocket health expenditure keeps climbing, from 62% in 2012 to that 68.5% in 2020. To put that in perspective, only Afghanistan has a higher rate. It seems we lack the political will to make sustained, positive change, and it’s the poor who continue to bear the brunt of essential healthcare costs, despite our aspirations of becoming a welfare state.
Another immediate and crucial challenge is the absence of effective systems of accountability at all levels, which, in combination with the lack of any decentralisation of real decision-making has resulted in a system that simply isn’t delivering the healthcare that the people of this country have a right to receive.
How would you assess the current capacity of our healthcare workforce, particularly in rural and underserved areas, and what strategies would you recommend for strengthening it?
The public health infrastructure in rural areas is generally good in terms of the network of primary and secondary facilities. What’s missing is the connection between these facilities, preventing them from functioning as a truly effective network. The situation is different in most urban areas, where we see plenty of secondary and tertiary care facilities but a significant absence of primary care.
In recent years, we have seen a rapid growth in new hospitals and facilities. However, a concerning number of these remain non-functional or only partially operational for months due to a lack of essential staff, equipment, supplies, and operating budgets. It’s honestly difficult to grasp the level of poor planning that leads to such a situation.
While we do invest heavily in training our healthcare providers, delivering quality care in remote or hard-to-reach areas is less about the capacity of the workforce. It’s much more about the availability of an adequate number of healthcare providers who have consistent access to the necessary resources – things like context-specific care protocols, medicines, supplies, equipment, and referral systems – to ensure quality care. They also need to work in an environment that fosters accountability.
How can the public healthcare system better integrate with other sectors, such as education, social welfare, and agriculture, to address the social determinants of health?
The concept of “social determinants of health” has certainly been a major topic of discussion and research, both globally and here in Bangladesh. However, I’m not entirely convinced that all this talk has translated into truly effective cross-sectoral strategies in our context. I wouldn’t presume to offer a specific prescription, except to say that the starting point absolutely has to be a well-informed political leadership that genuinely understands these interconnected issues and is committed to embarking on such a path. Unlike many other countries, health isn’t really a central part of national and local political discourse in Bangladesh, which hinders the drive for political change in this area. Until that changes, I see very little hope for the kind of effective political leadership needed to drive this kind of integration.
Given limited resources, what are the top three priority areas for strengthening the public healthcare system in Bangladesh?
If we’re talking about top priorities given limited resources, I would definitely focus on these three key areas: Reducing out-of-pocket health expenditure to below 20% recommended by WHO, accountability, and decentralisation/autonomy.