­

Global­Healthcare­
Financing­Policy­and­
Practice­in­Bangladesh

Preface
Bangladesh­ is­ a­ densely­ populated­ country­ with­ about­ 165
million­populations.­Health­is­a­basic­need­of­the­people­and
it­is­recognized­by­the­constitution­of­the­country.­Bangladesh
has­been­showing­remarkable­performances­in­health­sector
and­ setting­ extraordinary­ examples­ for­ the­ developing
countries­ in­ recent­ years.­ Meeting­ specific­ targets,­ the
country has­ been­ seen­ to­ surpass­ most­ of­ the­ South­Asian
countries­ in­ achieving­ relevant­ Millennium­ Development
Goals­ (MDGs)­ and­ Sustainable­ Development­ Goal
(SDGs).Bangladesh­has­gained­praise­from­around­the­world
for­its­impressive­performance­in­maternal­and­child­health
care.­ The­ decrease­ of­ infant,­ child­ and­ maternal­ mortality
rates,­ increase­ life expectancy­ over­ the­ past­ few­ years­ has
been­ impeccable,­ which­ has­ been­ possible­ through­ the
expanded­ public­ health interventions­ of­ immunization
and­family­planning programs.­A­good­organogram­of­the
health­system­combining­both­public­and­private­sectors­have
been­contributing­heavily­to­improve­the­health­status­of­the
country.­ The­ prime­ actors­ of­ healthcare­ financing­ in
Bangladesh­are­the­government,­foreign­donors,­NGOs,­and
households.­Financial­flow­for­the­public­sector­derives­from
general­tax­revenues,­foreign­development­funds,­corporations
and­autonomous­bodies.­On­the­contrary,­for­buying­healthcare,
households­or­individuals­contribute­from­their­own­pocket,
in­ other­ words,­ through­ out-of-pocket­ (OOP)­ payments.
Although­Bangladesh­achieved­number­of­triumphs­in­health
sector­ lately,­ the­ scenario­ of­ financing­ is­ not­ satisfactory.
Despite­ substantial­ improvement­ in­ most­ of­ the­ health
indicators,­the­country­is­suffering­from­scarcity­of­resources
in­ controlling­ many­ global­ public­ health­ concerns.­ During
COVID-19­ pandmic­ healthcare­ financing­ is­ seriously
challenged­ by­huge­complains­Within­many­uncertainties
still,­ the­ hope­ is­ long-term­ Health­ Care­ Financing­ Strategy
(HCFS)­2012-2032. The­budgetary­significance­of­the­ HCFS is
within­ the­ 2032 government­ will­ decrease­ the­ OOP to­ 32%.
The­rest­of­the­health­care­financing­will­be­supported­specifically
by­30%­of­the­government­expenditure,­another­32%­by­the
social­health­protection­fund­and­another­6%­from­the­external
sources.
Healthcare­financing­was­not­addressed­sufficiently­in­recent
years.­This­book­“Global Healthcare Financing Policy and
Practice in Bangladesh”­ for­ the­ first­ time­ explored­ the
healthcare­ financing­ scenario­ of­ Bangladesh­ and­ also
recommended­the­structural­remedy­of­the­crisis.­We­could
accommodate­ the­ recommendations­ of­ national­ and
international faculties­in­different­chapters.­The­book­also
elucidated­ the­ policy­ of­ the­ healthcare­ financing­ of­ the
developed,­developing­and­neighboring­countries­to­compare
and­for­understanding­of­the­situation.­
This­book­will­be­helpful­for­policy­makers,­researchers,­public
health­ specialists,­ health­ system­ learners,­ civil­ society­ and
different­stalk­holders­of­the­health­services.
As­it­is­the­first­edition­of­the­book,­there­may­be­huge­lacking
in­coordination­and­presentation­of­information.­I­would­appreciate
and­acknowledge­suggestions­from­academicians­and­learners
for­improving­the­quality­of­the­book.­Please­feel­free­to
forward­your­comments,­suggestions­and­recommendations,­if
any­to­shahinul@bsmmu.edu.bd.
Professor Dr. Shahinul Alam MBBS.MD.­FCPS
October­2020
Editor Dr Shah Mohammad Fahim, MBBS,­MPH
Research­Investigator 
Dr. Shahinul Alam, MBBS,­MD,­FCPS Nutrition­and­Clinical­Services­Division­(NCSD)
Professor International­Centre­for­Diarrhoeal­Disease­Research,­
Department­of­Hepatology Bangladesh­(icddr,b)
Bangabandhu­Sheikh­Mujib­Medical­University  68,­Shaheed­Tajuddin­Ahmed­Sarani,­
Dhaka.­Bangladesh. Mohakhali,­Dhaka­1212,­Bangladesh
Email­:­shahinul67@yahoo.com Email­: mohammad.fahim@icddrb.org 

Contributors : Dr. Md. Zakiul Hassan, MBBS

Assistant­Scientist
Dr. Farhana Begum, MCom, MPhil,­PhD
Infectious­Diseases­Division
Postdoctoral­Scholar­
68­Shaheed­Tajuddin­Ahmed­Sarani,­Mohakhal,­
Accounting­Research­Institute­(ARI)
Dhaka-1212,­Bangladesh
UniversitiTeknologiMARA(UITM)­40450,­Shah­Alam
+880-2-9827001-10,­Ext­:­2547
Selangor,­Malaysia.
Email­:­zhassan@icddrb.org
E-mail­:­farhanaju@yahoo.com
Dr Abu Hena Abid Zafr, MBBS
Prof. Dr. Normah Omar, CPA
Investigator
Director
Urban­Health­Research
Accounting­Research­Institute­(ARI)
25i­Green­Road.­Dhaka-1205
Higher­Institutions’­Centre­of­Excellence­(HICoE)
Bangladesh
Level­12,­SAAS­Building
Email­:­abid_zafr@yahoo.com
UniversitiTeknologi­MARA­Malaysia
Professor Md. Sayaduzzaman, MCom­PhD
Professor Dr. Jamaliah Said, PhD
Department­of­Accounting­and­Information­Systems
Deputy­Director
University­of­Rajshahi
Research­and­Networking­
Bangladesh
Accounting­Research­Institute­(ARI)
Email­:­milons66@yahoo.com
Level­12,­SAAS­Building,­
UniversitiTeknologi­MARA­Malaysia
Muhammad Abdul Baker Chowdhury, MPH,­MPS,­M.Sc Zareen Tasnim
Clinical­Biostatistician Research­Assistant
Department­of­Emergency­Medicine Urban­Health­Research
University­of­Florida­College­of­Medicine 25i­Green­Road.­Dhaka.
PO­Box­100186,­Gainesville,­FL­32610­-­0186 Bangladesh
P:­(352)­265-5911-ex-31458,­F­:­(352)­265-5606 Email:zareen658558@gmail.com
Email­:­mchow023@fiu.edu
Tahsinul Abedin
Dr. Mohammad Jahid Hasan, MBBS­MPH Language­Editor
Executive­Director Department­of­Computer­Science­and­Engineering
Pi­Research Consultancy Center.­Dhaka.­Bangladesh The­University­of­Sydney
Cell.01757­81­89­73 NSW.­Australia
Email:­dr.jahid61@gmail.com Email:­sshuantait@gmail.com

Dr. Rumanna Rahman Jyoti, MBBS­MPH Copyright: Professor­Dr­Shahinul­Alam

Investigator
Urban­Health­Research
25/I­Green­Road.­Dhaka
Bangladesh
Email­:­rumanna.jyoti34@gmail.com

Kazi Musa, PhD­Scholar 

Accounting­Research­Institute­(ARI)
UniversitiTeknologi­MARA
Shah­Alam,­Malaysia,­40450
Email­:­kazimusa1@gmail.com
 Table of Content

Chapter No Title Page

1. Health­Systems­Ranking­and­Bangladesh 13
2. Universal­Health­Coverage­and­Progress­of
Bangladesh 20
3. Out-of-Pocket­Spending­and­Catastrophic­Health
Expenditure­in­Bangladesh 36
4. Sustainable­Development­Goal­(SDG)-3­and
Healthcare­Financing­in­Bangladesh­ 43
5. Designing­Health­Insurance­for­Healthcare
Financing­in­Bangladesh 55
6. Analysis­of­Health­Policy­and­Health­
Budget­of­Bangladesh 66
7. Political­Economy­of­Healthcare­Financing­in
Bangladesh 81
8. Healthcare­Financing­in­Bangladesh:­Current­
Status,­Health­Budget­and­Fiscal­Space­for­Health 89
9. Healthcare­Financing­in­Malaysia­ 99
10. Healthcare­Financing­in­India­ 118
11. Healthcare­Financing­in­Cuba­ 124
12. Healthcare­Financing­in­Turkey 130
13. Healthcare­Financing­in­The­United­Kingdom­­ 136
14. Healthcare­Financing­in­The­United­State­
of­America­ 142
15. Recommendation­for­a­Better­Healthcare­
Financing­System­for­Bangladesh­ 149
Chapter­1
Health Systems Ranking and
Bangladesh
Farhana­Begum1,­Shahinul­Alam2
Abstract
A­health­system­of­a­country­is­represented­by­all­the­organizations,
human­and­physical­resources­that­are­actively­engaged­in
producing­and­supplying­healthcare­services­to­the­population.
However,­health­systems­are­not­identical­around­the­globe
and­they­differ­in­numerous­aspects,­mostly­in­case
of­ governance,­ healthcare­ delivery­ and­ financing­ system.
Every­ category­ of­ health­ systems­ of­ individual­ countries
have­ some­ unique­ qualities­ which­ could­ work­ for­ other
countries­as­well.­Nevertheless,­to­learn­from­a­respective
health­system,­it­should­be­evaluated­at­first­to­figure­out
how­much­of­health­needs­of­the­country­are­being­met­by
that­ particular­ system.­ Different­ health­ system­ could­ be
compared­ after­ their­ performance­ are­ properly­ assessed.
And­the­best­way­to­appraise­the­quality­of­health­systems
is­to­rank­them­according­to­their­efficient­functioning­of­a
number­ of­ health­ system­ indicators.­ Although­ a­ few­ of
1. Dr. Farhana Begum. BCom (Honors) MCom. MPhil , PhD. Accounting, Postdoctoral Scholar,
Accounting Research Institute( ARI) UniversitiTeknologiMARA(UITM) 40450, Shah Alam Selangor,
Malaysia.
2. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University Dhaka. Bangladesh.
13 Global­Healthcare
ranking­procedures­are­existent,­the­universally­approved
one­ given­ by­ the­ World­ Health­ Organization­ placed
Bangladesh­ in­ the­ 88th position­ among­ 191­ member
states.­ The­ health­ system­ of­ Bangladesh,­ however,­ has
experienced­a­bunch­of­alterations­in­the­meantime,­which
therefore­ requires­ updated­ versions­ of­ health­ system
rankings.
Key­words:­Health­system;­Ranking;­Bangladesh;­World
health­report­2000.
The­most­widely­accepted­definition­of­health­system­was
given­ by­ the­ World­ Health­ Organization­ in­ the­ World
Health­Report­published­in­2000,­which­is­as­follows:­“all
the­activities­whose­primary­purpose­is­to­promote,­restore
or­ maintain­ health”­ (1).­ Different­ countries­ in­ the­ world
possess­health­systems­that­differ­from­each­other­due­to
the­ countries­ having­ disparate­ characteristics­ and­ unique
components­(2).­Apart­from­components­from­the­health
sector,­ numerous­ supplementary­ factors­ exist,­ such­ as
poverty,­ education,­ infrastructure,­ and­ the­ broader­ social
and­ political­ environment,­ which­ work­ as­ influences­ for
people’s­ health­ (3).­ Moreover,­ health­ systems­ can­ react
differently­and­in­changeable­approaches­to­the­actions­of
different­ determinants­ of­ the­ health­ system,­ which­ label
them­ as­ complex­ adaptive­ systems­ (4).­ For­ quite­ a­ long
time­it­has­been­a­significant­issue­of­interest­to­the­policy
makers­and­researchers­to­find­out­the­finest­health
systems­around­the­globe­so­that­other­countries­can­adopt
the­characteristics­of­those­health­systems­that­are­feasible
for­them.­
Bangladesh­possesses­a­health­system­that­is­pluralistic­in
case­ of­ service­ delivery,­ on­ the­ other­ hand,­ in­ case­ of
Global­Healthcare 14
healthcare­financing,­it­is­a­mixed­system.­The­Ministry­of
Health­and­Family­Welfare­(MoHFW)­is­the­supervisory
body­of­the­broader­health­system­of­Bangladesh­pursuing
the­ obligations­ of­ the­ constitution.­ Government,­ Private
sector,­ Non-Government­ Organizations­ ­ (NGOs)­ and foreign
donor­agencies­are­the­four­key­actors­of­the­health­system
functioning,­ service­ delivery­ and­ financing­ (5).­ All­ the
sectors­are­jointly­responsible­for­providing­curative,
preventive,­promotive­and­rehabilitative­services­to­some
extent.­Bangladesh,­nevertheless,­has­a­number­of­informal
service­providers,­e.g.­traditional­healers,­village­doctors,
quacks­ etc.­ along­ with­ formal­ providers.­ According­ to
recent­data,­the­health­sector­has­74985­health­personnel
working­in­the­entire­health­system,­where­20914­of­them
are­doctors­(6).­The­public­sector­has­a­dual­system
incorporating­health­services­and­family­planning­services
administrated­ by­ the­ Directorates­ General­ of­ Health
Services­(DGHS)­and­Family­Planning­(DGFP)­respectively,
under­ the­ MoHFW.­ Healthcare­ is­ primarily­ financed­ by
the­government,­foreign­funds­and­out-of-pocket­(OOP).
The­ health­ system­ of­ Bangladesh­ has­ been­ acting­ upon
well­ in­ some­ segments,­ whereas­ it­ is­ not­ depicting
executions­ that­ are­ up­ to­ the­ mark­ comparing­ to­ some
other­countries­of­the­world.­
Through­ attributing­ ranks,­ performances­ of­ distinctive
health­ systems­ could­ be­ assessed.­ However,­ it­ has­ been
quite­challenging­for­researchers­to­discover­uncomplecated,
practical­ and­ comprehensible­ ranking­ methods­ (7).
Several­ organizations­ have­ offered­ contrasting­ ranking
systems­ to­ evaluate­ the­ health­ system­ performances­ of
countries­around­the­world.­All­of­them­mostly­differ­due
to­ their­ unique­ methodologies­ in­ order­ to­ conduct­ the
15 Global­Healthcare
assessment.­ Usually,­ debates­ arise­ regarding­ selection­ of
indicators­and­presentation­of­information­in­rank­format.
Nonetheless,­there­is­no­methodological­gold­standard­for
ranking­ mechanisms­ (2).­Among­ numbers­ of­ health
system­rankings,­a­2018­study­attempted­to­figure­out­the
best­one­where­a­few­search­engines­identified­a­total­of­9
rankings­ (2).­ The­ researchers­ chose­ only­ 3­ from­ the­ 9
rankings,­ and­ dropped­ the­ others­ due­ to­ not­ considering
measurements­ of­ any­ financial­ aspect.­ The­ selected­ 3
rankings­ were,­ “World­ Health­ Report­ 2000–­ Health
Systems:­ Improving­ Performance”­ by­ the­ World­ Health
Organization,­ “Mirror,­ Mirror­ on­ the­ Wall”­ by­ the
Commonwealth­ Fund­ and­ “Most­ Efficient­ Health­ Care
2014”­by­Bloomberg­(2).­
World­ Health­ Report­ 2000–­ Health­ Systems:­ Improving
Performance”­by­the­World­Health­Organization­was­the
first­ of­ its­ kind­ in­ assessing­ health­ system­ performances
(1).­ It­ brought­ upon­ huge­ impact,­ as­ well­ as­ prompted
numbers­of­controversies­among­researchers­in­the­health
sector.­ In­ the­ ranking­ specified­ in­ World­ Health­ Report
2000,­countries­were­ranked­based­on­their­overall­health
system­ performances.­ The­ WHO­ generated­ 5­ indexes
which­incorporated­the­measures­of­five­goals:­the­overall
level­of­health;­the­distribution­of­health­in­the­population;
the­ overall­ level­ of­ responsiveness;­ the­ distribution­ of
responsiveness;­and­the­distribution­of­financial­contribution
(1).­To­appraise­the­overall­goal­attainment,­a­composite
index­ was­ calculated­ combining­ the­ individual
attainments of­the­5­goals.­For­judging­the­performances
of­the­health­sector­an­index­for­performance­on­level­of
health­ was­ calculated.­ Moreover,­ health­ expenditure­ per
capita­of­individual­countries­was­also­incorporated­in­the
Global­Healthcare 16
calculation.­ Combining­ all­ these­ indexes,­ a­ rank­ for
“Overall­ health­ system­ performance”­ was­ specified.
Bangladesh­ secured­ the­ 88th position­ among­ the­ 191
member­states­of­the­WHO.­For­Bangladesh,­the­level­of
health­and­distribution­of­health­were­in­the­rank­of­140
and­ 125­ respectively,­ whereas­ the­ ranks­ for­ level
and distribution­of­responsiveness­were­in­178­and­181.
Furthermore,­the­rank­for­fairness­in­financial­contribution
was­ in­ between­ 51­ to­ 52.­ In­ the­ meantime,­ health
expenditure­ per­ capita­ indicator­ and­ the­ performance­ of
the­health­system­of­Bangladesh­for­level­of­health­ranks
were­respectively­in­144­and­103.­Overall,­Bangladesh’s
health­system­performance­placed­the­country­in­the­88th
position­ combining­ the­ ranks­ of­ all­ the­ indicators.­ The
country­ was­ ranked­ ahead­ of­ most­ of­ its­ neighboring
countries­ like­ India,­ Pakistan,­ Nepal,­ Bhutan,­ Myanmar,
and­ Maldives,­ who­ attained­ 112th,­ 122nd,­ 150th,­ 124th,
190th and­ 147th positions­ respectively.­ However,
Singapore,­Malaysia­and­Sri­Lanka­were­ranked­healthier
than­ Bangladesh­ placing­ 6th,­ 49th and­ 76th(1).­ On­ the
other­hand,­the­USA­having­the­highest­per­capita­health
expenditure­ in­ the­ world,­ could­ not­ secure­ a­ position
among­ the­ top­ 10­ countries,­ and­ was­ ranked­ 37th, whereas
France­topped­the­ranking­attaining­the­1st position.­
Another­renowned­ranking­system­is­the­“Mirror,­Mirror
on­ the­ Wall”­ series­ by­ the­ Commonwealth­ Fund­ (8).
Commonwealth­ Fund­ had­ their­ first­ publication­ in­ 2004
and­the­last­one­was­published­in­2014.­Despite­being­one
of­ the­ acclaimed­ ranking­ of­ health­ care­ systems,­ it
includes­ barely­ a­ few­ numbers­ of­ countries,­ unlike­ the
ranking­ given­ by­ the­ WHO.­ The­ study­ comprehended
merely­11­following­countries:­Australia,­Canada,­France,
17 Global­Healthcare
Germany,­ the­ Netherlands,­ New­ Zealand,­ Norway,
Sweden,­ Switzerland,­ the­ United­ Kingdom,­ and­ the
United­States.­It­evaluated­the­following­5­dimensions­of
health­ care-­ Quality,­ Access,­ Efficiency,­ Equity­ and
Healthy­Lives.­The­United­States­was­listed­as­the­last­one
according­to­the­place,­where­the­UK­topped­the­ranking.
The­US­ranked­last­on­overall­ranking­and­last­or­close­to
last­on­4­of­the­5­dimensions.­A­further­ranking­was­given
by­ Bloomberg,­ entitled­ “Most­ Efficient­ Health­ Care
2014”.­ Life­ expectancy,­ relative­ per­ capita­ healthcare
expenditure­ and­ absolute­ per­ capita­ healthcare
expenditure­were­the­three­criteria­that­were­measured­to
rank­ the­ health­ systems­ of­ 51­ countries.­ Bangladesh,
however, was­not­taken­into­account­of­in­the­study­too.­­­
The­health­system­ranking­provided­but­the­WHO­is
considered­the­widely­acceptable­one­till­date­due­to­using
the­ most­ complete­ and­ transparent­ methodology,­ considering
multiple­aspects­of­health­systems,­as­well­as­incorporating
the­highest­number­of­countries­around­the­globe­(2).­The
ranking­revealed­health­sector­issues­that­Bangladesh­had
to­work­on­comparing­to­other­countries­and­bring­upon
reforms.­However,­passing­of­two­decades­after­the ranking
was­ published,­ the­ health­ sector­ scenario­ has­ changed.
Therefore,­ another­ ranking­ by­ the­WHO­ is­ expected­ in
order­to­figuring­out­the­lacking­of­health sectors­of
not­only­Bangladesh,­but­also­other­countries­on­a­global
scale.­­­
Global­Healthcare 18
References:
1.­ World­Health­Organization.­The­World­Health­Report­2000.­Healths­Systems:­Improving
Performance­[Internet].­Vol.­78.­2000.­Available­from:
http://www.who.int/whr/2000/en/whr00_en.pdf
2.­ Schütte­S,­Acevedo­PNM,­Flahault­A.­Health­systems­around­the­world­-­a­comparison­of
existing­health­system­rankings.­J­Glob­Health.­2018;8(1).­
3.­ World­Bank.­Healthy­Development:­The­World­Bank­Strategy­for­HNP­Results.­2007.­
4.­ Plesk­P,­Wilson­T.­Complexity,­leadership,­and­management­in­healthcare­organizations.
BMJ­[Internet].­2001;323(September):746–9.­Available­from:­
http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Complexity,+leader-
ship,+and+management+in+healthcare+organisations#2
5.­ World­Health­Organization.­Bangladesh­Health­System­Review.­Health­Syst­Transit.
2015;5(3):214.­
6.­ Management­Information­System,­DGHS,­MoHFW.­Health­Bulletin­2018.­;150-157.
Available­from:­www.dghs.gov.bd
7.­ Gray­SF,­Leung­GM.­Investing­in­health.­J­Public­Heal­(United­Kingdom).­
2012;34(3):319.­
8.­ Davis­K,­Stremikis­K,­Squires­D,­Schoen­C.­How­the­performance­of­the­U.S.­health­sys-
tem­compares­internationally.­Mirror,­Mirror­on­the­Wall:2014;1–31.­
19 Global­Healthcare
Chapter­2
Universal Health Coverage and
Progress of Bangladesh
Shahinul­Alam1­Zareen­Tasnim2
Abstract
In­ the­ age­ of­ Sustainable­ Development­ Goals­ (SDGs),
Universal­ Health­ Coverage­ (UHC)­ is­ one­ of­ the­ leading
interests­ worldwide.­ It­ characterizes­ accessibility­ to­ all
variations­ of­ healthcare­ for­ the­ entire­ population­ of­ a
country,­ where­ they­ don’t­ fall­ under­ financial­ distress­ in
the­ course­ of­ getting­ the­ services.­ Health­ is­ being­ given
the­ utmost­ importance­ in­ current­ world­ and­ all­ the
countries­ are­ now­ shifting­ their­ focus­ in­ the­ direction­ of
bringing­about­UHC.­UHC­is­best­elucidated­through­the
three­dimensions­representing­population­covered,­ranges
of­services­covered­and­healthcare­payments­covered­by­a
pooled­fund.­Along­with­other­countries­moving­forward
to­attaining­UHC,­Bangladesh­has­been­taking­initiatives
as­well.­Bangladesh­showed­marvelous­performance­in­the
Millennium­Development­Goals­(MDGs)­era,­and­at­this
instant,­UHC­being­a­goal­of­SDG,­it­is­greatly­anticipated
that­Bangladesh­would­be­able­to­reach­it­within­2030­as
proposed­ by­ the­ government­ if­ the­ country­ continues­ to
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
2. Zareen Tasnim, Research Assistant, Urban Health Research, 25/i Green Road. Dhaka,
Bangladesh
Global­Healthcare 20
have­ the­ current­ pace­ of­ development­ in­ reforming­ the
health­ system­ but­ must­ have­ to­ go­ through­ numerous
challenges.­ The­ journey­ to­ achieve­ the­ UHC­ is­ a­ long
way­ with­ huge­ challenges­ for­ Bangladesh­ will­ have­ to
overcome.­ Financing­ of­ UHC­ should­ be­ the­ state
responsibility on­the­priority­basis.
Key­ words:­ Universal­ Health­ Coverage;­ Bangladesh;
healthcare­financing.
Universal­ Health­ Coverage­ (UHC)­ is­ one­ of­ the­ major
targets­of­the­Sustainable­Development­Goals­(SDGs)­that
ensures­all­citizens­have­access­to­quality­health­services
when­needed­without­financial­risk.­UHC­is­not­an­ancient
term­ in­ the­ development­ arena­ as­ well­ as­ the­ healthcare
sector­of­the­world.­Several­alternative­theoretical phrasings,
e.g.­ Universal­ Health­ Care,­ Universal­ Health­ System,
Universal­Health­Care­Coverage­are­mentioned­in literatures
as­well­in­order­to­define­the­same­concept­for­years­(1).
All­of­those­refer­to­an­identical­concept,­which­proclaims
that­all­forms­of­health­care­should­be­accessible­to­each
and­every­individual­of­the­world­in­a­way­that­does­not
force­them­to­suffer­from­financial­hardship­or­fall­under
the­ poverty­ line­ due­ to­ paying­ for­ medical­ expenses
regardless­of­their­social­or­financial­context­(2).­Hence,
UHC­keeps­our­focus­not­only­on­the­basic­medical­care,
but­also­to­the­non-traditional­view­of­healthcare­including
service­delivery,­accessibility,­equity,­efficiency,­community
participation­and­financing­(3).
Although­ the­ term­ UHC­ is­ not­ too­ old,­ however,­ the
existence­of­its­notion­can­be­traced­back­in­World­Health
Organization’s­(WHO)­constitution­of­1948,­where­health
21 Global­Healthcare
was­affirmed­to­be­a­fundamental­human­right.­Health­was
reiterated­ as­ one­ of­ the­ fundamental­ human­ rights­ at­ the
Alma-Ata­ conference­ that­ held­ in­ 1978­ through­ the
“Health­for­All”­declaration­(2).­In­2005,­the­WHO­gave
recognition­ to­ UHC­ once­ again­ at­ the­ World­ Health
Assembly,­ and­ defined­ UCH­ in­ the­ report­ by­ the
Secretariat­as­follows:­“Universal­coverage­is­defined­as
access­ to­ key­ promotive,­ preventive,­ curative­ and
rehabilitative­health­interventions­for­all­at­an­affordable
cost,­ thereby­ achieving­ equity­ in­ access”­ (4).
Improvement­ of­ the­ health­ financing­ structures­ of­ the
member­ states­ was­ envisioned­ so­ that­ people­ do­ not­ get
trapped­ into­ economic­ hardship­ while­ paying­ for
healthcare.­ In­ the­ World­ Health­ Report­ 2010,­ the­ WHO
focused­on­constructing­health­financing­systems­around
the­world­with­raising­more­resources­targeting­to­achieve
UHC­ through ensuring­ equity­ and­ efficiency­ (2).­ The
World­ Health­ Report­ 2010­ created­ a­ huge­ impact
among­ countries­ and­ a­ range­ of policy­measurements
and­ interventions­ started­ in­ order­ to­ achieve­ UHC.­ As
soon­ as­ the­ period­ of­ Millennium­ Development­ Goals
(MDGs)­ ended­ in­ 2015­ and­ the­ era­ of­ Sustainable
Development­Goals­(SDGs)­initiated,­UHC­was­taken­as­a
target,­ target­ 3.8:­ “Achieve­ universal­ health­ coverage,
including­financial­risk­protection,­access­to­quality
essential­health-care­services­and­access­to­safe,­effective,
quality­ and­ affordable­ essential­ medicines­ and­ vaccines
for­all”­under­goal­no.­3­among­the­17­goals,­that­is­“Good
Health­and­Wellbeing”­(5).­Currently,­countries­all­around
the­ world­ are­ taking­ actions­ and­ developing­ their distinctive
health­systems­to­attain­UHC­by­2030­as­per­the­SDGs’
aim.­
Global­Healthcare 22

Figure 1: Three dimensions of UHC
Source: World Health Report 2010, WHO
In­ recent­ years,­ UHC­ has­ been­ a­ burning­ issue­ globally
and­countries­across­the­globe­are­working­deliberately­to
reform­health­systems­as­per­the­requisitions­of­achieving
it.­ According­ to­ many­ explanations­ and­ descriptions­ of
UHC,­ it­ tends­ to­ establish­ that­ all­ people­ of­ a­ country
should­be­able­to­receive­needed­healthcare­of­any­type­–
promotion,­ prevention,­ treatment,­ rehabilitation,­ at­ the
moment­they­require­it,­without­falling­into­financial
suffering­which­in­turn­might­bring­upon­impoverishment.
Moreover,­ UHC­ aims­ to­ not­ only­ address­ access­ and
affordability,­but­quality­of­care­in­addition.­The­WHO­has
proposed­ 3­ dimensions­ of­ UHC­ which­ are­ universally
portrayed­as­a­cube.­A­health­system­will­be­able­to­move
towards­ UHC­ if­ 3­ categories­ of­ coverage­ are­ expanded.
The­three­hands­of­the­cube­represent­the­3­dimensions­of
UHC,­where­the­breadth­of­the­cube­reflects­the population
23 Global­Healthcare
coverage;­the­depth­indicates­the­services­covered­and­the
height­shows­how­much­of­the­healthcare­cost­is­shared­or
covered­ (2,6).­ The­ box­ labeled­ “current­ pooled­ fund”­ is
the­ collection­ of­ financial­ resources­ collected­ through
contributions­from­prepayment­mechanisms­such­as­taxes
and­ insurance­ premiums.­ It­ refers­ to­ the­ current­ pooled
fund­of­a­hypothetical­country,­through­which­some­of­the
healthcare­services­are­being­reachable­to­a­chunk­of­the
population­and­a­part­of­the­healthcare­costs­are­covered
through­pre-payments­(2,6).­The­pre-payments­mechanisms
may­ vary­ from­ country­ to­ country­ including­ financing
from­ general­ taxation,­ social­ health­ protection­ schemes,
public-private­partnership­insurance­regulated­by governments
etc.­The­bigger­the­pooled­fund­will­be,­the­more­will­be
the­ coverage­ in­ each­ of­ the­ dimensions,­ as­ a­ result,­ the
journey­towards­universal­coverage­will­be­smoother­for­a
country­ (2).­ Pooling­ of­ funds­ ensures­ that­ the­ financial
risk­ is­ shared­ by­ all­ the­ contributors­ of­ the­ pool­ and
nobody­is­exposed­to­unbearable­economic­hardship­when
in­ need­ of­ healthcare.­ Furthermore,­ it­ helps­ to­ reduce
out-of-pocket­payment­at­the­point­of­receiving­services.
Most­ of­ the­ countries­ that­ have­ chosen­ risk­ pooling
mechanisms funded­by­government­or­quasi­government
sources­have­been­able­to­achieve­UHC­(2).­
The­breadth­of­the­cube­shows­the­portion­of­the­population
that­has­access­to­healthcare­services­of­the­country.­The
WHO­advises­to­undertake­required­for­incorporating­the
poor­and­susceptible­under­the­coverage­to­reach­further
towards­ UHC­ (6).­ Next­ in­ order,­ the­ array­ of­ healthcare
services­ available­ to­ the­ consumers­ reflecting­ the­ needs
and­demand­of­the­population­of­the­specific­countries­is
demonstrated­by­the­depth.­Researchers­have­recommended
Global­Healthcare 24
that­a­crucial­obligation­of­approaching­UHC­is­creation­of
an­“essential­benefit­package”­(6,7).­The­third­dimension
illustrates­the­proportion­of­the­cost­covered­through­the
height­ of­ the­ cube.­ It­ delineates­ the­ slice­ of­ healthcare
expenditure­of­a­country­that­can­be­covered­by­means­of
the­ pooled­ fund­ which­ has­ been­ created­ through­ pre-
payments. Generally,­ people­ of­ the­ countries­ that­ lack
health­ protection­ schemes­ have­ to­ spend­ out-of-pocket
payments­ and­ those­ who­ cannot­ pay­ for­ their­ healthcare
services­ drift­ away­ from­ the­ coverage.­ Individual­ countries,
however,­ has­ to­ make­ trade-offs­ between­ the­ three­ dimensions
according­to­the­population­need,­economic­and­political
contexts­of­the­country­and­reach­to­unique­combinations
in­ order­ to­ refine­ their­ health­ financing­ systems­ and
redesign­policies­in­view­of­that.­
Since­ 2010,­ more­ than­ 100­ countries­ have­ been­ offered
technical­ assistance­ regarding­ UHC­ by­ the­ World­ Bank
and­ the­ WHO­ (8).­ ­ Under­ the­ circumstances,­ the
governments of­nations­around­the­globe­initiated­agendas and
interventions,­ developing­ the­ healthcare­ financing­ strategies
being­ the­ preliminary­ steps.­ Different­ countries­ have
reached­ different­ levels­ of­ attaining­ UHC­ at­ by­ incorporating
UHC-inspired­health­system­reforms­at­different­paces.­In
2011­ at­ the­ 64th­ World­ Health­ Assembly­ (WHA),
the­ government of­Bangladesh­vowed­to­achieve­UHC
within­ 2030.­ In­ 2012,­ the­ Health­ Economics­ Unit­ of­ the
Ministry­ of­ Health­ and­ Family­ Welfare­ published­ the
Healthcare­ Financing­ Strategy­ 2012-2032­ entitled
“Expanding­ Social­ Protection­ for­ Health:­ Towards
Universal­Coverage”­(9).­
Target­of­UHC­defined­by­WHO­are­those­member­countries
should­achieve­by­2030­as­part­of­their­progress­and­every
25 Global­Healthcare
member­ state­ has­ committed­ to­ these­ goals.­ The­ targets
should­ be­ achieve­ at­ least­ 80%­ essential­ health-service
coverage­ for­ their­ entire­ population­ irrespective­ of­ the
economic­ status,­ gender,­ or­ place­ of­ residence,­ and­ full
protection­from­catastrophic­and­impoverishing­payment
for­health­services­by­2030.The­WHO­and­the­World­Bank
jointly­ proposed­ a­ framework­ for­ monitoring­ progress
towards­ UHC­ titled­ “Monitoring­ Progress­ towards
Universal­Health­Coverage­at­Country­and­Global­levels”
in­ 2014­ which­ aimed­ at­ estimating­ different­ countries’
UHC-advancements.­ The­ health­ experts­ of­ Bangladesh
executed­ slight­ modifications­ to­ match­ the­ unique
country-characteristics­ of­ Bangladesh­ and­ developed­ a
UHC monitoring­ tool­ exclusively­ for­ Bangladesh­ which
was­ led­ by­ Health­ Economics­ Unit,­ MOHFW,
Government­of­Bangladesh­(10).­In­order­to­evaluate­the
progress,­the­framework­suggests­assessing­service­coverage,
financial­risk­protection­coverage­and­equity­in­coverage
through­their­respective­indicators.­In­case­of­Bangladesh,
the­level­of­service­coverage­is­advised­to­be­assessed­by
measuring­ set­ of­ interventions­ related­ to­ MDGs­ and
Chronic­Conditions­and­Injuries­(CCIs)­along­with­other
indicators­ related­ to­ the­ 6­ building­ blocks­ of­ the­ health
system.­Interventions­related­to­MDGs­should­have­focus
on­ communicable­ diseases,­ reproductive­ health­ and
maternal and­ children­ nutritional­ status.­ On­ the­ other
hand,­the­indicators­for­CCIs­should­be­focused­on­NCDs,
mental­ health­ and­ injuries.­ To­ estimate­ the­ progress­ in
coverage­of­financial­risk­protection,­the­incidences­of
catastrophic health­expenditure­and­impoverishment­due
to­ OOP­ health­ payments­ should­ be­ measured.­The­ other
dimension­ to­ be­ measured­ is­ the­ equity­ in­ coverage­ that
has­ been­ ensured­ for­ the­ population.­ The­ framework
Global­Healthcare­26
suggests­ to­ take­ three­ primary­ elements­ in­ consideration
which­ are,­ income,­ gender­ and­ place­ of­ residence.
Indicators­ for­ each­ of­ these­ dimensions­ have­ been
proposed­ and­ refined­ multiple­ times­ as­ the­ UHC
monitoring­ tools­ before­ the­ health­ expert­ team­ of
Bangladesh­finalized­the­specific­and­definitive­indicators.
However,­ a­ recent­ comparative­ study­ on­ Bangladesh’s
Universal­Health­Coverage­(UHC)­monitoring­framework
with­ the­ global-level­ recommendations­ found­ that­ the
Bangladesh­framework­lack­indicators­related­to­palliative
care,­ mental­ health,­ cataract­ surgery,­ neglected­ tropical
dis eas es ,­ and­ meas ur ement­ of ­ s er v ice­ need,
an d recommended­to­include­the­mentioned­aspects­(11).
In­past­few­years,­the­health­sector­of­Bangladesh­showed
astonishing­successes­by­attaining­MDGs,­some­of­which
are­ also­ associated­ with­ UHC.­ Expansion­ of­ essential­ public
health­interventions­and­immunization­programs­has­been
determinants­ of­ decreased­ maternal­ and­ child­ mortality
rates.­A­study­conducted­on­movements­and­predictions­of
needles­of­universal­health­coverage­in­Bangladesh
estimated­ that­ by­ 2030­ coverage­ of­ better-quality­ water,
oral­ rehydration­ treatment,­ family­ planning­ facilities,
child­ vaccinations­ and­ the­ decline­ of­ tobacco­ usage­ will
achieve­ the­ 80%­ of­ the­ targets­ (12).­ Nonetheless,
little secondary­and­tertiary­service­coverage­is­available
in­the­country­(9).­Moreover,­there­barely­exists­any
pre-payment­mechanism­for­health­sector­in­the­country.
As­ proposed­ in­ the­ Healthcare­ Financing­ Strategy­ 2012-
2032,­ a­ pilot­ program-­ Shasthyo­ Shuroksha­ Karmasuchi
(SSK)­is­currently­running­in­three­Upazila­of­the­country
by­ the­ government,­ which­ is­ a­ Social­ Health­ Protection
Scheme­for­people­who­are­below­the­poverty­line­(9).­An
27 Global­Healthcare
insignificant­fraction­of­the­population­takes­private­insurance
schemes,­accounting­for­0.2%­of­total­health­expenditure
(9).­ Whereas­ about­ 71.82%­ of­ the­ healthcare­ costs­ are
being­ forced­ to­ be­ paid­ out-of-pocket­ as­ a­ result­ of
absence­ of­ necessary­ health­ protection­ mechanisms.­ A
sizeable­ portion­ of­ the­ populace­ misses­ out­ healthcare
facilities­ when­ in­ need­ due­ to­ not­ being­ able­ to­ pay­ and
consequently­ they­ fall­ into­ impoverishment.­ Studies
revealed­that,­significant­inequity­prevails­in­the­access­of
formal­healthcare­use­among­the­richest­and­poorest­quintiles
in­ the­ rural­ areas­ of­ Bangladesh­ (13).­ Projections­ demonstrates
that­about­23%­of­households­in­the­country­will­undergo
financial­ suffering­ as­ a­ consequence­ of­ paying­ OOP­ by
2030,­ indicating­ that­ if­ the­ policy-makers­ of­ the­ country
do­ not­ focus­ on­ reforming­ health­ financing­ mechanisms
immediately,­Bangladesh­will­not­able­to­reach­UHC­(12).
Moreover,­ in­ recent­ years,­ the­ worldwide­ prevalence­ of
Non-Communicable­ Diseases­ (NCDs)­ is­ increasing
hurriedly.­ Bangladesh­ is­ likewise­ fronting­ an­ equivalent
scenario.­According­to­researchers,­along­with­restructuring
health­ financing­ system,­ government­ should­ look­ into
addressing­prevention­of­NCDs­by­strengthening­healthcare
facilities­and­implementing­prevention­and­risk­reduction
services­ in­ the­ view­ of­ tackling­ NCDs­ issues­ (12).
Emergence­ and­ reemergence­ of­ infectious­ disease,
epidemics­ and­ pandemics­ necessitates­ special­ attention
like­COVID­19.
The­Constitution­of­the­People’s­Republic­of­Bangladesh
guarantees­that­‘Health­is­the­basic­right­of­every­citizen
of­ the­ Republic’.­Article­ 15­ of­ the­ constitution­ says,­ “It
shall­be­a­fundamental­responsibility­of­the­state­to­attain,
through­planned­economic­growth,­a­constant­increase­of
Global­Healthcare 28
productive­forces­and­a­steady­improvement­in­the­material
and­cultural­standard­of­living­of­the­people”.­With­a­view
to­ securing­ its­ citizens­ –­ (a)­ the­ provision­ of­ the­ basic
necessities­of­life,­including­food,­clothing,­shelter,­education
and­medical­care;­(b)­the­right­to­work,­that­is­the­right­to
guaranteed­ employment­ at­ a­ reasonable­ wage­ having
regard­to­the­quantity­and­quality­of­work;­(c)­the­right­to
reasonable­rest,­recreation­and­leisure;­and­(d)­the­right­to
social­security,­that­is­to­say,­to­public­assistance­in­cases
of­undeserved­want­arising­from­unemployment,­illness­or
disablement,­or­suffered­by­widows­or­orphans­or­in­old
age,­or­in­other­such­cases”.­Article­16.­States­that­“The
State­shall­adopt­effective­measures­to­bring­about­a­radical
transformation­in­the­rural­areas­through­the­promotion­of
an­agricultural­revolution,­the­provision­of­rural­electrification,
the­ development­ of­ cottage­ and­ other­ industries,­ and­ the
improvement­ of­ education,­ communications­ and­ public
health,­ in­ those­ areas,­ so­ as­ progressively­ to­ remove­ the
disparity­in­the­standards­of­living­between­the­urban­and
the­rural­areas”.­Article­18­states­that”­1.­The­State­shall
regard­ the­ raising­ of­ the­ level­ of­ nutrition­ and­ the
improvement of­public­health­as­among­its­primary­duties,
and­in­particular­shall­adopt­effective­measures­to­prevent
the­consumption,­except­for­medical­purposes­or­for­such
other­purposes­as­may­be­prescribed­by­law,­of­alcoholic
and­other­intoxicating­drinks­and­of­drugs­which­are­injurious
to­ health.­ 2.­ The­ State­ shall­ adopt­ effective­ measures­ to
prevent­ prostitution­ and­ gambling”.­ The­ third­ goal­ and
objective­of­the­National­Health­Policy­2011­is­to­ensure
optimum­quality,­acceptance,­and­availability­of­primary
healthcare­ and­ governmental­ medical­ services.­ The
Ministry­of­Health­and­Family­Welfare­(MoHFW)­is
currently­ implementing­ its­ fourth­ Sector­ Program­ titled
‘4th­Health,­Population­and­Nutrition­Sector­Program­(4th
29 Global­Healthcare
HPNSP)’­ covering­ a­ 5.5-year­ period­ between­ January
2017­ and­ June­ 2022,­ at­ an­ estimated­ cost­ of­ US$­ 14.7
billion.The­ 4th­ HPNSP­ is­ built­ upon­ the­ existing
achievements to­ improve­ equity,­ quality,­ and­ efficiency
with­a­view­to­moving­gradually­towards­UHC­(14).
Even­though­Bangladesh­has­shown­progress­in­a­number
of­healthcare­aspects,­however,­a­lot­more­is­yet­to­be
concentrated­on­and­relevant­interventions­and­actions­are
yet­ to­ be­ undertaken.­ The­ advancements­ that­ have­ been
attained­ till­ now­ should­ be­ sustained­ and­ a­ number­ of
fine-tunings­and­health­system­reforms­should­be­done­by
the­government­in­order­to­ensure­Bangladesh’s­achievement
of­ UHC­ by­ 2032.Financing­ of­ UHC­ should­ be­ the­ state
responsibility­on­the­priority­basis.
Case Study of UHC in Bangladesh
Ever­ since­ the­ World­ Health­ Report­ 2010­ brought­ upon
UHC­ as­ a­ major­ health­ related­ issue,­ the­ heath­ sectors
from­ countries­ around­ the­ world­ has­ initiated­ policies,
projects­and­intervention­in­order­to­reform­the­total­health
systems­ and­ achieve­ UHC.­ The­ government­ of
Bangladesh,­has­targeted­to­achieve­it­within­2032­as­per
the­Healthcare­Financing­Strategy­2016-2032.­However,­it
has­been­long­since­Bangladesh­started­to­move­towards
attaining­UHC­and­to­measure­and­evaluate­the­progress,
the­ government­ has­ proposed­ the­ Framework­ for
Monitoring­Progress­towards­Universal­Health­Coverage
in­ Bangladesh.­ The­ framework­ is­ for­ monitoring­ the
whole­health­system­of­the­country­concentrating­on­the
inputs,­ outputs,­ outcomes­ and­ impacts­ of­ interventions
implemented­in­different­categories­and­areas­of­the­entire
system­in­order­to­move­towards­UHC.
Global­Healthcare 30
The­ framework­ has­ provided­ 43­ indicators­ under­ the­ 4
sections­ which­ are­ the­ inputs,­ outputs,­ outcomes­ and
impacts.­ Each­ of­ the­ 4­ sections­ has­ several­ other
categories which­ are­ comprised­ by­ the­ 43­ indicators­ in
total.­Current­state­of­all­the­indicators­are­given­below:

Input and process

Section: Health Workforce

31 Global­Healthcare Global­Healthcare 32
33 Global­Healthcare Global­Healthcare 34
 Chapter­3

Out-of-Pocket Spending and

Catastrophic Health Expenditure
References:
1.­ Abiiro­GA,­De­Allegri­M.­Universal­health­coverage­from­multiple­perspectives:­A­synthesis in Bangladesh
Shahinul­Alam1,­Zareen­Tasnim2
of­conceptual­literature­and­global­debates.­BMC­Int­Health­Hum­Rights.­2015;15(1):1–7.­
2.­ WHO­ (World­ Health­ Organization).­ The­ World­ Health­ Report.­ Health­ Systems­ Financing:
The­path­to­universal­coverage.­2010.­

Abstract:
3.­ Odugleh-kolev­A,­Parrish-sprowl­J.­Universal­health­coverage­and­community­engagement.
Bull­World­Health­Organ.­2018;(May):660–1.­
4.­ Fifty-eighth­World­Health­Assembly.­Social­health­insurance:­Sustainable­health­financing,
The­amount­spent­by­the­consumer­from­his­own­pocket­at
the­ point­ of­ use­ of­ the­ service­ is­ known­ as­ the­ Out-of-
universal­coverage­and­social­health­insurance.­World­Health­Organization.­2005.­

5.­ World­Health­Organization.­SDG­3:­Ensure­healthy­lives­and­promote­wellbeing­for­all­at­all
ages­[Internet].­2017.­Available­from:­https://www.who.int/sdg/targets/en/
Pocket­(OOP)­health­expenditure. OOP­in­Bangladesh­is
6.­ WHO­ (World­ Health­ Organization).­The­World­ Health­ Report.­ Primary­ Health­ Care:­ Now 67%­and­that­is­highest­in­this­region. The­OOP­ranges­in
Bangladesh­from­64­to­71.82%­in­different­years.­World
More­Than­Ever.­2008.­
7.­ Ochalek­J,­Manthalu­G,­Smith­PC.­Squaring­the­cube:­Towards­an­operational­model­of
optimal­universal­health­coverage.­J­Health­Econ.­2020;­ Health­ Organization­ (WHO)­ recommends­ that­ OOP
spending should­ not­ exceed­ 15-20%­ of­ the­ total­ health
8.­ WHO,­World­Bank.­Tracking­universal­health­coverage:­first­global­monitoring­report.­2015.­
9.­ Health­Economics­Unit­Ministry­of­Health­and­Family­Welfare­Government­of­the­People’s
Republic­ of­ Bangladesh.­ Health­ Care­ Financing­ Strategy­ 2012-2032.­ Expanding­ Social expenditure­ of­ a­ country. About­ 5.7­ million­ households
are­being­forced­in­to­poverty­due­to,­catastrophic­health
Protection­for­Health?:­Towards­Universal­Coverage.­2012.­
10.­ Health­ Economics­ Unit,­ Ministry­ of­ Health­ and­ Family­ Welfare,­ Govt.­ of­ the­ People’s
Republic­ of­ Bangladesh.­ Framework­ for­ Monitoring­ Progress­ towards­ Universal­ Health
expenditure­each­year­in­Bangladesh.­Catastrophic­health
expenditure­occurs­when­the­healthcare­cost­is­exceedingly
Coverage­in­Bangladesh.­2014.­
11.­ Gupta­R­Das,­Shahabuddin­A.­Measuring­Progress­Toward­Universal­Health­Coverage:­Does
the­ Monitoring­ Framework­ of­ Bangladesh­ Need­ Further­ Improvement?­ Cureus.
2018;10(1):1–8.­
inflated­ in­ a­ manner­ so­ that­ people­ have­ to­ pay­ OOP
12.­ Rahman­MS,­Rahman­MM,­Gilmour­S,­Swe­KT,­Krull­Abe­S,­Shibuya­K.­Trends­in,­and payments­cutting­down­their­necessary­consumption­and
depending­ on­ debts.­ Increase­ budgetary­ allocation,
projections­of,­indicators­of­universal­health­coverage­in­Bangladesh,­1995–2030:­a­Bayesian
analysis­of­population-based­household­data.­Lancet­Glob­Heal.­2018;6(1):e84–94.­
Universal­ Health­ Coverage­ (UHC)­ by­ the­ government,
social­ coverage,­ health­ insurance­ by­ public­ private
13.­ Hamid­SA,­Ahsan­SM,­Begum­A,­Asif­CA­Al.­Inequity­in­formal­health­care­use:­evidence
from­rural­Bangladesh.­J­Int­Dev.­2015;27:36–54.­
14.­­­­Health­Bulletin,­2018.Directorate­General­of­Health­Services­(DGHS),­Ministry­of­Health­and
Family­Welfare­Government­of­the­People’s­Republic­of­Bangladesh
partnership­may­solve­this­painful­situation.
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, bangabandhu Sheikh
Mujib Medical University, Dhaka. Bangladesh.

2. ZareenTasnim, Research Assistant, Urban Health Research, 25i Green Road. Dhaka, Bangladesh

35 Global­Healthcare Global­Healthcare 36
Key words: Out-of-Pocket­ (OOP)­ health­ expenditure;
Bangladesh;­ health­ expenditure;­ catastrophic­ health
expenditure.
Spending­ very­ few­ on­ health­ expenditures,­ Bangladesh
has­made­commendable­improvement­in­the­health­sector
lately.­The­decrease­of­child­and­maternal­mortality­rates
in­ recent­ years­ has­ been­ exemplary.­ Nevertheless,­ the
health­sector­of­the­country­is­undergoing­some­hurdles,
among­ which,­ one­ of­ the­ most­ horrifying­ issue­ is­ the
excessive­amount­of­Out-of-Pocket­(OOP)­health spending.
The­ amount­ spent­ on­ healthcare­ that­ is­ paid­ by­ the
consumer­from­his­own­pocket­at­the­point­of­use­of­the
service­ is­ known­ as­ the­ OOP­ health­ expenditure.­ OOP
payments­ work­ as­ a­ source­ of­ financing­ of­ healthcare,
being­a­part­of­cost­of­the­service­and­functioning­of­the
health­ system.­ Commonly,­ user­ fees­ for­ public­ services,
physician­fees,­cost­of­medicines­and­diagnostic­tests­and
cost­sharing­of­insurance­comprise­the­OOP­expenditures.
Even­though­some­degree­of­OOP­spending­is­an­aid­for
the­ efficient­ execution­ of­ health­ system,­ inefficiency
arises­when­the­amount­is­unregulated,­and­turns­out­to­be
excessively­high.­WHO­recommends­that­OOP­spending
should­not­exceed­15-20%­of­the­total­health­expenditure
of­a­country­(1).­However,­this­is­not­the­scenario­in­most
developing­ countries­ where­ prepayment­ mechanisms­ are
lacking;­ as­ a­ consequence,­ OOP­ payments­ constitute­ the
prime­share­of­healthcare­financing­(2).­Lately,­numerous
studies­ have­ been­ conducted­ regarding­ OOP­ payments
globally.­ A­ study­ found­ that,­ in­ Kenya,­ OOP­ payments
push­ around­ 1.48­ million­ people­ below­ the­ national
poverty line­ for­ catastrophic­ health­ expenditure­ (3).­ In
Nepal­ and­ Vietnam,­ the­ OOP­ expenditures­ absorb
37 Global­Healthcare
one-third­ or­ more­ of­ the­ total­ health­ expenditure­ (4).
Morocco­being­a­lower-middle­income­country­constitutes
more­ than­ half­ of­ its­ total­ health­ expenditure­ by­ OOP
payments­(5).­According­to­World­Bank­and­as­claimed­by
the­ National­ Health­Accounts­ it­ is­ estimated­ that­ OOP in
Bangladesh­ is­ 67%­ and­ that­ is­ highest­ in­ this­ region,
followed­by­India­with­62%­and­far­away­from­Maldives
with­ its­ 18%.­ OOP is­ composed­ of­ spending­ 69.4­ %­ for
medicines. Globally,­25­million­households­push­towards
poverty­each­year­for­health­care­financing.­In­Bangladesh
5.7­million­being­forced­in­to­poverty­due­to,­catastrophic
health­expenditure­each­year.
OOP has­ relentlessly­ been­ the­ leading­ component­ of­ the
total­healthcare­expenditure­in­Bangladesh.­In­the­records
of­ World­ Bank,­ the­ percentage­ is­ OOP spending­ in
Bangladesh­ was­ around­ 71.82%­ in­ 2016.­ Figure­ 1
illustrates­ the­ trend­ of­ OOP expenditure­ in­ Bangladesh.
The­amount­has­been­increasing­constantly­for­a­long period
of­ time.­ Following­ an­ increasing­ trend,­ it­ reached­ to
71.89%­of­the­total­health­expenditure­by­2016.­The­major
portion­ of­ OOP in­ Bangladesh­ is­ spent­ behind­ drugs.
Although­the­percentage­has­declined­slightly­from­78%
in­ 1997­ to­ 69%­ in­ 2015,­ yet,­ it­ continues­ to­ be­ biggest
share­ of OOP expenditures­ (6).­Apart­ from­ the­ drug
outlays,­curative­care­accounts­for­a­fair­amount­of­OOP­in
Bangladesh.­In­2015,­in-patient­curative­care­expenditure and
out-patient­curative­care­expenditure­contributed­12%­and
11%­ to­ the­ OOP expenditure­ respectively­ (6).­ The
percentage­ spent­ for­ out-patient­ curative­ care­ remained
more­ or­ less­ around­ the­ same­ during­ 1997­ to­ 2015,
whereas­the­share­of in-patient­curative­care­expenditure
increased­ progressively­ from­ 5%­ to­ 13%­ in­ the­ stated
Global­Healthcare 38
period­ (6).­ According­ to­ Bangladesh­ National­ Health
Accounts­1997-2015,­the­plausible­causes­of­the­increase
in-patient­ curative­ care­ spending­ are­ higher­ costs­ of
healthcare­in­private­facilities­and­the­tendency­of­seeking
healthcare­ from­ private­ sector.­A­ study­ conducted­ using
Household­Income­and­Expenditure­Survey­(HIES)­2011
found­that­average­household­OOP­expenditure­per­month
was­644­BDT­(7).­The­study­also­found­that­rural­households
had­significantly­higher­average­OOP­healthcare­spending
(709.1­ BDT),­ whereas­ OOP­ payments­ of­ the­ urban
households were­comparatively­lower­(468.5­BDT)­(7).
Source:­World­Bank­Data
Figure 1: Out-of-Pocket expenditure in Bangladesh as a % of
total health expenditure
The­ uncertainty­ and­ unpredictability­ associated­ with
healthcare­ expenditure­ forces­ households­ towards
financial catastrophe­ when­ it­ is­ relatively­ large­ and­ no
prepayment­ mechanism­ is­ prevalent.­ Catastrophic­ health
expenditure­occurs­when­the­healthcare­cost­is­exceedingly
inflated­ in­ a­ manner­ so­ that­ people­ have­ to­ pay­ OOP
payments­cutting­down­their­necessary­consumption­and
depending­on­debts­(8).­In­extreme­situations­households
39 Global­Healthcare
are­ exposed­ to­ impoverishment­ trying­ to­ cover­ their
healthcare­ expenditure.­ Catastrophic­ health­ expenditure
can­occur­in­countries­from­all­income­levels.­Even­if­the
amount­ is­ not­ so­ sky-scraping,­ healthcare­ spending­ may
appear­ as­ catastrophic.­ Relatively­ small­ amount­ of
healthcare spending­ happens­ to­ be­ a­ reason­ of­ financial
catastrophe­ for­ poor­ households,­ similarly­ for­ counties
having­lower­income­levels­(9).­There­are­a­few­thresholds
to­ measure­ healthcare­ expenditures­ that­ are­ catastrophic,
that­ are­ commonly­ used.­ Generally,­ when­ the­ healthcare
expenditure­ exceeds­ 40%­ of­ a­ household’s­ non-food
expenditure,­ the­ expenditure­ is­ known­ as­ catastrophic
(10).­A­study­on­89­countries­estimated­that,­per­year­globally
150­ million­ people­ face­ financial­ catastrophe­ due­ to
burden­of­OOP­payments­and­approximately­100­million
are­ revealed­ to­ impoverishment­ (9).In­ the­ same­ study,­ it
was­ found­ that­ the­ incidence­ of­ catastrophic­ healthcare
expenditure­ in­ low-,­ middle-­ and­ high­ income­ countries
were­ correspondingly­ 3.1,­ 1.8­ and­ 0.6%­ (9).­Around­ 37
million­people­are­dragged­below­the­poverty­line­by­OOP
payments­in­India­(11).­In­Bangladesh,­due­to­high­level­of
OOP­ payments­ and­ absence­ of­ risk­ pooling­ mechanisms,
incidence­ of­ catastrophic­ health­ expenditure­ has­ turned
out­to­be­a­huge­setback­for­the­health­sector.­Bangladesh
appeared­ as­ the­ most­ affected­ country­ with­ the­ highest
incidence­of­catastrophic­health­expenditure­of­15.6%­(12)
A­ study­ based­ on­ a­ survey­ conducted­ in­ Rajshahi
city discovered­that­approximately­9%­of­the­households
were­ incurring­ catastrophic­ health­ expenditures­ at­ the
threshold­ of­ 40%­ (13).­ Another­ study­ based­ on­ HIES
observed­that­14.2%­of­households­incurred­catastrophic
health­expenditures­nationally,­and­it­was­more­intense­in
rural­(16.3%)­than­urban­(8.6%)­populations­(7).­In­addition,
Global­Healthcare 40
households­ with­ lower­ socioeconomic­ status­ were­ more
prone­ to­ catastrophic­ health­ spending.­ In­ two­ studies­ of
2006­ and­ 2010,­ OOP­ payments­ contributed­ to­ 3.8%­ (2)
and­ 3.5%­ (7)­ respectively.­ Therefore,­ although
Bangladesh­ is­ having­ robust­ economic­ growth­ and­ the
poverty­ rate­ is­ declining,­ not­ much­ reduction­ in­ poverty
could­be­attributed­to­health­sector­due­to­the­OOP
payments­(2).­­­
Bangladesh­ National­ Health­ Policy­ 2011­ states­ in­ its
vision­ that­ health­ being­ a­ human­ right;­ it­ should­ be
ensured­ regardless­ of­ age,­ gender,­ race­ and­ economic
status. This­leads­us­to­Universal­Health­Coverage­(UHC),
which­ is­ a­ target­ goal­ of­ Sustainable­ Development­ Goal
(SDG)­3.­UHC­refers­to­accessibility­to­quality­healthcare
services­for­all,­without­falling­into­financial­catastrophe
through­bearing­high­OOP­payments.­According­to­Health
Policy­ the­ OOP­ in­ Bangladesh­ should­ be­ gradually
reduced­ to­ 32%­ as­ advised­ by­ WHO.­ Bangladesh,­ thus,
will­be­able­to­attain­UHC,­if­the­amount­of­towering­OOP
payments­can­be­controlled.­UHC­must­be­ensured­by­the
government­fund.­Social­coverage,­health­insurance­with
contribution­of­public­and­private­partnership­could­solve
this­problem­in­near­future.
References:
1.­ Xu­Ke,­Priyanka­S,­Matthew­J,­Chandika­I­et­al. Exploring­the­thresholds
of­health­expenditure­for­protection­against­financial­risk. World health
report, Background Paper 2010;19: 328–333.
2.­ van­Doorslaer­E,­O’Donnell­O,­Rannan-Eliya­RP­et­al.­Effect­of
payments­for­health­care­on­poverty­estimates­in­11­countries­in­Asia:
an­analysis­of­household­survey­data.­Lancet.­2006;368(9544):1357–64.­
3.­ Chuma­J,­Maina­T.­Catastrophic­health­care­spending­and­impoverishment
in­Kenya.­BMC­Health­Serv­Res.­2012;12:413.­
41 Global­Healthcare
4.­ Doorslaer­E­Van,­O’Donnell­O,­Rannan-Eliya­RP,­et­al.­Catastrophic
payments­for­health­care­in­Asia.­J­Health­Econ.
2008;1131(2007):1127–31.­
5.­ Oudmane­M,­Mourji­F,­Ezzrari­A.­The­impact­of­out-of-pocket­health
expenditure­on­household­impoverishment:­Evidence­from­Morocco.
Int­J­Health­Plann­Manage.­2019;(May):1–17.­
6.­ Health­Economics­Unit­Ministry­of­Health­and­Family­Welfare
Government­of­the­People­’­s­Republic­of­Bangladesh.­Bangladesh
National­Health­Accounts­1997-2015.­Vol.­306.­2015.­
7.­ Khan­JAM,­Ahmed­S,­Evans­TG.­Catastrophic­healthcare­expenditure
and­poverty­related­to­out-of-pocket­payments­for­healthcare­in
Bangladesh-­A­n­estimation­of­financial­risk­protection­of­universal
health­coverage.­Health­Policy­Plan.­2017;32(8):1102–10.­
8.­ World­Health­Organization.­Technical­Briefs­for­Policy-Makers:
Designing­Health­Financing­Systems­to­Reduce­Catastrophic­Health
Expenditure.­2005.­
9.­ Xu­K,­Evans­DB,­Carrin­G,­Aguilar-Rivera­AM,­Musgrove­P,­Evans­T.
Protecting­households­from­catastrophic­health­spending.­Health­Aff.
2007;26(4):972–83.­
10.­ Xu­K,­Evans­DB,­KawabatK,­ZeramdiniR,­Klavus­J,­Murry­CJL.
Household­catastrophic­health­expenditure:­a­multicountry­analysis.
Lancet2003;­362:111–17
11.­ Flores­G,­Krishnakumar­J,­O’Donnell­O,­Doorslaer­E­Van.­Coping­with
health-care­costs:­implications­for­the­measurement­of­catastrophic
health­expenditure­and­poverty.­J­Health­Econ.
2008;1131(2007):1127–31.­
12.­Van­Doorslaer­E,­O’Donnell­O,­Rannan-Eliya­RP­et­al.­­Catastrophic
payments­for­health­care­in­Asia.­Health­Economics­2007;­16:­1159–84.
13.­ Rahman­MM,­Gilmour­S,­Saito­E,­Sultana­P,­Shibuya­K.­Health-
Related­Financial­Catastrophe,­Inequality­and­Chronic­Illness­in
Bangladesh.­PLoS­One.­2013;8(2).­
Global­Healthcare 42
Chapter­4
Sustainable­Development­Goal
(SDG)-3­and­Healthcare­
Financing­in­Bangladesh
Shahinul­Alam1,­Farhana­Begum2,­
Rumanna­Rahman­Jyoti3
Abstract:
The­ Sustainable­ Development­ Goals­ (SDGs)­ were
adopted in­ September,­ 2015­ by­ the­ United­ Nation’s
General­ Assembly.­ These­ includes­ global­ direction­ for­ 17
development goals,­ one­ of­ which,­ SDG­ 3,­ focuses­ on
health.­ Sustainable­ Development­ Goal-3­ which­ is­ “to
ensure­ healthy­ lives­ and­ promote­ wellbeing­ for­ all­ at­ all
ages”­ indicates­ to­ endorse­ physical­ and­ mental­ health
and­ wellbeing­ and­ to­ enhance­ life­ expectancy­ for­ all­ by
achieving­Universal­Health­Coverage­(UHC)­and­accessing
to­ quality­ health­ care.­ The­ estimated­ additional­ cost­ per
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of
Hepatology, Bangabandhu Sheikh Mujib Medical University
Dhaka. Bangladesh.
2. Dr. Farhana Begum. BCom (Honors) MCom. MPhil , PhD. Accounting,
Postdoctoral Scholar, Accounting Research Institute( ARI)
UniversitiTeknologiMARA(UITM) 40450, Shah Alam Selangor, Malaysia.
3. Dr. Rumanna Rahman Jyoti MBBS. MPH, Investigator, Urban Health
Research, 25i Green Road. Dhaka, Bangladesh
43 Global­Healthcare
person­ per­ year­ is­ $41­ to­ $58­ with­ the­ total­ health-care
spending­ would­ increase­ to­ a­ population-weighted­ mean
of­$271­per­person­to­achieve­SDG­3.­Per­capita­for­health
expenditure­Bangladesh­was­34­US­dollars­in­2016.­So­we
have­ to­ mobilize­ huge­ resources­ to­ ensure­ UHC­ from
private­ and­ public­ sectors.­ So­ health­ budget­ should­ be­ 3
times­ higher­ the­ present­ allocated­ amount­ that­ would­ be
15%­of­total­national­budget.
Key words: Sustainable­ Development­ Goals­ (SDGs);
Universal­Health­Coverage­(UHC);­healthcare­financing;
Bangladesh;­health­budget.
About­seventy-five­years­ago,­after­witnessing­the­devastation
of­World­War­II,­United­Nations­had­been­formed­as­a­call
for­action­to­change­our­world­by­the­world­leaders.­From
the­ remnants­ of­ war­ and­ disunion,­ the­ United­ Nations
vowed­to­uphold­universal­harmony­and­security,­develop
relations­amongst­nations,­promote­collaboration­between
states­ with­ the­ intention­ of­ solving­ social,­ financial,
cultural­or­global­humanitarian­problems­(1).­As­a­part­of
this­ giant­ venture,­ in­ 2000­ Millennium­ Development
Goals­popularly­known­as­MDGs­were­undertaken­which
furnished­ a­ significant­ outline­ for­ development.­ Though
noteworthy­growth­and­progress­had­been­noticed­to­some
extent­but­the­unevenness­of­the­advancement­predominantly
in­Africa,­least­developed­countries,­landlocked­developing
countries­ and­ small­ island­ evolving­ states­ and­ some
off-track­ goals­ mostly­ those­ related­ to­ new­ born,­ child,
maternal­ and­ reproductive­ health­ left­ MDGs­ with­ not
much­ glory.­With­ this­ scenario­ open;­ on­ the­ verge­ of­ its
seventieth­anniversary,­the­United­Nations­at­its­headquarter
in­New­York­with­the­presence­of­the­Heads­of­Countries
Global­Healthcare 44
and­ higher­ representatives­ announced­ the­ new­ global
Sustainable­ Development­ Goals­ from­ 25th to­ 27th
September,­2015­with­full­commitment­for­the­execution
of­ this­ agenda­ by­ 2030.­ The­ Sustainable­ Development
Goals­ (SDGs)­ were­ shaped­ upon­ the­ attainments­ of­ the
MDGs­ and­ further­ addressed­ to­ pursue­ the­ incomplete
tasks.­
With­ the­ determination­ of­ creating­ an­ equitable­ world
where­all­individuals­must­relish­a­basic­standard­of­living;
the­ brave,­ transformative­ and­ ambitious­ measures­ were
considered­ through­ the­ 17­ Sustainable­ Development
Goalsand­169­targets­with­241­indicators.­This­new­universal
agenda­had­come­into­account­on­1st January­of­2016­and
guided­the­choices­of­the­world­leaders­since­then­and­will
be­ continuing­ to­ do­ so­ for­ the­ next­ 15­ years.­ These
integrated and­indivisible­sustainable­goals­acknowledged
that­ every­ nation­ should­ be­ freely­ exercising­ complete
permanent­ sovereignty­ over­ all­ its­ wealth,­ natural
resources­and­economic­activity­to­implement­the­agenda
for­the­full­benefit­of­all­as­well­as­our­future­generations.
Over­two­years­of­rigorous­public­consultation­with­civil
society­ and­ other­ stakeholders’­ engagement­ around­ the
world,­this­agenda­is­a­plan­of­action­particular­attention
to­the­voices­of­the­underprivileged­and­most­vulnerable
people­(1).­
To­demolish­the­rising­discriminations­within­and­among
countries­ and­ to­ combat­ the­ enormous­ inequalities­ of
wealth­and­power,­there­are­5P­included­in­SDGs:­people,
planet,­prosperity,­peace­and­partnership­which­elaborates
the­ending­of­poverty­and­hunger­among­people,­protecting
45 Global­Healthcare
the­planet­from­degradation,­ensuring­prosperous­life­for
all­ human­ beings,­ fostering­ a­ peaceful­ society­ free­ from
violence­and­implementing­a­revitalized­universal­partnership
for­sustainable­development­respectively.­It­is­an­agenda
of­the­people,­by­the­people­and­for­the­people­—to­ensure
a­ better­ life­ for­ all­ including­ the­ loads­ who­ have­ been
deprived­ of­ the­ chances­ to­ lead­ decent,­ dignified­ and
satisfying­lives­and­to­achieve­their­full­human­potential.
Sustainable­ Development­ Goal-3­ which­ is­ “to ensure
healthy lives and promote wellbeing for all at all ages”
indicates­ to­ endorse­ physical­ and­ mental­ health­ and
wellbeing­ and­ to­ enhance­ life­ expectancy­ for­ all­ by
achieving­Universal­Health­Coverage­(UHC)­and­accessing
to­quality­health­care.­Meanwhile,­the­pace­of­progression
attained­through­MDGs­in­fighting­malaria,­tuberculosis,
hepatitis,­ HIV/AIDS,­ ebola­ and­ other­ communicable
diseases­and­epidemics­and­growing­antimicrobial­resistance
has­ been­ accelerated­ since­ 2016.­ Noncommunicable
diseases also­ denote­ a­ major­ challenge­ for­ sustainable
development­ throughout­ the­ world.­ Health­ related
Sustainable­Development­Goal-3­with­all­targets­has­been
mentioned­thoroughly­below­by­the­United­Nations-
“3.1:­By­2030,­reduce­the­global­maternal­mortality­ratio
to­less­than­70­per­100,000­­­­live­births
3.2:­ By­ 2030,­ end­ preventable­ deaths­ of­ new­ born­ and
children­under­5­years­of­age,­with­all­countries­aiming­to
reduce­ neonatal­ mortality­ to­ at­ least­ as­ low­ as­ 12­ per
1,000­live­births­and­under­5­mortality­to­at­least­as­low
as­25­per­1,000­live­births
3.3:­ By­ 2030,­ end­ the­ epidemics­ of­AIDS,­ tuberculosis,
Global­Healthcare 46
malaria­and­neglected­tropical­diseases­and­combat­hepatitis,
waterborne­diseases­and­other­communicable­diseases
3.4:­ By­ 2030,­ reduce­ by­ one­ third­ premature­ mortality
from­ noncommunicable­ diseases­ through­ prevention­ and
treatment­and­promote­mental­health­and­wellbeing
3.5:­Strengthen­the­prevention­and­treatment­of­substance
abuse,­ including­ narcotic­ drug­ abuse­ and­ harmful­ use­ of
alcohol
3.6:­ By­ 2020,­ halve­ the­ number­ of­ global­ deaths­ and
injuries­from­road­traffic­accidents
3.7:­ By­ 2030,­ ensure­ universal­ access­ to­ sexual­ and
reproductive­ healthcare­ services,­ including­ for­ family
planning,­ information­ and­ education,­ and­ the­ integration
of­ reproductive­ health­ into­ national­ strategies­ and
programmes
3.8:­Achieve­universal­health­coverage,­including financial
risk­ protection,­ access­ to­ quality­ essential­ healthcare
services­and­access­to­safe,­effective,­quality­and­affordable
essential­medicines­and­vaccines­for­all
3.9:­ By­ 2030,­ substantially­ reduce­ the­ number­ of­ deaths
and­illnesses­from­hazardous­chemicals­and­air,­water­and
soil­pollution­and­contamination
3.­a:­Strengthen­the­implementation­of­the­World­Health
Organization­Framework­Convention­on­Tobacco­Control
in­all­countries,­as­appropriate­
3.b:­ Support­ the­ research­ and­ development­ of­ vaccines
and­medicines­for­the­communicable­and­noncommunicable
diseases­ that­ primarily­ affect­ developing­ countries,
provide­ access­ to­ affordable­ essential­ medicines­ and
vaccines,­in­accordance­with­the­Doha­Declaration­on­the
Trade­ Related­ Aspects­ of­ Intellectual­ Property­ Rights
(TRIPS)­Agreement­and­Public­Health,­which­affirms­the
47 Global­Healthcare
right­ of­ developing­ countries­ to­ use­ to­ the­ full­ the
provisions­in­the­Agreement­on­Trade­Related­Aspects­of
Intellectual­Property­Rights­regarding­flexibilities­to­protect
public­health,­and,­in­particular,­provide­access­to­medicines
for­all
3.c:­ Substantially­ increase­ health­ financing­ and­ the
recruitment,­ development,­ training­ and­ retention­ of­ the
health­ workforce­ in­ developing­ countries,­ especially­ in
least­ developed­ countries­ and­ small­ island­ developing
States
3.d­Strengthen­the­capacity­of­all­countries,­in­particular
developing­ countries,­ for­ early­ warning,­ risk­ reduction
and­management­of­national­and­global­health­risks”­(2).
Way of Bangladesh to achieve SDG-3
As­each­country­faces­specific­challenges­in­its­pursuit­of
sustainable­ development­ goals,­ Bangladesh­ is­ not­ an
exception­in­this­regard.­Since­the­rise­of­Bangladesh­as­an
independent­republic,­it­has­been­given­priority­to­health
as­ a­ basic­ human­ right­ of­ the­ people.­ Being­ one­ of­ the
successful countries­ in­ achieving­ the­ health-related
Millennium­ Development­ Goals­ (MDGs),­ Bangladesh­ is
also­in­track­of­evolving­policies­and­actions­for­achieving
the­targets­of­Sustainable­Development­Goals­(SDGs).­In
doing­so,­as­part­of­strategies­a­‘SDG­Co-ordination­Cell’
has­been­established­at­the­Prime­Minister’s­Office­(PMO)
to­ guide­ the­ national­ SDG­ agenda.­ The­ existing­ 7th
Five-Year­ Plan­ (FYP­ 2016-2020)­ and­ the­ 4th­ Health,
Population­ and­ Nutrition­ Sector­ Program­ (HPNSP
2017-2022)­ are­ the­ reflection­ of­ policy­ to­ accomplish
health-related SDG­ by­ 2030­ (3).Although­ Government­ is
the­largest­health­care­service­provider­in­Bangladesh,­the
Global­Healthcare 48
service­of­the­private­sectors­is­also­extensive.­Along­with
coordinated­and­persistent­effort­at­the­national­level,­all
stakeholders­and­health­service­providers­of­the­grassroots
level­are­also­needed­to­attain­the­health-related­SDG­tar-
gets­(3).­
At­ present­ the­ MoHFW­ is­ executing­ its­ fourth­ Sector
Program­ titled­ ‘4th­ Health,­ Population­ and­ Nutrition
Sector­Program­(4th­ HPNSP)’­covering­a­5.5-year­period
between­January­2017­and­June­2022,­at­an­estimated­cost
of­US$­14.7­billion­which­aligns­with­the­7th­FYP­targets
for­achieving­UHC­and­SDGs­by­2030.­To­illustrate­global
development­agenda­into­the­national­plan,­health-related
SDG­has­been­taken­into­consideration­in­the­4th HPNSP
strategy.­The­main­goal­of­this­program­is­“To­ensure­that
all­citizens­of­Bangladesh­enjoy­health­and­wellbeing­by
expanding­access­to­quality­and­equitable­healthcare­in­a
healthy­environment”­(4).
SDG­Health­Goal-3­includes­13­targets­and­25­indicators.
Government­ has­ commenced­ a­ project­ named­ ‘Upazila
Governance­ Project’­ to­ make­ a­ link­ of­ SDGs­ with­ the
community­ and­ to­ make­ the­ key­ local­ government
functionaries­ aware­ about­ 17­ goals­ and­ 169­ targets­ and
responsibilities­of­local­government­institutions­(LGIs)­in
applying­and­localizing­the­goals­by­preparing­action­plan
at­local­level.In­case­of­SDG-­3,­for­12­indicators­data­is
fully­available,­data­is­partially­available­for­10­indicators
and­ not­ available­ for­ the­ rest­ of­ the­ 3­ indicators­ in
Bangladesh­(5).
49 Global­Healthcare
Financing for SDG–3 in low and middle income countries
In­ 2009,­ WHO­ estimated­ for­ the­ resources­ needed­ for
Millennium­ Development­ Goals­ (MDGs)­ by­ 2015­ for
low-income­countries­to­strengthen­health­service­delivery
was­total­mean­spending­need­of­$54­per­head.­This­was
presented­through­the­High-level­Taskforce­on­Innovative
International­ Financing­ for­ Health­ Systems­ (HLTF)­ (6).
Sustainable­ Development­ Goals­ (SDGs)­ adopted­ in
September,­2015,­since­then­estimation­of­resources­needed
to­ achieve­ the­ health-related­ SDG­ targets­ is­ importantly
recognized.­The­analysis­should­provide­health­systems­at
central­to­achievement­of­SDG­3­with­compelling­arguments
that­investments­in­health­need­to­focus­not­only­on­direct
service­ delivery­ but­ also­ on­ overall­ health-systems
strengthening.­ So­ Ministries­ of­ health­ negotiate­ for
additional­ domestic­ and­ international­ resources­ to
increased­ health­ spending­ as­ it­ has­ effect­ on­ life­ expectancy,
healthy­ life-years,­ and­ financial­ empowerment­ of
households.­Though­the­health­SDGs­are­ambitious,­but­it
is­clear­that,­where­consistent,­sustained­political commitment
exists,­ they­ are­ within­ reach.­As­ Bangladesh­ is continuously
growing­economically­so­that­transition­to­middle-income
status­will­probably­reach­the­UHC­target,­assuming­that
they­have­the­right­policies­in­place­and­the­political
commitment­to­raise­resources­domestically.­Investments
in­research­and­new­technology­by­international­financial
assistance­have­also­been­emphasized­for­improving­global
health­(7).­
The­UHC­is­defined­as­access­for­all­people­and­communities
to­services­that­they­need­without­financial­hardship­(8).
SDG­ 3—“Ensure­ healthy­ lives­ and­ promote­ well-being
Global­Healthcare 50
for­all­at­all­ages”—is­a­broad­health­goal­through­UHC.
Many­ countries­ are­ still­ far­ from­ UHC­ and­ furthermore,
100­ million­ people­ yearly­ are­ pushed­ below­ the­ poverty
line­because­of­direct­health­care­cost­(9).Equitable­access
to­a­set­of­key­health­services­is­the­principle­of­UHC­entitles
universalism,­whereby­services­increases­with­time,­starting
with­ the­ poorest.­ The­ service­ provided­ is­ progressively
expanded,­ and­ an­ increasing­ share­ of­ costs­ is­ covered
through­pooled­funding,­thereby­reducing­OOP­payments.
The­ multisectoral­ links­ between­ the­ SDGs­ are­ crucial,
because­ many­ goals­ represent­ different­ sectors­ that­ are
essential­ to­ address­ the­ environmental­ and­ social
determinants of­health­(10).
Figure 1: Conceptual framework for transforming
A­ recent­ estimation­ analysis­ was­ funded­ by­ WHO­ and health systems towards SDG 3 targets.
Stenberg­ K­ et­ al.(11)explored­ ­ the­ projected­ resource SDGs=Sustainable­Development­Goals.­(Source:
needs­ in­ 67­ low-income­ and­ middle-income­ countries­ to Reference­11)
achieve­the­health­Sustainable­Development­Goals.­­
Overall­contextual­factors­include­climate­change,­poverty,
They­ estimated­ that­ an­ additional­ US$274­ to­ US$371 migration,­ and­ changes­ in­ the­ level­ and­ distribution­ of
billion spending­on­health­is­needed­per­year­by­2030­to wealth.­ Country-specific­ contextual­ factors­ include
make­progress­towards­the­SDG­3­targets.­The­estimated epidemiological­and­demographic­transitions,­urbanization,
additional­cost­per­person­per­year­is­$41­to­$58­with­the and­recovery­from­conflict­and­disasters.­
total­health-care­spending­would­increase­to­a­population-
weighted­ mean­ of­ $271­ per­ person.­ Mean­ health­ care This­analysis­considers­in­addition­to­SDG­3,­other­including
expenditure­would­be­7.5%­of­gross­domestic­product.­Of SDGs­2,­6,­and­7­in­relation­to­health­such­as­those­related
to­ education,­ gender­ equality­ and­ expanded­ provision­ of
these­ around­ 75%­ of­ costs­ are­ for­ health­ systems,­ with
service­ packages­ delivered­ through­ multiple­ platforms
health­ workforce­ and­ infrastructure­ and­ medical
(Figure­1).­This­conceived­resilient­health­systems­at­the
equipment; as­the­main­cost­drivers.­These­fund­will­save
centre,­with­a­people-centred­approach­to­service­delivery.
97­million­lives­and­increase­life­expectancy­by­3·1–8·4
years,­according­to­the­country­profile.

51 Global­Healthcare Global­Healthcare 52
Financing to achieve SDG-3 in Bangladesh
Per­capita­for­health­expenditure­Bangladesh­was­34­US
dollars­in­2016­(12).The­fifth­Bangladesh­National­Health
Accounts­ (BNHA)­ 1997-2015­ estimated­ total­ health
expenditure­per­capita­increased­from­US$­27­in­2012­to
US$­ 37­ in­ 2015.­ Bangladesh­ spends­ 3.0%­ of­ its­ GDP
while­government­health­expenditure­in­relation­to­GDP­is
only­0.69%­placing­the­country­among­the­countries­that
least­spends­on­health­(13).­Further­solid­data­is­not­available
through­ assuming­ that­ it­ is­ increasing.­ But­ it­ is­ confirm
that­ the­ amount­ is­ least­ to­ achieve­ the­ SDG-3.­ Because
estimated­ per­ capita­ expenditure­ to­ achieve­ the­ goal­ is
$271­per­year­(11).­So­we­have­to­mobilize­huge­resources
to­ensure­UHC­from­private­and­public­sectors.­So­health
budget­should­be­15%­of­the­total­national­budget­and­3
times­higher­the­present­allocated­amount.
8.­ UN.­Transforming­our­world:­the­2030­agenda­for­sustainable­develop-
ment.­New­York:­United­Nations,­2015.
9.­ Xu­K,Evans­DB,­Carrin­G,­Aguilar-Rivera­AM,­Musgrove­P,­Evans­T.
Protecting­households­from­catastrophic­health­spending.­Health Aff
(Millwood) 2007;­26: 972–83.
10.­ Becerra-Posada­F.­Health­in­all­policies:­a­strategy­to­support­the
Sustainable­Development­Goals.­Lancet Glob Health 2015;­3: e360.
11.­ Stenberg­K, Hanssen­O, Edejer­TT, Bertram­M, Brindley­C,
Meshreky­A­et­al.­Financing­transformative­health­systems­towards
achievement­of­the­health­Sustainable­Development­Goals:­a­model­for
projected­resource­needs­in­67­low-income­and­middle-income­countries.
Lancet­Glob­Health. 2017­Sep;­5(9):e875-e887.
12.­ https://knoema.com/atlas/Bangladesh/topics/Health/Health-
Expenditure/Health-expenditure-per-capita.­(Accessed­on­11.04.2020)
13.­ World­Health­Organization.­Bangladesh­National­Health­Accounts,
an­overview­on­the­public­and­private­expenditures­in­health­sector.
http://www.searo.who.int/bangladesh/bnha/en/(accessed­on
11.04.2020)

References:
1. https://en.wikipedia.org/wiki/United_Nations
2.­United­Nations.­Transforming­our­world:­The­2030­agenda­for­sustainable
development.UN­2018
https://sustainabledevelopment.un.org/post2015/transformingourworld
3.­ Chowdhury­ME.­Policy­research­institutions­and­the­health­SDGs:
building­momentum­in­South­Asia-Bangladesh­study.
4.­ MIS,­Directorate­General­of­Health­Services.­Health­Bulletin­2018.
Government­of­the­People’s­Republic­of­Bangladesh,­MOHFW.
Available­at:­www.dghs.gov.bd­(Accessed­on­6.4.2020)
5. NIPORT,­Ministry­of­Health­and­Family­welfare.­Bangladesh­Health
Facility­Survey­2017.­Government­of­the­People’s­Republic­of
Bangladesh­and­USAID,­Bangladesh.­2018.
6.­ Fryatt­R,­Mills­A,­Nordstrom­A.­Financing­of­health­systems­to­achieve
the­health­Millennium­Development­Goals­in­low-income­countries.
Lancet­2010;­375: 419–26.
7.­ Jamison­DT,­Summers­LH,­Alleyne­G,­et­al.­Global­health­2035:­a
world­converging­within­a­generation.­Lancet­2013;­382: 1898–955.­­

53 Global­Healthcare Global­Healthcare 54
Chapter­5
Designing Health Insurance
for Healthcare Financing
in Bangladesh
Abu­Hena­Abid­Zafr1,­Shahinul­Alam2
Abstract:
In­absence­of­any­risk-pooling­mechanisms,­health-cost­is
mainly­ met­ by­ out-of-pocket­ payments­ in­ addition­ to­ public
fund.­By­health­insurance­people­unitedly­pool­the­risk­of
catastrophic­medical­expenses.­Health­insurance­is­needed
more­ than­ ever­ before­ because­ of­ skyrocketing­ medical
costs.­ Poor­ households­ in­ Bangladesh­ confronted­ by
sudden­illness­surrender­to­the­trap­of­‘Mohagony­Loan’
or­sell­their­bread-earning­fixed­and­current­assets­above
the­deposits­and­propagate­a­vicious­cycle­of­poverty.­It­is
the­political­commitment­and­constitutional­responsibility
of­ the­ government­ to­ ensure­ health­ of­ the­ citizens,­ but
there­ are­ certain­ issues­ which­ cannot­ be­ met­ by­ the
government­ alone,­ it­ needs­ private­ initiative­ also.
Government­ can­ promote­ not-for-profit­ public-private
partnership­in­this­sector.­Ministry­of­Health­and­Family
Welfare­ has­ taken­ an­ initiative­ ‘Shasthyo Suroksha
Karmosuchi’,­ which­ offered­ 50,000­ BDT­ medical
1. Dr Abu Hena Abid Zafr MBBS, Investigator, Urban Health Research, 25i Green Road. Dhaka-
1205, Bangladesh
2. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
55 Global­Healthcare
coverage­ (for­ 78­ different­ diseases)­ per­ household;­ the
premium­is­paid­by­the­government.­This­insurance­model
is piloted­ at­ Kalihati,­ Modhupur­ and­ Ghatail­ Upazila.
Health­ Insurance­ is­ at­ conceptual­ level­ in­ the­ country.
For­ a comfortable­ beginning­ we­ propose­ a­ tailor-made
policy.­ Details­ of­ the­ policy­ should­ be­ prefixed–­ what­ it
covers,­and­what­it­doesn’t,­and­the­co-pay.­A­rational pricing
system­ and­ standard­ treatment­ guidelines­ should­ be
practiced,­ and­ our­ morality­ has­ to­ improve.­ Achieving
Universal­ Health­ Coverage­ by­ 2032 is­ our­ national
commitment.­ By­ increasing­ health­ insurance­ we­ shall
ensure­ a­ safety­ net­ for­ the­ poor­ and­ will­ build­ a­ healthy
nation.
Key words: Health­ insurance;­ health­ financing;
Bangladesh;­universal­health­coverage;­Shasthyo­Suroksha
Karmosuchi;­health­policy.
Health­is­among­the­basic­necessities­that­gives­value­to
human­life.­Better­health­needs­greater­and­more­equitably
distributed­ wealth­ by­ ensuring­ human­ and­ social­ capital
and­ consecutively­ increasing­ productivity.­ It­ has­ been
found­that­the­cost­of­healthcare­itself­can­be­a­cause­of
poverty­ through­ loss­ of­ income,­ and­ irreversible­ crisis
coping­mechanisms­that­involve­asset­and­savings­depletion.
Of­ all­ the­ risks­ thatmiddle­ class­ households­ are­ facing,
health­risk­probably­pose­the­greatest­threat­to­their­livelihoods.
Cost­burdens­of­healthcare­may­deter­healthcare­utilization
or­promote­use­of­less­effective,­unscientific­&­indigenous
healthcare­ practices.­ In­ the­ absence­ of­ any­ risk-pooling
mechanisms­ and­ pre-payments,­ expenditure­ on­ health­ is
mainly­met­by­out-of-pocket­(OOP)­payments.­This­mode
of­payment­for­health-expenditure­is­the­most­repressive
Global­Healthcare 56
one­and­exposes­people­to­great­financial­risk­and­makes
the­health­system­inequitable.
Health­ insurance,­ is­ a­ form­ of­ collectivism­ by­ means­ of
which­ people­ unitedly­ pool­ their­ risk­ and­ incur­ medical
expenses­ collectively­ (1).­ Heal­ thinsurance­ policy­ is­ a
contract­between­an­insurance­company­and­an­individual,
by­which­the­insurer­agrees­to­pay­(partial­or­full­bill)­for
specified­treatment­cost­at­an­agreed-upon­price.­The­type
and­amount­of­health­care­cost­that­will­be­covered­by­the
insurance company­are­specified­in­advance.The­premium
can­be­paid­in­monthly­or­yearly­installments.­Insurance
companies­ can­ provide­ direct­ payment­ or­ reimbursement
for­expenses­associated­with illnesses­and­injuries.
Health­ insurance­ relieves­ the­ burden­ of­ any­ unexpected
medical­ emergencies,­ which­ made­ it­ important­ for­ both
individuals­and­families.­The­benefits­of­health­care­insurance
are­ clear;­ it­ provides­ us­ with­ the­ means­ to­ look­ after
ourselves­ and­ our­ families,­ without­ worrying­ about­ the
cost­ of­ medical­ care­ though­ it­ was­ prepaid.­ Health
insurance is­ our­ protection­ against­ medical­ costs.­ Every
year­the­cost­of­health­care­is­increasing­dramatically­ (2).
Health­insurance­is­needed­more­now­than­ever­because­of
skyrocketing­ medical­ costs,­ increasing­ need­ for­ routine
medical­checkups­and­care,­development­of­advanced­&
more­ effective­ but­ more­ expensive­ treatment­ protocols,
more­ intensive­ diagnostic­ testing,­ advances­ in­ medical
technology etc.
Why Bangladesh need health insurance?
Health­care­is­inaccessible­for­many­Bangladeshis.­A­large
population­of­the­country­lives­below­the­poverty­line.­It
57 Global­Healthcare
comes­ as­ no­ surprise­ that­ due­ to­ the­ high­ population
density,­ coupled­ with­ the­ developing­ economy­ of­ the
country,­ health­ care­ for­ the­ whole­ population­ is­ a­ major
concern­ that­ is­ rather­ difficult­ to­ address.­ Despite­ the
daunting­ challenges­ of­ providing­ health­ care,
Bangladesh’s­health­system­is­pretty­well-organized­(3)­–
Big­ hospitals­ cater­ to­ cities,­ Extensive­ clinics­ provide
services­in­districts­to­Upazila,­Small­set­ups­are­there­up
to­ unions­ or­ villages.­ The­ public­ hospitals­ provides­ its
health­services­at­very­low­costs.­But,­the­quality­of­care
remains­a­question.
In­Bangladesh,­financing­in­ailments­results­a­huge­out-of-
pocket­(OOP)­health­care­expenditures­for­households.­It
has­ been­ found­ that­ the­ poor­ and­ underprivileged
households with­only­a­few­assets­are­likely­to­struggle­to
meet­ even­ small­ extra-budgetary­ healthcare­ expenses.­A
poor­ household­ confronted­ by­ sudden­ illness­ or­ in­ an
emergency­surgery­incurring­average­amount­of­expenses,
they­surrender­to­the­trap­of­‘Mohagony­Loan’­with­high
rate­of­interest­or­have­to­sell­their­bread-earning­farming
land­or­livestock’s,­liquid­assets,­fixed­assets­and­destined
to­perpetuate­a­vicious­cycle­of­poverty.
Encouraging entrepreneurship
It­is­the­political­commitment­and­constitutional­responsibility
of­the­government­to­ensure­health­of­the­citizens­allotting
sufficient­ budgetary­ provision­ (4).­ But,­ there­ are­ certain
issues­ which­ cannot­ be­ met­ by­ the­ government­ alone,­ it
needs­ private­ initiative­ &­ support,­ rather­ private­ health
concerns­and­big­enterprises­should­come­up­with­corporate
social­responsibilities.­
Global­Healthcare 58
Government­can­own­and­operate­as­a­business­enterprise
as­ all­ other­ registered­ private­ health­ funds.­ It­ is­ better­ if
government­patronizes­private­initiatives­by­offering­easy
bank­loans,­reducing­taxes­&­duty­exemption­for­qualified
services.­A­big­health­insurance­company­can­be­formed
floating­ public­ shares.­ Government­ should­ encourage
promoting public-private­partnership­in­this­sector.
A­task­force­should­be­formed­for­the­collaboration­with
the­ government­ and­ other­ entrepreneur­ agencies­ to
facilitate an­initial­not-for-profit­health­insurance­fund­for
the­ operation­ (on­ public-private­ partnership)­ to­ begin­ on
test-basis.­Recovery­from­new­revenue­through­premium
will­automatically­be­reimbursed.
All­adult­resident­tax­payers­and­all­people­working­will
be­obliged­by­law­to­purchase­the­coverage­from­an­insurance
company­of­their­choice.­Insurance­companies­will­not­be
allowed­ to­ deny­ coverage­ to­ any­ person­ applying­ for­ a
policy, or­to­charge­anything­other­than­their­nationally­set
and­ published­ standard­ premiums.­ Family­ members­ of
insured­people­are­eligible­for­benefits.
All­insurance­companies­will­be­funded­from­the­equalization
pool­to­help­cover­the­cost­of­a­government­set­minimum
standard­ level­ of­ coverage­ or­ universal­ health­ coverage
(UHC).­Or­the­total­fund­could­be­handled­by­the­government
as­in­UK.­This­pool­will­be­run­by­a­regulatory­body­who
will­ collect­ salary-based­ contributions­ from­ employers,
and­ funding­ from­ the­ government­ to­ cover­ people­ who
cannot­afford­insurance­premium.
We­ can­ exchange­ ideas­ with­ senior­ business­ leaders,
authorities­ of­ financial­ institutions­ &­ hospitals,­ and
industrial enterprises­for­promoting­health­insurance.­The
59 Global­Healthcare
big­corporate­hospitals­can­start­offering­services­to­individuals
or­employees­of­big­companies­(e.g.­cellphone­operators,
NGOs­ like­TMSS­ or­ BRAC,­ Banks­ like­ IBBL­ etc)­ on­ a
pre-paid­ basis­ and­ analyses­ their­ experience­ in­ favor­ of
health­insurance­scheme.
Currently­ few­ community-based­ programs­ are­ being
operated­by­NGOs­and­local­hospitals.­These­are­integrated
schemes­in­the­sense­that­they­are­insurer­as­well­as­service
provider.­ These­ schemes­ have­ dubious­ success­ and
contribution­to­total­national­spending­is­negligible.
A step towards Universal Health Coverage: Piloting
social health protection for Bangladeshi poor
Ministry­of­Health­and­Family­Welfare­has­adopted­a­new
financial­ protection­ naming­ ‘Shasthyo Suroksha
Karmosuchi’­for­the­below-poverty-line­population­(5).­In
this­scheme­every­household­is­offered­up­to­50,000­BDT
(620­ US$)­ medical­ coverage­ (reimbursable­ benefit
package for­predefined­78­different­disease­group)­every
year,­ and­ a­ 1,000­ BDT­ (12­ US$)­ annual­ premium­ per
household­is­paid­by­the­Government.­They­don’t­have­to
pay­any­money­at­the­point­of­service­delivery.­This­health
insurance­model­is­being­piloted­initially­at­rural­Kalihati,
Modhupur­ and­ Ghatail­ Upazilas,­ with­ the­ support­ from
German­ KfW­ Development­ Bank,­ with­ an­ intention­ to
scale-up­nation-wide.
The­pilot­program­launched­on­24­March­2016­in­Kalihati,
was­extended­to­Modhupur­and­Ghatail­on­12­September
2017.­The­scheme­is­now­covering­around­400,000­people
living­in­around­100,000­households­considered­to­be­the
poorest­ in­ three­ Upazilas­ of­ Tangail­ district­ with­ a­ total
Global­Healthcare­60
population­of­over­1.3­million.­Health­card­is­provided­to
every­ below-poverty-line­ household.­ The­ card­ provides
poor­ families­ to­ cost-free­ access­ to­ a­ doctor­ at­ OPD­ in
Upazilla­ Health­ complex,­ diagnostic­ facilities­ and
in-patient care,­if­needed­referral­to­District­Hospital­with
transportation­and­hospitalization,­if­needed­surgical­care
also.­Card-holders­get­free­medicines­from­a­special­pharmacy
within­the­hospitals.­However,­it­is­not­yet­clear­how­far
the­scheme­is­successful­and­what­the­impact­of­it­on­the
target­population­is.
For a comfortable beginning in Bangladesh, a
prospective insurance company may consider some
criteria for a period of time, and customize their policy
accordingly:
The­ health­ insurance­ systems­ of­ different­ countries­ vary
widely.­There­ are­ various­ types­ of­ &­ different­ levels­ of­ preset
coverage­ plan­ and­ different­ formula­ for­ calculation­ of
premium depending­on­source­of­fund. All­those­countries
withcompetitive­ insurance­ markets­ allow­ consumers­ a
choice­of­health­plan­(6).­We­have­the­opportunity­to­learn
from­insurance­innovations­in­those­countries,­and­we­can
formulate­ a­ tailor-made­ proposal­ which­ will­ suite­ us­ the
best.­ To­ maximize­ the­ poverty-alleviation­ effect,­ health
insurance­need­to­be­designed­according­to­the­needs­and
priorities­ of­ the­ disadvantaged.­ Such­ health­ insurance
policy will­ allow­ access­ to­ the­ poor­ or­ middle­ class,
irrespective­of­their­ability­to­pay,­and­will­be­responsive
to­ their­ needs­ and­ priorities.­ We­ can­ examine­ how­ the
design­ of­ insurance­ coverage­ can­ affect­ access­ to­ care,
financial­protection­against­high­medical­costs,­and­insurance
complexity.
61 Global­Healthcare
An­important­element­of­the­insurance­system­should­be
solidarity:­ the­ more­ ill­ a­ person­ becomes,­ the­ less­ the
person­will­pay.­The­government­can­partially­reimburses
the­costs­for­low-wage­workers,­most­senior­citizens­and
low-income­families­who­meet­certain­eligibility­criteria.
Senior­ citizens,­ high-risk­ individuals­ will­ get­ more­ from
the­pool.­
We­can­carry­out­policy­dialogue­and­advocacy­with­the
national,­ int’l­ financial­ &­ health­ organizations­ and­ work
on­to­make­health­care­accessible­for­people­who­cannot
pay­ for­ services.Medical­ Insurance­ program­ must­ be
incorporated,­ and­ should­ be­ a­ priority­ in­ the­ National
Health­Policy.
A­health­plan­can­also­refer­to­a­subscription-based medical
care­arrangement­offered­through­a­panel­of­hospitals­(i.e.
managed­ care­ of­ standard­ quality­ by­ a­ list­ of­ providers
preselected­by­the­insurance­company).­The­company­will
offer­ discounted­ coinsurance,­ or­ additional­ benefits,­ to­ a
member­ to­ see­ an­ in-network­ provider.­ Generally,
providers­ in­ network­ are­ providers­ who­ have­ a­ contract
with­the­company­to­accept­rates­further­discounted­from
the­‘usual­and­customary’­charges,­lower­than­commercial
clinic­fees.­The­insurance­company­pays­to­the­health­care
providers­ in­ a­ reasonable­ way.­ It­ generally­ costs­ the
patient­ less­ to­ use­ an­ in­ a­ group­ of­ health­ care­ provider.
But­freedom­to­select­their­own­doctor­&­hospital­will­be
there.­The­number­of­physicians­and­hospitals­allowed­to
accept­ health­ insurance­ reimbursement­ in­ a­ given­ locale
will­ be­ regulated­ by­ the­ government­ authority­ and
professional medical­societies.
Usual­ health­ insurance­ plan­ is­ a­ basic­ policy­ providing
Global­Healthcare 62
access­to­day-to-day­health­care,­and­benefits­are­limited.
Most­ health­ insurance­ policies­ pay­ a­ percentage­ of­ the
cost­of­hospital­and­physician­charges­after­a­deductible­or
a­co-pay­is­met­by­the­patient­himself.­Government­may
ensure­ Universal­ Health­ Coverage­ (UHC)­ to­ everybody
everywhere.­A­private­health­insurance­policies­differ­as­to
coverage,­benefits,­costs­and­services.­Not­all­services­are
covered­usually.­The­insured­person­have­to­pay­the­full
cost­of­non-covered­services­out­of­their­own­pocket.­
In­ certain­ occupation­ or­ jobs­ health­ insurance­ should­ be
seriously­taken­to­consideration.­‘Accident­and­disability
coverage’­for­vehicle­drivers­and­heavy­machinery operators
should­be­offered­mandatory,­whoever­pays­the­premium.
This­health­insurance­scheme­should­be­an­obligatory­part
for­the­licensing­procedure.­Ideally­the­scheme­should­be
co-financed­by­employer­and­employee­jointly­(employer
matching­the­contribution­of­the­employee),­covering­all
occupational­risks-­short­term­as­well­as­long­term­care­in
cases­ where­ a­ person­ is­ not­ able­ to­ manage­ his­ daily
routine­work.
How to combat moral hazards?
There­ is­ wide­ disparities­ in­ charges­ &­ cost­ of­ services
depending­on­the­differences­in­the­type­of­hospital­used
and­ variation­ of­ amenities­ enjoyed,­ also­ on­ the­ level­ of
skill­&­technical­know-how­availed­and­the­sophistication
level­of­instrumentation­needed.­A­rational­pricing­system
should­be­practiced­in­general­throughout­the­country.
An­ agreed-upon­ standard­ treatment­ protocol­ has­ to­ be
followed­ in­ practice,­ deviation­ from­ which­ will­ not­ be
covered.
63 Global­Healthcare
Every­patient­should­have­the­right­to­sue­for­damages­due
to­medical­incompetence­and­in­proven­negligent­acts.
Claim­should­be­responded­without­hassle.­An­authoritative
steering­committee­formation­is­very­important­to­resolve
the­claim­sharply,­and­everything­should­be­transparent.
Moral­hazards­from­both­provider­and­consumer­perspective
will­only­reduce­when­our­law-abiding­attitude,­morality,
and­ethical­conscience­improve­(9).
MoHFW­is­executing­The­Health­Care­Financing­Strategy
2012-2032­ provides­ a­ framework­ for­ health­ financing­ in
Bangladesh.This­ strategy­ planned­ for­ Social­ Health
Protection­ Scheme,­ determine­ institutional­ arrangements
for­Social­Health­Protection­Scheme,­implement­SSK­for
below­poverty­line­(BPL),­design­social­health­protection
scheme­ for­ above­ BPL­ formal­ and­ informal­ proposes­ to
cover­the­poor­and­the­formal­sector,­including government,
private­and­NGO­employees,­and­progressively­extending
the­coverage­to­the­remaining­segment­of­the­population
by­2032­(10).
Health­care­is­our­constitutional­responsibility.­Achieving
UHC­by­2030­is­our­national­commitment­(11).­Primary
health-care­services­are­officially­free­at­public­hospitals.
Health­ Insurance­ is­ at­ conceptual­ level­ in­ Bangladesh.
Medical­ insurance­ scheme­ offered­ in­ Bangladesh­ is­ in
very­small­scale.­With the­increasing­efforts­to­make­available
better­health­services­that­will­reach­greater­portion­of­the
population­and­sincere­intention­to­remove­the­burden­of
financing­the­ailing­system,­will­make­the­government­a
strong­ proponent­ of­ health­ insurance­ services.­ Emphasis
on­insurance­expansion,­benefit­standardization,­limits­on
Global­Healthcare 64
cost­for­those­with­lower­income­should­be­seriously­taken Chapter­6
to­consideration.­By­increasing­health­insurance­coverage
will­ensure­a­safety­net­for­the­poorest­we­will­be­able­to
build­a­healthy­nation.

Analysis of Health Policy and

References:

1.­ Town­N,­Muchiri­AW,­Okello­B,­Wagoki­J.­Use­of­national­health­insurance­fund­platform­as

Health Budget of Bangladesh

a­competitive­strategy­in­enhancing­performance­of­private­hospitals­in­Nakuru­town,­Kenya.
ISOR­Journal­of­Business­Management.­2016;18(4):112–9.­

2.­ Leibach­E.­Healthcare­costs­are­increasing­dramatically.­Clin­Lab­Sci­J­Am­Soc­Med­Technol.

Kazi­Musa1,­Jamaliah­Said2,­Farhana­Begum3
2011;24:233–4.­

3.­ Mahmood­ SAI.­ Editorial­ Health­ Systems­ in­ Bangladesh.­ Heal­ Syst­ policy­ Res.
2012;1(1):1–4.­

4.­ Swendiman­KS.­Health­Care?:­Constitutional­Rights­and­Legislative­Powers.­2012.­ Abstract:

5.­ Ahmed­S,­Hasan­Z,­Ahmed­MW,­Dorin­F,­Sultana­M,­Islam­Z,­et­al.­Evaluating­the­imple-
mentation­related­challenges­of­Shasthyo­Suroksha­Karmasuchi­(­health­protection­scheme­)
of­ the­ government­ of­ Bangladesh?:­ a­ study­ protocol.­ BMC­ Health­ Serv­ Res.
2018;18(552):1–8.­
6.­ World­Health­Organization.­Regulation­private­health­insurance­to­serve­the­public­interest
policy­issues­for­developing­countries.­2005.­
7.­ Health+­ Waiting­ periods­ and­ exclusions­ [Internet].­ Assupol.­ Available­ from:
https://assupol.co.za/legal-requirements/health-waiting-periods-
8.­ Conditions­ covered­ [Internet].­ Council­ for­ medical­ schemes.­ Available­ from:
https://www.medicalschemes.com/medical_schemes_pmb/conditions_covered.htm
Health­care­service­is­one­of­the­basic­needs­of­human­life,
which­ is­ also­ acknowledged­ by­ the­ constitution­ of
Bangladesh.­However,­Bangladesh­has­a­moderate­health
care­ system­ which­ is­ highly­ dependent­ on­ private
hospitals­and­clinics.­Despite­the­many­flaws,­the­health
care­system­has­been­considered­as­one­of­the­prioritized
policies­ from­ the­ very­ beginning­ the­ country­ gained
independence­ in­ 1971.­ Though­ the­ first­ formal­ National

Health­Policy­is­adopted­in­2011­which­is­revised­from­the
9.­ Einav­L,­Finkelstein­A.­Moral­hazard­in­health­insurance?:­What­we­know­and­how­we­know
it.­J­Eur­Econ­Assoc.­2018;16(4):957–82.­

10. HEU,­MoHFW.­Health­Care­Financing­Strategy­2012-2032, proposed­ national­ health­ policy­ of­ 2000.­ In­ recent­ fiscal
years­ national­ health­ budget­ in­ around­ 5%­ of­ aggregate
https://heu.portal.gov.bd/sites/default/files/files/heu.portal.gov.bd/files/9ce6e5e8_01eb_4d1b
_8516_38b45871b5b0/2020-02-17-17-29-83405f52b52d507a3cfcbad37a7d51a2.pdf(Access
on­13.04.2020)
national­budget.­In­general,­public­healthcare­facilities­are
11.­ Sameh­EIS,­Powers­SS,­Helene­B­et­al.­The­path­to­universal­health­coverage­in­Bangladesh:
bridging­ the­ gap­ of­ human­ resources­ for­ health­ (English). A­ World­ Bank­ Report­ 2015 going­ through­ the­ low­ budget,­ inadequate­ logistics,
Number­ 96623.­ Washington,­ D.C.:­ World­ Bank­
http://documents.worldbank.org/curated/en/686591467986284082/The-path-to-universal-
Group. insufficiently­skilled­workforce­and­huge­amount­of service
health-coverage-in-Bangladesh-bridging-the-gap-of-human-resources-for-health
1. Kazi Musa, PhD Scholar, Accounting Research Institute (ARI), UniversitiTeknologi MARA, Shah
Alam, Malaysia, 40450

2. Professor Dr Jamaliah Said, PhD. Deputy Director, Research and Networking, Accounting
Research Institute (ARI), Level 12, SAAS Building, UniversitiTeknologi MARA Malaysia,
40450,UiTM Shah Alam, Selangor, MALAYSIA,

3. Dr. Farhana Begum. BCom (Honors) MCom. MPhil, PhD. Accounting, Postdoctoral Scholar,
Accounting Research Institute (ARI), UniversitiTeknologi MARA (UITM) 40450, Shah Alam
Selangor, Malaysia.

65 Global­Healthcare Global­Healthcare 66
demand­then­the­capability­has­shrunk­its­service­capability.
Consequently,­ people­ are­ being­ forced­ to­ find­ health
services­from­the­private­sector­at­a­high­price.­However,
private­participation­that­includes­out­of­pocket­expenditure
and­non-government­participation­for­health­care­financing
is­ around­ 75%­ of­ total­ expenditure.­ Considering­ these
challenges­ government­ has­ adopted­ several­ short-term,
medium­ and­ long-term­ policies.­ According­ to­ National
Health­ Policy,­ health­ budget­ is­ likely­ to­ be­ 15%­ of­ total
budget­ and­ out­ of­ pocket­ health­ expenditure­ will­ be
reduced­to­32%­from­the­current­level­of­70%­or­above.
This­chapter­aims­to­discuss­the­evolution­of­health­policy
and­health­budget­of­Bangladesh.
Keywords: Health­policy;­health­budget;­Bangladesh;­out
of­pocket­health­expenditure;­primary­health­care
Health Policy:
Bangladesh­ is­ one­ of­ the­ emerging­ countries­ despite
having­ numerous­ challenges­ in­ every­ sector.­ Since­ the
independence­ in­ 1971,­ the­ country­ has­ been­ trying­ to
establish­its­institutions­to­serve­the­people.­Unfortunately,
it­ has­ passed­ through­ most­ of­ its­ time­ with­ considerable
political­ unrest,­ authoritarian­ regimes,­ and­ weak
democratic governments.­As­a­result,­the­country­is­still
experiencing­a­fragile­instructional­system­even­in­this­age
of­ modern­ civilization.Reportedly,­ health­ care­ sector­ is
also­ a­ part­ of­ the­ whole­ institutional­ system­ and­ moving
forward fighting­ against­ many­ adversities.­ Despite­ the
adversities,­ this sector­ has­ been­ considered­ as­ one­ of
the­ prioritized sectors­ since­ independence­ and­ recent
progressive leadership­ achieved­ significant­ improvement
in­last­decade.
Bangladesh­has­experienced­many­ups­and­downs­on­its
67 Global­Healthcare
way­ to­ develop.­ At­ present­ the­ country­ has­ a­ relatively
strong­public­and­private­health­care­system­and­achieved
Millennium­Development­Goals­as­(MDG)-4­focusing­on
the­key­indicators­including­maternal­death,­immunization
coverage,­and­survival­from­some infectious­diseases­such
as­malaria,­tuberculosis,­and­diarrhea­(1).­Progress­toward
better­ health­ systems­ has­ shown­ tremendous improvement
in­Bangladesh.­For­example,in 2018, child­mortality­rate
for Bangladesh was­30.2­deaths­per­1,000­live­births­fell
gradually from 224.1­ deaths­ per­ 1,000­ live­ births in
1969.­In­term­of­life­expectancy­for­Bangladesh­in­2019
was 72.43 years,­ increase from­ 2018­ was 72.15 years
and­ in­ 2017­ was 71.88 years.­ Similarly,­ Human
Development­ Index­ (HDI)­ which­ measures­ a­ composite
index of­ life­ expectancy,­ education,­ and­ per­ capita
income­ has­ showed­ that­ between­ 1990­ and­ 2018,
Bangladesh’s­HDI­value­increased­from­0.388­to­0.614,­an
increase­of­58.3­percent­indicating­good­progress.­Despite
improving,­ Bangladesh­ still­ facing­ poor­ access­ to­ health
service,­ low­ quality­ of­ care,­ high­ rate­ of­ mortality­ and
poor­ status­ of­ child­ health­ (14)­ compare­ to­ most­ other
surrounding­developing countries.
Historically,­ before­ 1947,­ Bangladesh­ was­ the­ part­ of
India­under­the­British­colony­and­at­that­time­health­care
system­ mainly­ was­ urban­ based.­ Rural­ and­ peripheral
health­ care­ facility­ was­ mainly­ dependent­ on­ quack,
conventional­ progenitors,­ and­ kaviraj­ (traditional
healer/quack).­In­1946,­for­the­first­time,­a­Health­Survey
and­Development­Committee­was­formed­named­“Bhore
Committee”­ to­ develop­ a­ national­ health­ care­ system­ all
over­ the­ country­ (2).­ The­ committee­ proposed­ a
comprehensive­ health­ care­ policy­ “Inter­ Alia”­ for­ all.
After­the­colonial­period,­until­1947­Bangladesh­was­the
Global­Healthcare 68
part­of­Pakistan­and­also­continued­almost­similar­urban-
based­health­care­facilities.During­1960,­some­health­policies
have­ been­ recommended­ under­ “Inter­Alia”­ ­ such­ as­ (a)
scheme­ of­ Rural­ Health­ Systems,­ comprising­ one­ rural
health­center­and­three­sub­centers­for­every­50­000­people;
(b)­Malaria­Eradication­Program;­and­(c)­Family­Planning
Program­that­over­time­turned­into­a­department­under­the
Ministry­of­Health­and­Family­Welfare­(MoHFW)­(2).­
The­ first­ five-year­ health­ care­ policy­ has­ adopted­ after
independence­ in­ 1972­ and­ which­ was­ extended­ to­ 1980.
The­ policy­ focused­ on­ some­ primary­ health­ care­ (PHC)
issues­recommended­by­the­“Alma-Ata­Declaration”­1978
(2).­Following­the­declaration,­the­government­set­up­31
bed­ Upazila­ Health­ Complex­ in­ remote­ sub-districts­ in
second­and­third­five-year­plans­(2).­Within­the­year­2000
by­ third­ and­ fourth­ five-year­ health­ care­ policy,­ the
government­has­taken­several­initiatives­to­develop­viable
health­ care­ systems­ all­ over­ the­ country­ which­ deserves
praise­ indeed.­ The­ key­ initiatives­ were­ Expanded
Programme­on­Immunization­(EPI),­Control­of­Diarrhoeal
Diseases­ (CDD),­ the­ Acute­ Respiratory­ Infection­ (ARI)
Control­ Project­ and­ the­ Night­ Blindness­ Prevention
Programme­during­the­period.­
In­the­nineties,­the­Bangladesh­government­modernize­its
health­care­sector­and­consists­relatively­a­strong­structure
of­ the­ health­ care­ system­ along­ with­ the­ World­ Bank,
World­Health­Organization­(WHO)­and­other­stakeholders.
Structural­ improvements­ have­ been­ modernized­ by­ the
Ministry­of­Health­and­Family­Welfare­(2).­In­1997,­another
significant­strategy­adopted­to­create­more­organized health
care­ institutions­ and­ a­ cost-effective­ medical­ system for
everyone­ was­ Health­ and­ Population­ Sector­ Strategy
(HPSS)­(2).­
69 Global­Healthcare
From­ 1998­ to­ 2002­ Bangladesh­ government­ has­ been
concentrating­on­the­principles­of­HPSS.­In­the­meantime,
the­first­National­Health­Policy­has­been­drafted­in­2000
but­ not­ start­ actions.­ However,­ in­ 1998­ another­ program
designed­ called­ Health­ and­ Population­ Sector­ Program
(HPSP)­implemented­within­2003­respectively.­Afterward,
the­ government­ set­ up­ a­ new­ target­ named­ Health
Population­ and­ Nutrition­ Sector­ Program­ (HPNSP)­ for
2003­ to­ 2010.­After­ 2000,­ the­ government­ emphasis­ on
nutrition,­community-based­health­care­system,­developing
skilled­manpower,­nursing­system­and­so­on­followed­by
the­health­policies.
After­its­expiry,­the­government­designed­policy­for­2011
to­2016­were­focused­on­improving­nutrition­and­uphold
its­service­in­multiple­levels­under­the­health­care­policy
of­ MoHFW,­ 2011.­ However,­ it­ was­ the­ first­ completed
National­Health­Policy­(NHP)­revised­of­NHP­2000­and
addressed­ most­ of­ the­ issues­ concerning­ to­ country’s
health­care­delivery­system­including­national­health­care
expenditure­ in­ the­ national­ budget­ (3,4).­ However,­ the
general­goals­of­NHPs­are­health­care­service­for­all­people,
special­facilities­for­the­marginal­people,­deliver­primary
health­ care­ facilities­ at­ the­ union­ and­ Upazila­ levels,
improve­maternal­as­well­as­child­health­facilities,­increase
reproductive­health­facilities­and­strengthen­family planning
services­(5).
Though­ the­ health­ care­ sector­ of­ Bangladesh­ has­ many
weaknesses­and­the­most­recent­fifth-year­plan­focus­on­to
overcome­ the­ drawbacks­ as­ well­ as­ to­ strengthen­ the
previously planned­ policies.­ However,­ the­ Ministry­ of
Health­and­Family­Welfare­of­Bangladesh­planned­2017­to
2022­ health­ care­ policy­ by­ considering­ sector-wide
approach­ (SWAp)­ to­ achieve­ the­ goals­ of­ health-related
Global­Healthcare 70
goals­of­SDG­popularly­known­as­4th­Health,­Population
and­Nutrition­Sector­Program­(4th­HPNSP)­(9).­Parallelly
the­ country­ is­ following­ the­ long-run­ health­ care­ goals
projected­by­the2012­to­2032­Health­Care­Strategy.
These­ key­ points­ have­ been­ developed­ inline­ with­ the
recommendations­ of­ World­ Health­ Organization­ (WHO)
and­ governments’­ long-run­ health­ care­ Sustainable
Development­ Goal(SDG).Therefore,­ MoHWFworking
with­several­of­short-run,­medium­and­long-run­policies­to
achieve­its­projected­goals.The­next­section­analyses­the
health­ budget­ trend­ in­ Bangladesh­ to­ assess­ whether­ the
health­budget­consistent­with­the­budget­policy.

Health Budget:
Health­ care­ financing­ in­ one­ of­ the­ prime­ sectors­ of­ the
national­budget­of­any­country.­Bangladesh­has­considerable
progress­in­the­health­care­sector­but­these­days­government
health­ care­ expenditure­ is­ in­ a­ downward­ trend­ (3).
Consequently,­out­of­pocket­expenditure­is­enlarging­and
Independence
people­ are­ facing­ hardship­ for­ managing­ health­ care
Traditional health 5 years health Adopted multiple Adopt long
system. care policy health policy and run policy to expenditure­from­their­daily­budget­or­savings­(11).­The
Mainly dependent adopted. follow MDG minimize OOP matter­ of­ hope­ is­ the­ government­ has­ taken­ some­ recent
on quack,
traditional Kaviraj
Health facilities
reached to
health Goals.
Private health
and increase
govt. health
initiatives­ to­ increase­ the­ health­ budget­ to­ release­ this
and urban based village level cost increased expenditure burden from­people­by­adopting­its­first­National­Health
few hospitals Policy­(NHP)­2011.­
Figure 1: Evolution of health facilities of Bangladesh Constitutionally­ people­ of­ Bangladesh­ have­ the­ right­ to
have­access­to­health­care­services­from­the­government.
Key­Points­of­2012-2032­Health­Care­Strategy:­ As­ the­ government­ should­ set­ up­ a­ health­ care­ budget
n Support­ information­ exchange­ platform/knowledge according­to­the­priority.­However,­it­is­sad­to­say­that­the
hub/resources­pool­ continuous­ health­ care­ sector­ is­ disdained­ in­ budgetary
n Develop­the­capacity­to­design­and­manage­the­social allocation.­Moreover,­the­WHO­also­emphasized­allocating
health­protection­scheme­ in­this­sector­at­least­15%­of­the­whole­budget­to­develop
n Strengthen­Financial­Management­and­Accountability­ the­ nation-wide­ health­ facility­ (6).­ Unfortunately,­ the
n Improve­monitoring­and­evaluation­ actual­budget­allocation­in­this­sector­is­far­away­from­the
n Introduce­ mechanisms­ to­ support­ the­ production­ of recommendation of­national­and­international­development
additional­ key­ staff­ (nurses,­ paramedics­ and­ medical organizations­ and­ the­ constitutional­ constraint­ of­ the
technicians). country.

71 Global­Healthcare Global­Healthcare 72
Chart­1.1­shows­that­government­health­expenditure­is­in­a
decreasing­ mode­ and­ far­ below­ the­ recommended
allocation­by­World­Health­Organization­(WHO)­which
recommended that­ a­ country­ has­ to­ allocate­ at­ least­ 5
percent of­GDP­for­healthcare­to­facilitate­equal­access­of
citizen.­ Currently­ the­ Bangladesh­ governmentallocated­ less
than­1­percent­of­GDP­on­health­sector.­This­percentage in­fact
the­lowest­allocation­compare­to­other­South­Asian­countries
Another­ significant­ point­ is­ in­ 2000,­ health­ expenditure
was­ 5.209­ percent­ of­ total­ expenditure­ wherein­ 2017
health­ expenditure­ was­ only­ about3­ percent­ which­ is­ far
lower­ than­ the­ last­ decade.­ In­ recent­ years­ health­ care
expenditure­has­been­increased­in­amount­but­comparative
share­of­whole­budge­is­in­a­diminishing­mode.In­a­word
it­can­be­said­that­based­on­the­data,­the­effort­of­government
on­this­sector­was­stronger­in­previous­decade.­
Chart 1: Domestic general government health expenditure
(% of general government expenditure) (13)
73 Global­Healthcare
Chart­ 2­ indicates­ that­ almost­ every­ year­ private­ health
expenditure­is­thriving­in­Bangladesh.­In­the­recent­year
2017,­it­was­reported­about­77­percent­of­health­expenditure
is­shared­privately.­On­the­contrary­government­is­sharing
only­ 17­ percent­ in­ the­ same­ year.­ However,the­ scenario
was­relatively­tolerant­in­the­year­of­2000­and­share­of­private
health­expenditure­was63%.­Another­significant­point,­in
some­year’s­private­expenditure­spikes­reportedly­in­2001,
2005,­ and­ 2015­ which­ means­ in­ those­ specific­ years
governments’­health­budget­was­low.­Chart­2­is­showing
the­effort­of­government­was­relatively­low­those­specific
years.­However,­in­recent­years­private­health­expenditure
is­ more­ than­ 70%­ and­ still­ has­ an­ increasing­ trend.
Besides,­ the­ government­ is­ contributing­ only­ about­ 20%
share­and­the­rest­of­the­portion­is­carried­by­the­different
types­ of­ national­ and­ international­ aids.­As­ it­ is­ hard­ to
avail­health­care­facilities­for­the­marginalized­people­and
even­ many­ solvent­ families­ become­ destitute­ to­ avail
health­facilities­in­an­emergency.
Chart 2: Domestic private and general government health
expenditure (% of current health expenditure) (13)
Global­Healthcare 74
Besides,­ these­ two­ major­ participants­ in­ health­ care
expenditure­ some­ aids­ from­ national­ and­ international
agencies­ also­ helping­ to­ ease­ the­ whole­ sector.­ So,­ the
overall­summary­of­the­chart­is­governments’­share­is­in
downward­ trend­ and­ private­ or­ peoples’­ expenditure­ is
increasing­gradually.­­

In­addition,­statistics­show­that­the­Bangladesh­government
shares­ a­ relatively­ lower­ portion­ of­ total­ health
expenditure­ as­ out­ of­ pocket­ (OOP)­ payment­ is
higher­ in­ the­ country.­ Government­ per­ capita­ health
allocation­is­considered­a­significant­factor­in­the­financial
sustainability of­ the­ whole­ healthcare­ sector­ all­ over­ the
world­ (7).­ Many­ health­ care­ experts,­ as­ well­ as­ national
and­ international­ development­ organizations,­ have­ been
recommending­to­the­Bangladesh­government­to­increase
its­ health­ care­ expenditure.­ Especially,­ WHO­ had­ specific
recommendations during­ the­ drafting­ of­ National Chart 3: Current Health Expenditure Per Capita of
Health­ Policy.­ The­ proposed per­ capita­ health­ care Bangladesh (Current US$) (13)
budget­ of­ WHO­ was­ USD34­ which­ is­ revised­ and
increased­to­USD54­recently­(8).­Where,­the­reality­is­per Within­many­uncertainties­still,­the­hope­is­long-term­policy
capita­budget­is­only­USD31­in­2015­(8).­ of­2012­to­2032­Health­Care­Financing­(HCF)­policy.­The
budgetary­ significance­ of­ the­ HCF­ is­ within­ the­ 2032
However,­chart­3­shows­similar­data­on­per­capita­health government­will­decrease­the­OOP­to­32%.­The­rest­of­the
expenditure­of­Bangladesh.­­From­the­point­of­view­of­per health­ care­ financing­ will­ be­ supported­ specifically­ by
capita­ expenditure­ in­ health­ care­ sector­ is­ in­ a­ smooth 30%­of­the­government­expenditure,­another­32%­by­the
upward­trend­since­2000­to­2017­(based­on­data­availability). social­ health­ protection­ fund­ and­ another­ 6%­ from­ the
In­ 2017,­ the­ per­ capita­ expenditure­ reached­ to­ USD36 external­sources.­HCF­2012-2032­defines­health­protection
which­was­only­USD8­in­2000.­In­addition,­this­consistent as­community­health­insurance­and­external­sources­mean
improvement­in­health­expenditure­helped­Bangladesh­to foreign­aids­or­any­other­donations­(10).­But­recent­health
achieve­ MDG­ goals­ and­ still­ helping­ to­ reach­ SDG­ and care­budget­is­frustrating­which­shows­the­government­has
national­projected­health­care­policies.­ little­interest­in­implementing­this­policy.­

75 Global­Healthcare Global­Healthcare 76
How to Achieve the Goal:
In­ summary,­ it­ was­ obvious­ that­ there­ is­ mismatch
between­health­policies­and­health­budget­of­Bangladesh.
It­seems­that­the­government­is­more­serious­to­formulate
new­health­policies­without­adequate­health­budget­allocation
for­this­sector.It­has­developed­and­accepted­several­policies
concurrently,­but­the­actual­output­is­frustrating.­Though­it
has­ some­ positive­ and­ quick­ effects­ in­ the­ health­ care
sector­there­has­been­a­lack­of­adherence­to­the­specific
policy­as­well.­Moreover,­budgetary­shortage­and­unequal
distribution­of­resources­drive­this­sector­towards­a­stagnant
situation.­As­capitalist­corporatism­has­occupied­this sector
to­maximize­their­profit­in­the­scope­of­governments’­apathy
and­ultimate­sufferers­are­awfully­general­people.­
However,­ Bangladesh­ has­ a­ tolerable­ level­ of­ healthcare
infrastructure­all­over­the­country,­but­the­real­shortage­is
skilled­ health­ care­ manpower­ and­ logistics­ where­ the
government­ has­ already­ taken­ into­ consideration­ to
improve.­Workforce­shortage­cannot­be­solved­in­a­short
time,­ as­ government­ has­ positive­ gesture­ to­ adopt­ short
run,­ medium­ and­ long-run­ strategies­ to­ achieve­ the
projected­targets­both­in­public­and­private­sectors.­
Adopted­ fifth-year­ plans­ and­ in­ multiple­ policies,it­ has
been­ paid­ significant­ attention­ onCommunity­ Clinic­ to
delivery­health­care­facilities­towards­grassroots­level.­But
this­ facility­ is­ facing­ considerable­ weakness.Fortunately,
government­ also­ taken­ many­ initiatives­ to­ overcome­ the
weakness.­ Besides,­ some­ other­ significant­ affirmative
initiatives­ to­ achieve­ SDG­ goals­ are­ reinforcingUpazila
Health­Complexes­and­district-based­health­care­facilities
to­enable­them­to­function­as­the­principal­service hospitals
77 Global­Healthcare
for­the­general­people.­So,­a­lot­of­work­being­done­at­the
same­ time­ to­ achieve­ health­ care­ linked­ SDG­ goals­ and
outcomes­will­be­seen­in­the­near­future.
Within­ 2032,­ Bangladesh­ government­ prioritized­ to
decrease­ out­ of­ pocket­ (OOP)­ expenditure­ to­ 32%­ and
working­ hard­ to­ implement­ its­ major­ policies­ (10).
Consequently,government­also­pay­paramount­importance
to­increase­its­share­of­health­care­expenditure­andto­ease
the­overall­health­care­situation­of­the­country.­If­the policies
work­smoothly­then­individual­health­expenditure­will­be
decreased­ and­ people­ may­ avail­ health­ facilities­ more
comfortably.­
Some­recent­outbreak­such­as­Dengue­and­Chikungunya
show­ how­ challenging­ to­ fight­ against­ these­ calamities
with­the­existing­conventional­health­care­system.­It­will
be­a­mess­if­the­country­is­stricken­by­a­major­epidemic­or
pandemic.­However,­governments’­recent­sentient initiatives
to­ strengthen­ its­ medical­ facilities­ for­ everyone­ to­ fight
against­ any­ catastrophe­ are­ praiseworthy­ but­ these
initiatives­ are­ still­ on­ the­ way­ to­ improve.­ Moreover,
government­ has­ some­ special­ facilities,­ fund­ and­ health
care­ policy­ to­ fight­ against­ epidemic­ or­ pandemic­ like
Corona­ Virus­ outbreak,­ dengue­ and­ other­ natural
disasters.As­a­developing­country­and­having­a­burden­of
huge­population­still­it­is­difficult­to­handle­any­significant
adversity­ all­ alone.­ Thus,­ the­ country­ is­ working­ to
achieve­its­projected­policies­along­with­the­goals­of­SDG.
Global­Healthcare 78
Appendix:­

Used­health­care­data­of­Bangladesh­from­World­Bank­
References:
Biswas­T,­Pervin­S,­Tanim­MI,­Niessen­L,­Islam­A.­Bangladesh­policy­on­prevention­and­control­of
non-communicable­diseases:­a­policy­analysis.­BMC­Public­Health.­2017­Dec­1;­17(1):582.
World­Health­Organization.­Bangladesh­health­system­review.­Manila:­WHO­Regional­Office­for
the­Western­Pacific;­2015.
Fahim­SM,­Bhuayan­TA,­Hassan­MZ,­AbidZafr­AH,­Begum­F,­Rahman­MM,­Alam­S.­Financing
health­care­in­B­Bangladesh:­policy­responses­and­challenges­towards­achieving­universal­health
coverage.­The­International­journal­of­health­planning­and­management.­2019­Jan;­34(1):e11-20.
Mahumud­ RA,­ Sultana­ M,­ Sarker­AR.­Trend­ of­ healthcare­ expenditures­ in­ Bangladesh­ over­ last
decades.­Am­J­Econ­FinancManag.­2015;­1:97-101.
Osman­ FA.­ Health­ policy,­ programmes­ and­ system­ in­ Bangladesh:­ achievements­ and­ challenges.
South­Asian­Survey.­2008­Sep;­15(2):263-88.
Annual­Financial­Statement­(Budget)­Bangladesh:­Ministry­of­Finance,­Government­of­the­People’s
Republic­of­Bangladesh.­Available­from:­http://www.mof.gov.bd/en/
Mahumud­RA,­Sarker­AR,­Sultana­M,­Islam­Z,­Khan­J,­Morton­A.­Distribution­and­determinants­of
out-of-pocket­ healthcare­ expenditures­ in­ Bangladesh.­ Journal­ of­ Preventive­ Medicine­ and­ Public
Health.­2017­Mar;­50(2):91.
Hassan­MZ,­Fahim­SM,­Zafr­AH,­Islam­MS,­Alam­S.­Healthcare­financing­in­Bangladesh:­chal-
lenges­and­recommendations.­Bangladesh­Journal­of­Medical­Science.­2016­Dec­18;­15(4):505-10.
Annual­ Health­ Bulletin­ of­ Bangladesh:­ Ministry­ of­ Health­ &­ Family­ Welfare­ of­ Bangladesh.
Available­from:­https://dghs.gov.bd/index.php/en/home/4364-health-bulletin-2018
Ministry­of­Health­and­Family­Welfare.­Expanding­Social­Protection­for­Health:­Towards­Universal
Coverage:­Health­Care­Financing­Strategy­2012–2032.
Begum­ F,­ Alam­ S,­ Hossain­ A.­ Funds­ for­ treatment­ of­ hospitalized­ patients:­ evidence­ from
Bangladesh.­Journal­of­health,­population,­and­nutrition.­2014­Sep;­32(3):465.
Ministry­of­finance­Bangladesh.­Available­from:­http://www.mohfw.gov.bd/
World­Bank­data­bank.­Available­from:­https://databank.worldbank.org/source/world-development-
indicators­2020
Ferdous,­AO.­ (2008).­ “Health­ Policy­ Programmes­ and­ System­ in­ Bangladesh:­Achievements­ and
Challenges”.­South­Asian­Survey,­263-288

79 Global­Healthcare Global­Healthcare 80
Chapter­7
Political Economy of Healthcare
Financing in Bangladesh
Shah­Mohammad­Fahim1,­Shahinul­Alam2
Abstract
Healthcare­ in­ Bangladesh­ is­ underfunded;­ and­ therefore,
suffering­ from­ scarcity­ of­ resources­ in­ controlling­ many
global­ public­ health­ concerns.­ The­ major­ concern­ is
indiscriminate­ use­ of­ the­ allotted­ budgetary­ share­ for
health­throughout­the­health­systems­due­lack­of­political
commitment,­ absence­ of­ transparency­ in­ the­ resource
allocation and­ bureaucratic­ resistance.­ Moreover,­ the
health­ system­ of­ the­ country­ exhibits­ a­ continuous
contradiction between­the­expectations­of­the­people­for
a­free-of-cost­decent­healthcare­and­lack­of­coordination
within­the­healthcare­system­regarding­the­resource­allocation.
Political­leaders­either­in­the­government­or­in­the­opposition
are­negligent­about­healthcare­financing.­Civil­society­are
scared­of­about­health­system­and­financing.­Bureaucracy
alone­ can’t­ be­ able­ to­ explore­ the­ depth­ and­ extent­ of
health­system­without­professional­experts.­A­capitalistic
1. Dr. Shah Mohammad Fahim, MBBS, MPH, Research Investigator, Nutrition and Clinical
Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh
(icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
2. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
81 Global­Healthcare
attitude­are­harboring­in­the­mindset­educated­and­affluent
societies.­So­many­issues­are­raised­by­the­social­organization
but­not­the­healthcare­financing:­allocation,­corruption­and
good­governance.­We­recommend­a­strong­political­commitment
among­the­law-makers­as­well­as­determination­among­the
stakeholders­to­ensure­proper­allocation­and­utilization­of
scarce­resources­of­the­country.
Key words: Healthcare­financing;­Bangladesh;­governance;
health­ care­ delivery­ system;­ medical­ education;­ political
commitment.
Introduction
Healthcare­in­most­of­the­low-­and­middle-income­countries
are­ underfunded,­ and­ Bangladesh­ is­ not­ an­ exception
(1,2).­ Despite­ substantial­ improvement­ in­ most­ of­ the
health­indicators,­the­country­is­suffering­from­scarcity­of
resources­ in­ controlling­ many­ global­ public­ health
concerns­ (3).­ The­ health­ system­ of­ the­ country­ is
characterized by­poor­funding,­lack­of­access­to­essential
healthcare­and­inequity­in­utilization­of­healthcare­services
(2,4).­Amidst­of­such­disappointing­healthcare­system,­the
country­ did­ extremely­ well­ in­ achieving­ health­ related
millennium­ development­ goals­ (MDGs),­ reducing­ child
and­ maternal­ mortalities,­ improving­ immunization­ and
vaccination­status throughout­the­country,­and­reduction­of
major­public­health­threats­including­infectious­diseases­and
malnutrition­(5,6).­Therefore,­the­healthcare­of­the­country
is­termed­as­a­paradox7.­
Bangladesh­ has­ a­ well-organized­ hierarchy­ in­ healthcare
delivery­ systems­ from­ primary­ to­ tertiary­ care,­ although
questions­remain­whether­the­system­is­functioning­or­not8.
According­ to­ World­ Health­ Organization­ (WHO),­ the
Global­Healthcare 82
persistent­ challenges­ in­ the­ health­ system­ of­ Bangladesh
are­a­highly-centralized­healthcare­delivery­system,­weak
governance,­lack­of­management­and­institutional capacity
in­ the­ regulatory­ authority,­ and­ inadequate­ financial
resource­ allocation­ as­ well­ as­ inefficient­ use­ of­ the
resources­(9,10).­There­also­prevails­challenges­in­ensur-
ing­primary­care­health­services­and­providing­specialized
care­due­to­poor­maintenance­of­healthcare­facilities­and
medical­equipment­(4).­The­news­media­frequently­report
that­most­of­the­costly­medical­equipment­procured­by­the
government­ for­ public­ healthcare­ facilities­ remain
uninstalled­ or­ malfunctioned.­ All­ these­ issues­ can­ be
attributable­ to­ the­ inbuilt­ political­ economy­ persistent
within­the­health­system­of­the­country.­
Discussion
In­Bangladesh,­the­major­concern­is­indiscriminate­use­of
the­allotted­share­throughout­the­health­systems­due­lack
of­ political­ commitment,­ absence­ of­ transparency­ in­ the
resource­allocation­and­bureaucratic­resistance.­The budgetary
share­for­healthcare­and­education­–­two­vital­sectors­for
national­ development – is­ very­ low.­ A­ prominent
Bangladeshi­ anthropologist­ mentioned­ in­ his­ book­ that
when­the­country­buys­a­new­fighter­jet,­the­professor­in­a
public­medical­college­express­his­sheer­frustration­due­to
loss­ of­ an­ indispensable­ surgical­ instrument­ from­ the
operation­ theatre.­ This­ comment­ indicates­ the­ lack­ of
essential­instruments­even­in­the­public­medical­colleges
while­ a­ beefy­ share­ of­ budget­ is­ allocated­ for­ sectors
considered­politically­vital­by­the­law­makers.­
Social-origin,­income­status­and­occupation­prestige­of­the
law-makers­ as­ well­ as­ bureaucrats­ have­ potential­ role­ in
83 Global­Healthcare
the­reform­of­the­health­systems­ (11).­Therefore,­most­of
the­ reforms­ as­ well­ as­ decisions­ support­ the­ upper­ or
upper-middle­ class­ of­ the­ society.­ Civil­ surgeon­ and
UHFPO­are­the­administrative­posts­in­the­health­system­of
the country.­ The­ success­ of­ any­ administrative­ authority
depends­ on­ the­ capacity­ of­ the­ administrative­ capacity,
organizational­ capability,­ leadership­ skills­ and­ subject
expertise.­However,­there­remains­lack­of­commitment­to
train­ the­ administrative­ officers­ of­ the­ health­ systems.­ The
bureaucratic­resistance­as­well­as­inadequate­plan­from­the
government­ remain­ the­ major­ barriers­ for­ the­ inefficient
administrative­skills­in­the­hierarchy­of­the­health­systems
in­Bangladesh.
The­ country­ is­ also­ vulnerable­ for­ any­ public­ health
emergencies,­ for­ instance,­ epidemic­ or­ pandemic.­ The
recent­ incidence­ of­ Covid-19­ pandemic­ is­ the­ perfect
example­ of­ unpreparedness­ of­ health­ systems­ regarding
any­emergencies.­An­UNO­get­government­transport­costs
approximately­10­million­BDT,­where­the­doctors­works
in­ the­ same­ facility­ don’t­ get­ a­ single­ mask­ to­ treat­ the
patients­in­any­kind­of­emergency.­In­recent­Corona­virus
pandemic,­the­govt­only­allotted­100­crore­BDT­to manage
the­ case,­ and­ there­ remains­ extreme­ shortage­ of­ PPE
initially­for­the­physicians­throughout­the­health­systems.­A
government­ circular­ was­ issued­ in­ a­ largest­ medical
college­ hospital­ requesting­ doctors­ to­ buy­ the­ protection
equipment­of­his­own. The­qualitty­of­PPE­is­also­a burning
issue­till­now,­The­health­system­of­the­country­exhibits­a
continuous­contradiction­between­the­expectations­of­the
people­ for­ a­ free-of-cost­ decent­ healthcare­ and­ lack­ of
coordination­within­the­healthcare­system­regarding­the
resource allocation­ (12).­Although­ healthcare­ services
Global­Healthcare 84
in­public hospitals­of­Bangladesh­are­cheap,­there­remain
lack­of­adequate­facilities­for­specialized­care­and­shortage
of­skilled­health­workforce.­Most­of­the­specialized­facilities
and­skilled­healthcare­professionals­are­clustered­in­urban
areas,­ particularly­ in­ Dhaka­ (7).­ The­ health­ stewardship
often­argues­that­high­turnover­for­post-graduation­and
absenteeism­of­health­workers­in­peripheral­health facilities
are­responsible­for­such­clustering.­­However,­the­health
system­is­not­well­organized­and­the­blames­are­given­only
to­doctors,­while­there­lacks­a­well-coordinated­system­to
manage­the­patients.­The­number­of­healthcare­personnel
is­ very­ low­ in­ relation­ to­ the­ requirement­ to­ support­ the
health­ system­ in­ entire­ country.­ Evidence­ showed­ that
there­remains­a­severe­gap­between­sanctioned­and­filled
health­worker­positions­in­Bangladesh­(10).­
Dominance­ of­ the­ private­ sector­ in­ healthcare­ is­ a
common­phenomenon­in­the­developed­countries.­In­those
countries,­ public­ hospitals­ do­ not­ provide­ most­ of­ the
medical­services­need­by­the­people.­The­health­system­of
Bangladesh­ is­ also­ shifting­ towards­ that­ phenomenon.
Private­medical­colleges­and­healthcare­facilities­are­being
established­ considering­ only­ the­ financial­ benefits­ while
questions­ remain­ regarding­ services­ and­ quality­ of­ the
care.­Moreover,­the­lack­of­regulation­of­the­private­sector
is­ another­ concern.­ Private­ healthcare­ industry­ employs
more­ than­ two­ third­ of­ all­ physicians.­ But­ there­ is­ no
appropriate­regulatory­framework­for­capacity­development
as­well­as­utilization­of­these­healthcare­professionals­in
the­country.­
Rapid­growth­of­population,­double­burden­of­infectious
and­ non-communicable­ diseases­ as­ well­ as­ over-­ and
undernutrition,­and­poor­infrastructure­to­respond­to­any
healthcare­emergencies­are­the­major­challenges­of­in­the
85 Global­Healthcare
health­ system­ of­ Bangladesh.­ Hence,­ there­ should­ be
prioritization­in­financial­resource­allocation­for­efficient
and­effective­management­of­these­issues­in­an­equitable
manner.­ Moreover,­ in­ order­ to­ achieve­ universal­ health
coverage,­ there­ should­ be­ a­ strong­ political­ commitment
for­ adequate­ public­ healthcare­ expenditure­ by­ the
government.­ However,­ the­ scenario­ is­ not­ that­ much
satisfactory.­
The­prioritization­for­public­spending­more­often­depends
on­numerous­political­factors­and­bureaucratic­decisions.
Although­scientific­evidence­suggests­that­total­healthcare
expenditure­ by­ the­ government­ should­ be­ increased­ in
Bangladesh­ in­ order­ to­ combat­ all­ the­ healthcare
challenges,­ it­ seems­ to­ be­ out­ of­ the­ political­ agenda.
Therefore,­the­budgetary­share­of­healthcare­is­declining
in­ Bangladesh­ resulting­ in­ skyrocketing­ of­ the­ out-of-
pocket­expenditure.­Moreover,­the­centralized­healthcare
system­is­contributing­to­the­distribution­of­the­resources
to­ the­ top­ or­ highest­ facilities­ resulting­ in­ scarcity­ of
resources­in­local­or­deprived­areas.­In­addition,­corruption
is­ another­ major­ concern­ in­ healthcare­ financing­ of­ the
country.­In­most­of­the­cases,­those­who­are­involved­in
resource­ distribution­ have­ strong­ political­ connections,
and­they­are­also­reported­to­be­corrupted.­Owing­to­their
political­stand,­it­is­almost­impossible­to­ensure­equitable
distribution­of­the­resources.­
Political­commitment­for­health­care­service­in­Bangladesh
were­ neither­ highlighted­ nor­ being­ loudly­ spoken.
Interestingly­public­demand­in­this­aspect­was­never­raised
from­any­of­the­forum.­The­print­and electronic­media­or
the­ civil­ society­ never­ shouted­ in­ a­ manner­ for­ general
demand.­ The­ capitalistic­ society­ could­ find­ their­ place­ of
Global­Healthcare 86
regular­ checkup­ or­ health­ tourism­ in­ abroad­ funded­ by
black­money.­Even­in­national­election­the­political­parties
do­not­commit­strongly­for­a­better­health­care­system­of­the
country.­ In­ city­ corporation­ and­ other­ local­ government
election­a­very­few­words­are­expressed­in­election­manifesto
by­ competing­ person­ and­ parties.­ So­ till­ now­ health­ care
financing­could­not­achieve­the­position­of­political­agenda
of­the­country.­All­these­issues­require­to­be­managed­by­the­law
makers­by­considering the­issue­as­a­political­agenda­and
introducing­ an evidence-based­ model­ for­ allocating­ and
utilization­of­the­public­healthcare­funding.­
Conclusion
The­ constitution­ of­ Bangladesh­ is­ committed­ to­ ensure
health­for­all­citizen,­and­that­is­highlighted­in­the­health
policy­as­well.­But­the­commitment­does­not­reflect
during the­ allocation­ of­ the­ budgetary­ share­ for­ public
healthcare­ funding.­ The­ politics­ pertaining­ to­ decision
making­ in­ resource­ allocation­ and­ efficient­ utilization­ is
more­ complex­ and­ plays­ the­ vital­ role­ in­ financial
management­ of­ healthcare­ funding­ in­ the­ country.
Therefore,­ the­ healthcare­ in­ Bangladesh­ is­ facing­ terrible
situations­ regarding­ financial­ aspects.­ The­ rapidly­ increasing
healthcare­ costs­ coupled­ with­ inadequate­ number­ of
healthcare­ professionals,­ lower­ proportion­ of­ national
budget­ spent­ on­ health­ and­ privatization­ of­ essential
healthcare­services­are­the­major­concern­of­the­healthcare
systems­in­the­country.­We­recommend­a­strong­political
commitment­among­the­law-makers­and­all­political­parties
as­ well­ as­ determination­ in­ health­ stewardship­ and
stakeholders­to­solve­the­issues­and­ensure­proper­utilization
of­scarce­resources­to­achieve­essential­health­services­for
citizens­of­the­country.­
87 Global­Healthcare
References:
1. Mills A. Health care systems in low-and middle-income countries. New England Journal of
Medicine. 2014;370(6):552-557.
2. Fahim SM, Bhuayan TA, Hassan MZ, et al. Financing health care in B angladesh: P olicy
responses and challenges towards achieving universal health coverage. The International
journal of health planning and management. 2019;34(1):e11-e20.
3. Hassan MZ, Fahim SM, Zafr AHA, Islam MS, Alam S. Healthcare financing in Bangladesh:
challenges and recommendations. Bangladesh Journal of Medical Science. 2016;15(4):505-
510.
4. Islam A, Biswas T. Health system in Bangladesh: Challenges and opportunities. American
Journal of Health Research. 2014;2(6):366-374.
5. Osman FA. Health policy, programmes and system in Bangladesh: achievements and chal-
lenges. South Asian Survey. 2008;15(2):263-288.
6. Ahmed Z, Yeasmeen F. First world healthcare by third world provider: Position of
Bangladesh. Journal of Health Science Research. 2016;1(2):29-33.
7. Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The
Bangladesh paradox: exceptional health achievement despite economic poverty. The Lancet.
2013;382(9906):1734-1745.
8. Organization WH. Bangladesh health system review. Manila: WHO Regional Office for the
Western Pacific; 2015.
9. Truth AU. No health without a workforce. World Health Organisation (WHO) Report.
2013:1-104.
10. Organization. WH. Global Health Workforce Alliance: Country responses.
https://www.who.int/workforcealliance/countries/bgd/en/. Accessed 1 April 2020.
11. Alford RR. The political economy of health care: Dynamics without change. Politics &
Society. 1972;2(2):127-164.
12. Hipgrave DB, Anderson I, Sato M. A rapid assessment of the political economy of health at
district level, with a focus on maternal, newborn and child health, in Bangladesh, Indonesia,
Nepal and the Philippines. Health policy and planning. 2019;34(10):762-772.
Global­Healthcare 88
Chapter­8
Healthcare Financing in
Bangladesh: Current Status, Health
Budget and Fiscal Space for Health
Shahinul­Alam1,­Farhana­Begum2,­Shah
Mohammad­Fahim3,­Zakiul­Hasan4
Abstract:
A­combined­organogram­of­the­health­system­of­both­public
and­ private­ sector­ has­ been­ contributing­ heavily­ to
improve­ the­ health­ status­ of­ the­ country.­Although­ there
are­some­praiseworthy­successes,­the­health­system­of­the
country­is­still­lagging­behind­in­some­sectors.­There­are
large­number­of­shortage­of­Health­Care­Worker­(HCW),
budgetary­allocation,­utilization­of­funds­made­the­system
weakened.­Exploration­of­the­sources­of­funds­are­not­yet
adequate.­To­achieve­the­Sustainable­Development­Goals
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
2. Dr. Farhana Begum. BCom (Honors) MCom. MPhil , PhD. Accounting, Postdoctoral Scholar,
Accounting Research Institute( ARI)
Universiti Teknologi MARA(UITM) 40450, Shah Alam Selangor, Malaysia.
3. Dr. Shah Mohammad Fahim, MBBS, MPH, Research Investigator, Nutrition and Clinical
Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh
(icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
4 . Dr. Md. Zakiul Hassan MBBS, Assistant Scientist , Emerging Infections, Infectious Diseases
Division, 68 Shaheed Tajuddin Ahmed Sarani | Mohakhali| Dhaka 1212 | Bangladesh
89 Global­Healthcare
(SDGs),­ensure­the­Universal­Health­Coverage­(UHC)five
potential­ sources­ of­ fiscal­ space­ may­ be­ the­ options:
economic growth,­ reprioritization­ of­ health­ budget,
increased­ overseas­ development­ assistance­ for­ health,
increase­in­health-specific­resources­and­greater­efficiency
in­the­use­of­existing­health­budget­resources.
Key words: Health­budget;­Bangladesh;­universal­health
coverage;­fiscal­space;­sustainable­development­goal;­
Bangladesh­ has­ been­ showing­ remarkable­ performances
in­health­sector­and­setting­extraordinary­examples­for­the
developing­countries­in­recent­years.­Meeting­specific­targets,
the­ country­ has­ been­ seen­ to­ surpass­ most­ of­ the­ South
Asian­ countries­ in­ achieving­ relevant­ Sustainable
Development­ Goals­ (SDGs).­ Bangladesh­ has­ attained
noteworthy­ feat­ in­ child­ and­ maternal­ healthcare­ lately.
The­decrease­of­infant,­child­and­maternal­mortality­rates
over­ the­ past­ few­ years­ has­ been­ impeccable,­ which­ has
been­ possible­ through­ the­ expanded­ public­ health
interventions­ of­ immunization­ and­ family­ planning
programs.­ A­ good­ organogram­ of­ the­ health­ system
combining­ both­ public­ and­ private­ sector­ has­ been
contributing­ heavily­ to­ improve­ the­ health­ status­ of
the country.­Although­there­are­some­praiseworthy successes,
the­health­system­of­the­country­is­still­lagging­behind­in
some­sectors,­which­have­become­impediments­to­the­way
of­Bangladesh’s­rapid­progress­towards­SDGs.­A­number
of­ financial­ features­ of­ the­ health­ system­ of­ the­ country
can­be­held­as­the­cause­of­this­trend.­
Health­ workforce­ personnel­ currently­ working­ under
Directorate­ General­ of­ Health­ Services­ (DGHS)­ of
Ministry­of­Health­and­Family­Welfare­(MoHWF)­number
Global­Healthcare 90
of­personnel:­74,985­(103,743)­except­nurses,­number­of (8365posts)­for­Class­IV­staff­(1).­Under­the­Directorate­of
Doctors: 20,914­(25,980),­number­­of­registered­physicians: General­ Nursing­ and­ Midwifery­ sanctioned­ posts­ are
MBBS:­ 93358;­ BDS:­ 9569­ (According­ to­ BMDC), 36721­and­vacant­posts­are­4475­(2).
number­ of­ Medical­ technologists­ (MT):­ Total:­ 5,184
(7,920);­ Dental:­ 469­ (624);­ MT­ (EPI):­ 483­ (499);­ Lab:
1,488­ (2,237),­ Pharmacy:­ 1,546­ (2,905);­ Physiotherapy:
109­ (296);­ Radiography:­ 573­ (778);­ Radiotherapy:­ 41
(83); Sanitary­inspection:­475­(498),­number­ Sub-Assistant
Community­Medical­Officers­(SACMO):­3,801­(5,368)­,
number­­of­Community­Healthcare­Providers­(CHCPs)­for
Community­ Clinics:­ 13,507,­ number­ ­ Domiciliary­ Staff:
Health­ Inspectors­ (HI)­ 1,047­ (1,410);­ Assistant­ Health
Inspectors­ (AHI):­ 3,636­ (4,220);­ Health­Assistants­ (HA)
15,420­ (20,908)­ ­ (No.­ of­ sanctioned­ posts­ are­ given­ in
parentheses).­ Population-Health­ ­ Workforce­ Ratio
(According­to­SVRS­2017­total­population­-­162.7­million
was­ considered­ as­ the­ denominator­ in­ applicable­ cases)
Population­ per­ registered­ physician:­ 1,581,­ number
registered physicians­per­10,000­populations:­6.33,­number
of­doctors­working­under­DGHS­per­10,000­populations:
1.28,­ number­ ­ medical­ technologists­ working­ under Source: Global Health Expenditure Database
DGHS­per­10,000­populations:­0.32,­number­of­community Figure 1: Per capita health expenditure of SEARO countries (2016)
and­domiciliary­health­workers­working­under­DGHS­per
10,000­people:­2.13,­number­of­beds­in­DGHS-run­public Bangladesh­ has­ the­ lowest­ per­ capita­ health­ expenditure
hospitals­per­10,000­populations:­3.24,­number­of­­beds­in among­ the­ SEARO­ countries­ (Figure­ 1).­ The­ per­ capita
private­ hospitals­ (registered­ by­ DGHS)­ per­ 10,000 health­ expenditure­ of­ the­ country­ was­ $34­ in­ the­ year
populations: 5.57. 2016,­while­from­Global­health­Expenditure­Database­by
the­ WHO,­ we­ get­ the­ corresponding­ figure­ for­ Nepal,
Out­of­103743­sanctioned­posts­under­the­DGHS,­28758 India­ and­ Myanmar­ were­ the­ closest­ to­ that­ of
sanctioned­ posts­ remained­ vacant­ in­ November­ 2018, Bangladesh’s­ having­ $45,­ $62­ and­ $62­ respectively.­ On
which­ constituted­ 27.72%­ of­ the­ total­ sanctioned­ posts. the­other­hand,­Maldives­had­the­highest­per­capita­health
Vacancy­ rate­ was­ 19.50%­ (5066­ posts)­ for­ doctors, expenditure­ among­ the­ SEARO­ countries,­ which­ was
28.67%­ (14693­ posts)­ for­ Class­ III­ staff­ and­ 23.02% $1048.­ According­ to­ the­ World­ Bank,­ Bangladesh­ used

91 Global­Healthcare Global­Healthcare 92
only­ 2.4%­ of­ its­ GDP­ in­ health­ sector­ in­ 2016.­ Figure­ 1 Low­ level­ of­ healthcare­ spending­ by­ the­ government­ in
illustrates­ the­ per­ capita­ health­ expenditures­ of­ all­ the Bangladesh­ is­ a­ reflection­ of­ the­ lower­ budgetary
SEARO­countries. allocation for­health­sector.­And­this­low­level­of­budget
allocation­ transforms­ into­ inadequate­ service­ coverage
The­government­contribution­to­the­total­health­expenditure along­with­superfluous­Out­of­Pocket­(OOP)payments­(3).­
is­ dramatically­ low­ in­ Bangladesh.­ Surprisingly,­ despite
the­fact­that­the­total­health­expenditure­is­ever-increasing,
the­portion­of­it­which­is­financed­by­the­government­has
been­falling­for­a­long­span­of­time.­Figure­2­shows­thatin
2010,­the­government­health­expenditure­was­around­21%
of­the­total­health­expenditure.­The­percentage­gradually
declined­to­less­than­18%­by­2016.­

Figure 3: Health budget of Bangladesh by years (in

crore of BDT)
Figure­3­shows­that­budgetary­allocation­for­health­care­is
progressively­increasing­which­is­about­8­times­higher­in
2019-20­ than­ that­ of­ 2008-09.­ Health­ budget­ of
Bangladesh­ for­ 2019-20­ is­ 25732­ crore­ (BDT)­ and­ that
Source: World Bank Data was­increased­from­23393­crore­(BDT)­of­2018-19­(1USD
Figure 2: Government health expenditure of Bangladesh as a % =­ 85­ BDT)­ but­ the­ percentage­ of­ total­ budget­ decreased
current health expenditure (CHE)
from­5%­to­4.9%.­

93 Global­Healthcare Global­Healthcare 94

Figure 4 : Health budget in percent of total budget (Ref 4)
The­health­budget­is­stagnant­around­5­%­of­total­budget
and­ that­ is­ far­ away­ from­ Health­ Policy­ 2011.­ Health
budget­ is­ rather­ decreased­ in­ percentage­ from­ 2005-06
(Figure­ 4).­To­ achieve­ the­ level­ recommended­ in­ Health
Policy­we­have­to­go­far­away­from­the­present­status.­To
mobilize­ this­ huge­ fund­ allocation­ of­ budget­ and
involvement­ of­ public­ private­ partnership­ may­ be­ the
best­options.
As­ specified­ by­ the­ national­ budget­ FY­ 2019-20,­ the
allocation­ for­ health­ sector­ was­ only­ 4.9­ %­ of­ the­ total
budget­of­the­country,­whereas­according­to­the­recommendation
of­ WHO,­ budgetary­ allocation­ for­ health­ sector­ is
supposed­ to­ be­ 15%­ of­ the­ total­ budget(5).­ Statistics
demonstrate­that­the­percentage­has­been­lingering­around
the­same­figure­in­past­few­years,­which­is­the­lowest­in
most­of­the­South­Asian­countries(6),­and­the­figure­may
keep­acting­in­the­same­way­if­reconsideration­of­budget
allocations­ is­ not­ done.­ In­ view­ of­ the­ fact­ that­ a­ very
small­amount­of­financing­is­coming­from­the­government
for­a­country­having­one­of­the­largest­population­of­the
world,­ people­ are­ left­ with­ no­ choice­ other­ than­ bearing
healthcare­ expenditure­ from­ their­ own­ pocket.­ Health
95 Global­Healthcare
Care­ Financing­ Strategy­ 2012-2032­ defines­ inadequate
healthcare­ financing,­ inequity­ in­ health­ financing­ and
utilization,­ and­ inefficient­ use­ of­ existing­ resources­ as
the­key­challenges­that­the­health­sector­of­the­country­is
currently­facing.­Along­with­other­aims­of­the­strategy,­its
one­ target­ is­ to­ increase­ the­ health­ budget­ to­ 15%­ of
national­ budget­ within­ 2032,­ the­ year­ within­ which­ it
proposes­that­Bangladesh­will­achieve­Universal­Health
Coverage (UHC)­(7).
For­the­purpose­of­increasing­the­budgetary­allocation­for
health­sector­of­Bangladesh,­the­World­Bank­has­proposed
to­create­fiscal­space­for­health­(3).­Creating­Fiscal­space
for­ health­ indicates­ to­ generating­ capacity­ of­ budgetary
room for­the­health­sector­while­not­hampering­the­allocation
of­ the­ other­ sectors­ (3).­ Bangladesh­ is­ lately­ experiencing
demographic­and epidemiological­transition.­The­working
age­ population­ of­ the­ country­ has­ been­ increasing­ for­ a
considerable­time­(5),­and­in­near­future­this­portion­of­the
population­will­need­geriatric­care.­As­a­further­matter,­the
disease­pattern­of­the­country­is­also­taking­a­shift­towards
non-communicable­ diseases­ (NCDs)­ in­ the­ recent­ years.
During­the­time­span­of­1990­to­2013,­the­share­of­overall
disease­ burden­ attributable­ to­ NCDs­ experienced­ a­ rise
from­ 29%­ to­ 54%­ (1).­ To­ ensure­ the­ financing­ for­ new
interventions­ focusing­ improvements­ of­ health­ status
indicators­ along­ with­ the­ existing­ ones,­ generation­ of
fiscal space­ is­ suggested­ (3).­ In­ addition,­ as­ a­ result­ of
high­OOP­payments,­and­absence­of­risk­sharing­schemes
in­Bangladesh,­people­are­falling­below­the­poverty­line.
Nevertheless,­ according­ to­ the­ “Strategic­ Intervention”
section­of­the­Health­Care­Financing­Strategy­2012-2032,
designing­ and­ implementation­ of­ a­ non-contributory
Global­Healthcare 96
Social­Health­Protection­Scheme­named­Shasthyo­Shuro
ksha­Karmasuchi­(SSK)­has­been­projected­(7).­Currently,
the­ scheme­ is­ providing­ comprehensive­ inpatient­ care­ to
the­people­who­are­below­the­poverty­line.­ Health­ Care
Financing­ Strategy­ 2012-2032­ has­ proposed to­ extend
the­scheme­for­the­formal­sector­in­future(6).­However,­a
larger­health­budget­is­needed­for­the­enhanced­implementation
of­these­projects.­According­to­The­World­Bank,­there­are
five­ potential­ sources­ of­ fiscal­ space: 1.­ Economic
growth;2.Reprioritization­ of­ health­ budget;­ 3.­ Increased
overseas­ development­ assistance­ (ODA)­ for­ health;­ 4.
Increase­ in­ health-specific­ resources;­ and­ 5.­ Greater
efficiency­ in­ the­ use­ of­ existing­ health­ budget
resources(3).­In­case­of­economic­growth,­Bangladesh­has
been­showing­robust­growth­in­recent­years.­In­2018,­the
GDP­growth­rate­of­the­country­was­as­high­as­7.86%.­As
the­ economy­ grows,­ the­ budget­ allocation­ in­ real
terms­ for­ health­ sector­ is­ bound­ to­ increase.
Conversely,­ the­ 3rd potential­ source­ of­ fiscal­ space,
increased­ overseas­ development­ assistance­ (ODA)­ for
health,­does­not­suit­for­the­future­Bangladesh­since­along
with­the­constant­development­and­economic­expansion­of
the­country;­the­foreign­aids­are­decreasing­rapidly­(3).­­­­
Despite­the­fact­that­budgetary­allocation­is­short­for­the
health­ sector,­ successive­ Public­ Expenditure­ Reviews
(PER)­ reported­ that­ every­ year­ some­ of­ the­ budget
remains­ unspent­ (7).­ MoHFW­ has­ been­ using­ less­ than
90%­of­the­allocated­budget­for­a­long­period­of­time­(3).
According­ to­ the­ World­ Bank,­ a­ crucial­ basis­ for­ the
fragile­budget­execution­is­due­to­the­fragmented­way­of
budget­formulation­including­both­Financial­Management
and­ Audit­ Unit­ and­ Planning­ Wing­ of­ the­ MoHFW(2).
97 Global­Healthcare
Moreover,­the­budget­formulation­of­Bangladesh­follows
Medium­Term­Budgetary­Framework­(MTBF)­approach,
however,­the­health­budgeting­is­done­on­the­basis­of­line
items­ through­ incremental­ budgeting,­ which­ does­ not
reflect­the­needs­of­the­population.­­­­
To­ bring­ Bangladesh­ out­ of­ the­ chaos­ of­ inadequate­ and
inefficient­budgetary­allocation,­high­OOP­payments­and
impoverishment,­ government­ should­ redesign­ healthcare
policies­ and­ implement­ consequently.­ By­ reprioritizing
health­sector­and­acting­accordingly,­Bangladesh­will­soon
be­ able­ to­ ensure­ UHC.­ So,­ there­ minimum­ space­ was
allocated­ for­ health­ care­ financing­ in­ Bangladesh­ that
made­the­health­system­fragile­with­inadequate­facilities,
logistics,­ manpower­ and­ responses.­ For­ a­ better­ future
these­ spaces­ should­ be­ addressed­ by­ the­ policy­ makers,
executives­of­the­country.
References:
1.­ Directorate­General­of­Health­Services­(DGHS),­Ministry­of­Health­and­Family­Welfare
Government­of­the­People’s­Republic­of­Bangladesh.­Health­Bulletin,­2018.­
2.­­­­ Directorate­of­General­Nursing­and­Midwifery;­MoHFW.­http://dgnm.por
tal.gov.bd/sites/default/files/files/dgnm.portal.gov.bd/page/bed6055c_a808_4389_9378_9ed8
101b7fac/2020-02-18-16-00-64d635f84b3452b44debe3e8baee68c8.pdf.accessed­on
09.04.2020
3.­­­­ Vargas­V,­Begum­T, Ahmed­S, Smith­OK.Fiscal­space­for­health­in­Bangladesh­:­towards
Universal­Health­Coverage­(English).­World­Bank­Group; Washington,­D.C.2016­http://documents.
worldbank.org/curated/en/268141537541184327/Fiscal-space-for-health-in-Bangladesh-
towards-universal-health-coverage
4.­ https://mof.gov.bd/site/page/f9aab5cd-f644-47bb-bb94-a70cb64c15ce/Budget-in-Brief-(2000-
01-to-2016-17)­Accessed­on­03.05.2020
5.­ Jowett­M,­Brunal­MP,­Flores­G,­Cylus­J.­Spending­targets­for­health?:­no­magic­number.­2016.
6.­ Fahim­SM,­Bhuayan­TA,­Hassan­MZ,­Abid­Zafr­AH,­Begum­F,­Rahman­MM,­et­al.
Financing­health­care­in­Bangladesh:­Policy­responses­and­challenges­towards­achieving
universal­health­coverage.­Int­J­Health­Plann­Manage.­2019;34(1):e11–20.­
7.­ Health­Economics­Unit­Ministry­of­Health­and­Family­Welfare­Government­of­the­People’s
Republic­of­Bangladesh.­Expanding­Social­Protection­for­Health?:­Towards­Universal
Coverage­Health­Care­Financing­Strategy­2012-2032­September­2012.­2012.­
Global­Healthcare 98
Chapter­9
Healthcare Financing in Malaysia
Normah­Omar1, Farhana­Begum2
Abstract
The­present­healthcare­system­in­Malaysia­can­be­divided
into­two­main­sectors.­­The­first­sector­comprises­mainly
the­ government-led­ public­ healthcare­ services­ and­ is
funded­directly­by­the­government­through­its­annual­and
special­ budget­ packages­ to­ the­ Ministry­ of­ Health.
Currently,­ the­ public­ hospitals­ and­ clinics­ provide
healthcare­services­to­about­seventy­percent­(70%)­of­the
country’s­ population.­ Since­ public­ hospitals­ and­ clinics
are­highly­subsidized,­the­healthcare­cost­is­relatively­low
to­ make­ it­ affordable­ to­ the­ general­ public.­ ­The­ second
sector,­ is­ the­ booming­ private­ healthcare­ service­ sector
that­ offers­ almost­ every­ type­ of­ medical­ and­ surgical
services that­could­only­be­previously­found­in­developed
countries.­ Medical­ services­ provided­ by­ these­ private
healthcare­ hospitals­ are­ funded­ directly­ by­ the­ patients
themselves­ or­ through­ their­ insurers­ and­ corporate
1. Prof Dr. Normah Omar CPA. Director, Accounting Research Institute, Higher Institution Centre
of Excellence (HICoE), UniversitiTeknologi MARA, MALAYSIA
2. Dr. Farhana Begum. BCom (Honors) MCom. MPhil , PhD. Accounting, Postdoctoral Scholar,
Accounting Research Institute (ARI), UniversitiTeknologiMARA(UITM) 40450, Shah Alam
Selangor, Malaysia.
99 Global­Healthcare
employers.­ It­ is­ through­ the­ private­ hospitals’­ initiative
that­ the­ new­ “cosmetic­ and­ plastic­ surgery”­ healthcare
business­has­blossomed­for­Malaysia.­­Instead­of­merely
focusing­ on­ the­ remaining­ 30%­ population,­ the­ private
healthcare­ found­ a­ new­ market­ in­ the­ form­ of­ “medical
tourism”,­where­affordable­foreigners­come­to­Malaysia­to
seek­specialists’­treatment.­­­­Although­the­two­sectors­are
fairly­distinct­from­each­other,­especially­in­terms­of­both
service­ delivery­ and­ financing,­ a­ Public-Private
Healthcare Collaboration is­always­a­welcome­initiative
in­Malaysia.­­With­a­common­aim­of­improving­community
healthcare,­ the­ Ministry­ of­ Health­ (MoH)­ recently
collaborates­ with­ the­ private­ medical­ sector,­ to
enhance­ sample­ collection­ services­ from­ homes of
targeted­patients,­and­have­them­tested­for­Covid-19.­This
chapter­ examines­ both­ public­ and­ private­ healthcare
financing­ in­ Malaysia­ and­ proposes­ suitable­ economic
policy­model­that­can­be­used­to­strengthen­nation­building
through­healthcare­services.­
Healthcare System in Malaysia
The­ World­ Health­ Organization­ (WHO)­ considers­ the
Malaysian­ Healthcare­ system­ as­ advanced due­ to­ the
extensive­ support­ from­ the­ Malaysian­ government
through­ investment­ in­ hospital’s­ medical­ infrastructure.
The­healthcare­improvements­in­the­last­ten­years­in­terms
of­ both­ well-trained­ medical­ staff­ and­ excellent­ hospital
facilities­ have­ contributed­ to­ the­ global­ recognition­ that
Malaysia­ is­ on­ par­ with­ other­ well-developed­ countries.
Basically,­Malaysia­has­a­two­tier­(1) equally­strong­health
Global­Healthcare 100
care­system­consisting­of­the­public­and­private­sectors­that
run­ in­ parallel­ of­ each­ other.­ Within­ the­ public­ sector,
healthcare­ services­ are­ provided­ by­ the­ government
hospitals­(both­at­state­and­district levels)­and­clinics­(in
suburban­and­villages).­Healthcare­services­in­this­sector
is­ highly­ subsidized­ by­ the­ government­ and­ they­ are
provided mainly­for­almost­seventy­percent­(70%)­of­the
general­ population­ in­ the­ country.­ ­ The­ private­ sector
healthcare,­through­the­establishment­of­private­hospitals
and­private­clinics,­provides­services on­a­nonsubsidized,
fee­for­service­basis,­and­mainly­serves­those­who­can
afford­to­pay.­These­private­hospitals­are­usually­owned
and­founded­either­by­for-profit­companies­or­by non-profit
organizations.­­Figure­1­summarizes­the­number­of­large
public­and­private­hospitals­in­Malaysia.­­It­is­noted­that Source:­https://www.statista.com/statistics/794860/number-of-public-and-private-hospitals-malaysia/

Figure 1: Public and Private Hospitals in Malaysia

the­ services­ of­ private­ hospitals­ are­ blossoming
especially­ in­ areas­ such­ as­ in­ cosmetic­ and­ plastic
surgery.­ ­ In­ fact­ it­ is­ the­ private­ hospitals­ that­ are
championing­the­medical­tourism­in­Malaysia,­bringing
in­ tourists­ from­ nearby­ ASEAN­ neighbors­ to­ seek
medical­services­in­the­country.­The­booming­private
healthcare­ hospitals­ are­ also­ the­ ones­ that­ offer­ almost
every­type­of­high-end­medical­and­surgical­services­that
could­ only­ be­ previously­ found­ in­ developed
countries.The­Ministry­of­Health’s­main­role­is­basically
to­lay­the­policy­and­the­direction­of­health­services­(both
public­and­private­health­services)­in­the­country­and­to
show­the­commitment­of­the­government­of­Malaysia­that
health­is­of­utmost­importance­in­nation­building.­
Since­the­public­hospitals­are­serving­about­seventy­percent
of­ the­ population,­ it­ is­ expected­ that­ the­ hospitals­ are
larger­ in­ size­ (usually­ measured­ by­ the­ number­ of­ beds)
compared­to­the­private­hospitals.­­Figure­2­illustrates­that
in­2018,­there­were­around­42.3­thousand­beds­in­public
hospitals­in­Malaysia,­compared­to­only­around­16­thousand
beds­ in­ private­ hospitals.­ Naturally,­ the­ demographic
characteristics of­ clients­ who­ are­ seeking­ treatment­ in
these­hospitals­are­also­very­different.­­Specifically­for­the
private­hospitals,­since­the­patients­are­paying­full­medical
fees­for­their­healthcare­treatment,­they­are­also­expected
to­provide­first­class­facility­and­services.­

101 Global­Healthcare Global­Healthcare 102


Source:­https://www.statista.com/statistics/794860/number-of-public-and-private-hospitals-malaysia/
Figure 2: Number of Hospital Beds in
Public and Private Hospitals
In­addition­to­public­and­private­hospitals,­healthcare­services
are­ also­ served­ by­ government­ and­ private­ clinics.
These­ clinics­ are­ relatively­ small­ in­ size­ and­ provide
basic­out-patient­services,­especially­in­suburban­and­small­villages.
Source:­Abstracted­from­CEIC­latest­data­2016­
Figure 3: Distribution of Health Clinics in Different States
in Malaysia
103 Global­Healthcare
In­large­states­like­Sarawak,­Sabah­and­Pahang,­where­the
main­ population­ are­ living­ in­ remote­ places­ or­ in­ small
villages,­healthcare­clinics­are­the­best­mode­for­providing
healthcare­services.­­Figure­3­illustrates­the­health­clinics
distribution­by­states.­­Meanwhile,­several­cities­such­as
Kuala­ Lumpur,­ Putrajaya­ and­ Labuan­ are­ part­ of­ the
Federal­Territory­and­usually­provided­with­latest,­up-to-
date­public­and­private­hospitals.­­As­such,­the­number­of
health­clinics­in­these­cities­are­much­lower­compared­to
the­other­states­(2).­
Healthcare Professionals in Malaysia
On­the­big­picture,­institutions­such­as­hospitals­and­clinics
are­the­main­providers­of­healthcare­services­globally­and
in­Malaysia.­­Individual­professionals,­on­the­other­hand,
are­the­main­players­who­provide­specific­services­at­these
healthcare­ institutions.­ ­ Individual­ healthcare­ providers
include­both­health­professionals­such­as­doctors,­dentists,
pharmacists,­ optometrists,­ nurses­ and­ allied­ health
professionals­ such­ as­ dieticians,­ medical­ laboratory
technologists, therapists­and­community­health­workers.
These­ individuals­ can­ be­ an­ employee­ in­ a­ public­ or
private­hospital­or­clinic,­or­self-employed­as­a­consultant
or­health-related­researcher­and­medical­academics­at­the
institutions­of­higher­learning­in­the­country.­
The­World­Health­Organization­(WHO)­rightfully­defines
a­ healthcare­ system­ as­ the­ integration­ of­ organizations,
people­ and­ actions,­ whose­ primary­ intent­ is­ to­ promote,
restore­or­maintain­health.­While­the­ratio­of­the healthcare
profession­ to­ the­ population­ in­ Malaysia­ shows­ that­ the
gap­ is­ being­ reduced­ throughout­ the­ years­ many­ studies
cited­ that­ the­ Malaysian­ health­ system­ is­ still­ being
constrained­by­shortages­of­health­professionals­(3­-­4)­or
Global­Healthcare 104
shortages­of­public­hospitals5,­despite­the­increased­number Table 1: Healthcare Workers in Malaysia (2012-2017)
of­ medical­ graduates­ in­ recent­ years­ (5).­ Figure­ 3
summarizes­medical­personnel­to­population­ratio.­­It­can
be­noted­that­although­the­ratio­of­doctor­to­population­in
Malaysia­ had­ increased­ slightly­ from­ 2012­ to­ 2016,­ the
increase­ however­ is­ still­ far­ from­ the­ targeted­ ratio­ of
1:400­ (i.e.­ one­ doctor­ per­ 400­ population)­ by­ 2020.
Multiple-prong­efforts­to­improve­this­ratio­have­included
strategies­ such­ as­ (i)­ to­ increase­ the­ number­ of­ medical
student­ intake­ at­ public­ and­ private­ universities­ in­ the
country,­ (ii)­ to­ build­ more­ public­ hospitals­ to­ enable­ the
training­of­housemen,­(iii)­to­encourage­private­individuals
or­corporations­to­build­private­hospitals­to­allow­doctors
to­practice.

Source:­­Abstracted­from­MoH­Malaysia­Website­
http://www.moh.gov.my/index.php/pages/view/1919?mid=626)

Types of Healthcare Services

Figure 4 : Medical Personnel to Population
Ratio 2012-2016
Besides­ doctors,­ dentists­ and­ nurses,­ the­ Ministry­ of
Health­ (6)­ has­ also­ listed­ several­ other­ groups­ of
professionals in­ its­ website­ under­ the­ category­ Human
Resource for Health (HRH). This­is­summarized­in­Table
1­ below.­ An­ effective­ and­ efficient­ healthcare­ system
requires­a­combination­of­these­personnel.
The­World­Health­Organization­(WHO)­outlines­three­important
success­factors­to­achieve­an­effective­and­efficient­health­care
system.­­First,­a­well-trained­and­adequately­paid­workforce;
second,­delivery­of­high­quality­treatment­and­medicines­by
the­ healthcare­ providers­ and­ third,­ usage­ of­ advanced
technologies­for­enhanced­healthcare­services­in­hospitals­and
clinics.­ Within­ a­ two-tier­ healthcare­ environment,­ types­ of
healthcare­ services­ are­ also­ expected­ to­ be­ different.­ The
public-funded­ government­ health­ sector­ of­ Malaysia­ was
developed­in­1950s,­whereas­the­private­health­sector­started
to­ flourish­ around­ 1970s­ (7).­ Traditionally,­ the­ government
sector­ provides­ widespread­ quality­ health­ services­ which
encompass­primary­healthcare,­secondary­healthcare­and tertiary

105 Global­Healthcare Global­Healthcare 106

level­healthcare.­Malaysia’s­accomplishments­in­maternal­and
child­ health­ are­ renowned­ worldwide.­ Maternal­ and­ child
healthcare­ services,­ along­ with­ treatments­ for­ infectious
diseases­and­preventive­care­are­free­of­cost­for­the­people
(8). In-patients’­admissions­to­the­third­class­wards­are­fully
waived­ for­ the­ poor­ (9).­ Moreover,­ all­ public­ medical­ care
services­are­provided­for­free­to­the­public­sector­employees
(10).­ ­ ­ Table­ 2­ compares­ types­ of­ healthcare­ treatment­ and
their­comparative­costs­in­public­and­private­hospitals.­­The
Malaysian­ healthcare­ offers­ specialties­ in­ various­ medical
disciplines­ and­ conducts­ some­ of­ the­ most­ complicated
treatments­worldwide.­Today,­the­medical­care­in­Malaysia­on
par­ with­ the­ best­ in­ the­ world;­ where­ innovation­ and
international­expertise­are­key.
Table 2: Comparative Healthcare Services Costs in
Public and Private Hospitals
Source:­https://ringgitplus.com/en/blog/Insurance/Government-and-Private-Hospitals-
in-Malaysia-How-Much-Do-They-Really-Cost.html
The­private­health­sector­has­expanded­rapidly­throughout
the­ country­ in­ the­ past­ few­ decades.­ In­ view­ of­ its­ rapid
expansion,­ the­ Private­ Healthcare­ Facilities­ and­ Services
107 Global­Healthcare
Act­ 1998­ was­ passed­ and­ gazetted­ by­ the­ Malaysian
Parliament­ (11).­ ­ Basically,­ the­ Act­ provides­ for­ the
regulation­ and­ control­ of­ private­ healthcare­ facilities
and services­and­other­related­matters,­the­enforcement­of
which­is­within­the­jurisdiction­of­the­Ministry­of­Health,
Malaysia.­­­There­is­an­extensive­network­of­high-quality
private­healthcare­options­in­Malaysia.­These­are­generally
of­ an­ excellent­ standard­ and­ service­ mainly­ expats­ and
wealthy­ Malaysians.­ In­ order­ to­ make­ use­ of­ the­ private
healthcare­system,­the­Malaysian­government­requires­that
all­non-residents­and­expats­have­private­medical­insurance
(12).Of­ course,­ it­ does­ not­ necessarily­ mean­ that­ private
hospitals­offer­better­medical­treatments­than­the government
hospitals.­ However,­ one­ can­ expect­ to­ receive­ better
patient-care.­ Some­ of­ the­ most­ common­ traits­ of­ private
hospitals’­ customer­ charter­ includes­ things­ like­ shorter
waiting­ period­ (to­ receive­ medical­ treatment),­ well-
maintained and­clean­environment,­pleasant­and­luxurious
facilities,­ room­ service,­ and­ bigger­ food­ and­ medicine
selections­for­in-patients­receiving­treatment­at­the hospitals.
In­ addition,­ one­ can­ also­ enjoy­ longer­ visiting­ hours­ and
more­ privacy,­ as­ there­ are­ more­ private­ wards­ (albeit­ at
additional­costs)­should­you­prefer­to­have­your­own­room
(13).
Due­to­its­fairly­extensive­and­good­quality­services,­the
private­ hospitals­ have­ been­ successful­ in­ promoting
medical­ tourism­ in­ Malaysia.­ There­ are­ several­ reasons
why­Malaysia­is­an­ideal­destination­for­medical­tourism,
especially­among­those­within­the­ASEAN­region.­Unique
to­the­medical­tourism­sector­in­Malaysia­is­the­fact­it­is
being­ promoted­ by­ the­ government.­ This­ will­ truly­ give
tourists­assurance­of­quality,­safety­standards­and­regulations
Global­Healthcare 108
within­the­healthcare­industry.­­According­to­the­Medical
Tourism­Website­(14),­Malaysia­Healthcare­is­among­the
most­affordable­healthcare­services­in­the­world­that­offers
unparalleled­standards­of­quality­and­care.­In­2016­alone,
almost­1­million­health­travelers­were­seeking­healthcare
treatmentsin­ Malaysia­ from­ around­ the­ globe.Popular
treatments­ in­ medical­ tourism­ include­ orthopedics,
ophthalmology,­cardiology,­IVF,­neurology,­gastroenterology,
oncology,­dentistry,­cosmetic­surgery,­and­health­screening.
Figure­4­reports­the­increasing­revenue­stream (surpassing
the­RM1­billion­mark)­received­from­medical­tourism­in
Malaysia­from­2011­to­2018­(15).­­
https://www.statista.com/statistics/1013817/medical-tourism-revenue-malaysia/
Figure 5 : Revenue from medical tourism in
Malaysia from 2011 to 2018
Healthcare Financing in Malaysia
Basically,­ data­ on­ the­ national­ health­ accounts­ for­ the
country­ is­ published­ by­ the­ Malaysia­ National­ Health
Accounts­ (MNHA).­ ­ To­ date.­ More­ than­ twenty­ years
109 Global­Healthcare
health­ expenditure­ reports­ have­ been­ published.­ Using
standardized­ and­ internationally­ acceptable­ National
Health­ Accounts­ (NHA)­ methodology,­ several­ diagrams
and­Tables­for­this­chapter­have­been­sourced­from­these
reports.­­­The­Malaysian­government,­through­the­Ministry
of­Finance­(MoF)­allocates­its­annual­budget­to­the­various
ministries­and­related­federal­agencies,­state­agencies­and
local­ authorities.­ ­ Likewise,­ the­ Ministry­ of­ Health
receives­ its­ healthcare­ budget­ from­ the­ Ministry­ of
Finance.­­The­public­health­services­are­generally­funded
by­ means­ of­ government­ revenues­ collected­ through
taxation.­ ­ In­ 2019,­ a­ total­ of­ RM297­ billion­ or­ 18.4­ per
cent­ of­ the­ gross­ domestic­ product­ (GDP)­ was­ allocated
for­Budget­2020.­­Of­this­amount,­81.1­per­cent­or­RM241
billion­ is­ allocated­ for­ operating­ expenditure­ (OE)­ and
only­RM56­billion­is­for­development­expenditure­(DE).
It­is­also­noted­that­the­top­three­recipients­of­Budget­2020
are­the­Ministry­of­Education­(RM64.1­billion),­Ministry
of­ Finance­ (RM37.8­ billion)­ and­ Ministry­ of­ Health
(RM30.6­ billion),­ constituting­ 44.6­ per­ cent­ of­ total
expenditure­(16).­­Although­the­percentage­of­healthcare
budget­ allocated­ to­ the­ Ministry­ of­ Health­ Malaysia­ is
about­ 10%­ per­ cent­ of­ the­ total­ budget,­ the­ actual­ total
healthcare­ expenditure­ for­ the­ country­ far­ exceeded­ the
allocated­ budget.­ ­The­ percentage­ is­ also­ lower­ than­ the
proposed­ 7­ per­ cent­ of­ GDP­ by­ the­ World­ Health
Organization­(WHO).­­In­2018,­total­expenditure­on­health
was­RM60.1­billion.­ Figures­6­illustrates­the­twenty-year
trend­of­healthcare­expenditure­(%)­for­Malaysia.­­Figure
6­depicts­the­actual­amount­(RM)­of­health­expenditure.
Global­Healthcare 110

Source:­Department­of­Statistics­Malaysia­DOSM
Figure 6 : Total Expenditure on Health as Percentage of GDP
Figure 7 : Total Expenditure on Health (TEH in RM
million) 1997-2018 (17)
Based­on­Figure­7,­it­is­noted­that­the­financing­of­the­healthcare
services­ in­ Malaysia­ is­ being­ shared­ by­ the­ Malaysian
government­(through­its­annual­budget­to­MoH)­and­other
111 Global­Healthcare
related­ agencies­ in­ the­ country.­ ­ Figure­ 7­ notes­ that­ the
healthcare­expenditure­is­shared­almost­equally­between­the
public­(government)­and­the­private­sectors­(17).
Figure 8 : The Shared by Public and Private Sectors
The­global­report­Global Spending on Health: A World in
Transition (2019)­(18)­published­by­the­WHO,­identifies
four­different­categories­of­healthcare­expenditure­funding,
namely­ “government”,­ “out-of-pocket”,­ “donor”­ and
“other­private­sources”.­For­a­more­elaborate­components
of­both­the­public­and­private­sectors­that­contribute­to­the
healthcare­financing­in­Malaysia,­Figure­9­describes.­­The
public­sector­components­are­contributed­by­the­Ministry
of­ Health­ (44%),­ Ministry­ of­ Education­ (2%),­ Federal
Agencies­ (4%)­ and­ other­ government­ agencies­ (4%).
Meanwhile,­the­private­sector­contributions­are­borne­by
private­ household­ (out-of-pocket­ –­ 35%),­ private
insurance (4%)­and­corporations­(4%).
Global­Healthcare 112

Figure 9 : Healthcare Financing in Malaysia (17)
The­ close­ collaboration­ between­ the­ public­ and­ private
sector­in­financing­the­healthcare­expenditure­in­Malaysia
signifies­a­very­significant­and­strong­partnership­towards
nation­building.­­Table­3­lists­the­different­public­sources
of­financing­for­years­2017­and­2018.
Table 3: Health Expenditure by Public Sources of Financing
2017 & 2018
113 Global­Healthcare
Table­4­depicts­the­sources­of­financing­from­the­private
sector.­­Interestingly,­the­private­household­out-of-pocket
(OOP) expenditure­is­the­largest­contributors­from­the­private
sector.­ Out-of-pocket­ payments­ (OOPs)­ are­ defined­ as
direct­ payments­ made­ by­ individuals­ to­ health­ care
providers­at­the­time­of­service­use.­OOPs­usually­exclude
any­prepayment­for­health­services,­such­as­taxes­or­specific
insurance­premiums­or­contributions­and,­where possible,
net­of­any­reimbursements­to­the­individual­who­made­the
payments­ (19).Private­ financing­ system­ predominantly
comprises­ of­ out-of-pocket­ payments,­ Managed­ Care
Organizations­ and­ third­ party­ providers,­ that­ is,­ private
insurances.­ However,­ out-of-pocket­ expenditures­ cover
bulk­of­the­private­sector­spending.­
Table 4: Total Expenditure Health by Private
Financing (17)
Although­ public­ and­ private­ hospitals­ are­ the­ main
providers­of­healthcare­services­in­Malaysia,­there­are­also
other­equally­important­providers­of­health­care­as­depicted
by­ Figure­ 10­ below.­ Other­ health­ services­ include
ambulatory­ care,­ general­ administration­ and­ medical
goods.­
zGlobal­Healthcare 114

Figure 10 : Total Expenditure of Health by Health Providers (17)
As­a­conclusion,­it­is­important­to­note­that­the­healthcare
program­of­one­country­is­different­from­another­country.
The­World­Health­Organization­(WHO)­in­its­global­report
(18)­concluded­that­for­a­low­income­country­for­example,
the­largest­source­of­health­funding­would­come­from­the
out-of-pocket­ private­ funding,­ followed­ by­ private­ donors
and­the­government­(see­Figure­11­below).­The­government’s
contributions­toward­healthcare­progressively­increased­as
the­countries’­level­of­income­improved.­­For­high­income
nation,­ the­ government’s­ contribution­ is­ the­ highest
compared­to­other­sources­of­health­funding.­­
Figure 11 : Countries level of income and Healthcare
Expenditures
115 Global­Healthcare
Since­ Malaysia­ is­ in­ the­ category­ of­ “upper­ middle
income”­ group,­ it­ is­ understandable­ that­ both­ the­ public
and­ private­ sectors­ work­ collaboratively­ to­ enhance­ the
healthcare­ services­ for­ the­ country.­ ­ Interestingly,­ the
emergence­ of­ a­ third­ sector,­ the­ non-profit­ and
non-governmental­group­to­facilitate­the­enhancement­of
the­healthcare­services­in­Malaysia­is­certainly­a­welcome
contribution.­Figure­12­illustrates­the­contribution­of­the
three­sectors­in­building­hospitals­for­the­country­(17).­In
a­ recent­ Covid­ 19­ in­ Malaysia,­ the­ close­ collaboration
between­the­three­sectors­to­fight­the­pandemic­was­very
much­visible­and­tested.­­With­a­common­aim­of­improving
community­ healthcare,­ the­ Ministry­ of­ Health­ (MoH)
recently­ collaborates­ with­ the­ private­ medical­ sector,­ to
enhance­sample­collection­services­from­homes­of­targeted
patients,­and­have­them­tested­for­Covid-19.­­Meanwhile
the­non-profit­sector­provides­volunteers­to­help­the­front
liners­to­take­care­of­the­Covid­19­patients.
Figure 12 : Healthcare Expenditures Shared by the
Three Sectors (17)
Global­Healthcare 116
References
1.­ https://www.statista.com/statistics/794860/number-of-public-and-private-hospitals-malaysia/
Chapter­10
2. https://www.ceicdata.com/en/malaysia/health-statistics-number-hospitals—clinics3.
Sebastian­A,­Alzain­MA,­Asweto­CO,­Mahara­G,­Guo­X,­Song­­M,­­Wang­Y­and­Wang­W,
The­Malaysian­Health­Care­System:­Ecology,­Plans,­and­Reforms.­­Family­Medicine­and
Community­Health,­Volume­4,­Number­3,­1­July­2016,­pp.­19-29(11)4.­Loh­SY,­Bonfice­G,
Mackenize­L,­Richards­L­(2017)­Professional­Autonomy­and­Progress­of­Occupational
Therapy­-­A­Case­Study­on­a­Neglected­Health­Profession­in­Malaysia.­J­Hosp­Health­Care
Admin:­JHHA-105.­2017.­DOI:­10.29011/JHHA-105.­1000055.­Shariff­SSR,­Moin­NH,
Omar­M.­Location­allocation­modeling­for­healthcare­facility­planning­in­Malaysia.­Comput

Healthcare Financing in India

Ind­Eng­62:1000–1010,­20126.
http://www.moh.gov.my/index.php/pages/view/1919?mid=626
7. Hamid­AJ,­Razif­IM,­Tan­EH,­Darzi­A.­Improving­Health­Care­Coverage,­Equity,­And
Financial­Protection­Through­A­Hybrid­System:­Malaysia’s­Experience.­Health­Aff.
2016;35(5):838–46.­
Md.­Sayaduzzaman1,­Farhana­Begum2,­
Shahinul­Alam3
8. Sukeri­S,­Mirzaei­M,­Jan­S.­Does­tax-based­health­fi­nancing­offer­protection­from­fi­nancial
catastrophe??­Findings­from­a­household­economic­impact­survey­of­ischaemic­heart­dis-

Abstract:
ease­in­Malaysia.­2016;1–7.­

Health­ is­ an­ important­ constituent­ of­ human­ resource

9. Chua­HT,­Chee­J,­Cheah­H.­Financing­Universal­Coverage­in­Malaysia?:­a­case­study.
BMC­Public­Health­[Internet].­2012;12(Suppl­1):S7.­Available­from:­http://www.biomed-
central.com/1471-2458/12/S1/S7
development.­ Good­ health­ is­ real­ wealth­ of­ Society.
10. Ramadhani­Khija,­ludovick­Uttoh­MKT.­World­Health­Statistics­2015.­Vol.­13,­Ekp.­World
Health­Organization;­2015.­1576–1580­p.­
Health­has­been­declared­as­a­fundamental­human­rights.
11. https://www.mma.org.my/images/pdfs/Link-LawOfMsiaAct/private-healthcare-facilities- Healthcare­ services­ help­ to­ reduce­ infant­ mortality­ rate,
and-services-act-1998.pdf check­ crude­ death­ rate,­ keep­ diseases­ under­ control­ and
12. https://ringgitplus.com/en/blog/Insurance/Government-and-Private-Hospitals-in-Malaysia-
raise­life­expectancy.­India­is­second­position­in­the­world
in­ terms­ of­ population.­ As­ per­ July­ 2018,­ 136.64­ crore
How-Much-Do-They-Really-Cost.html
13. https://www.allianzcare.com/en/support/health-and-wellness/national-healthcare-
systems/healthcare-in-malaysia.html (approx)­ population­ lives­ in­ India­ which­ 17.70%­ of­ the
14. https://medicaltourismmalaysia.com/ world­population.­WHO­define­of­the­health­financing­is
15. https://www.statista.com/statistics/1013817/medical-tourism-revenue-malaysia/
the­ “Function­ of­ a­ health­ system­ concerned­ with­ the
16. https://www.nst.com.my/news/nation/2019/10/528942/govt-allocates-rm297-billion-budget-
2020 mobilization,­ accumulation­ and­ allocation­ of­ money­ to
17. http://www.moh.gov.my/moh/resources/Penerbitan/Penerbitan%20Utama/MNHA/Slaid_ cover­ the­ health­ needs­ of­ the­ people,­ individually­ and
Pembentangan_Mesyuarat_Jawatankuasa_Pemandu_MNHA_2019_(14_Nov_2019)_- collectively­in­the­health­system”.­Healthcare­financing­is
_MNHA_National_Health_Expenditure_Report_1997-2018.pdf
mobilization­of­funds­for­healthcare;­allocation­of­funds­to
18. https://www.who.int/health_financing/documents/health-expenditure-report-2019.pdf?ua=1
19. https://www.who.int/health_financing/topics/financial-protection/out-of-pocket-
payments/en/ 1. Professor Md Sayaduzzaman MCom. PhD, Department of Accounting and Information
Systems, University of Rajshahi, Bangladesh
2. Dr. Farhana Begum. BCom (Honors) MCom. MPhil , PhD. Accounting, Postdoctoral Scholar,
Accounting Research Institute( ARI) Universiti Teknologi MARA (UITM) 40450, Shah Alam
Selangor, Malaysia.
3. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.

117 Global­Healthcare Global­Healthcare 118

the­regions­and­population­groups­and­for­specific­types­of health­for­all­regardless­of­people’s­financial­ability­and­in
health­ care;­ and­ mechanisms­ for­ paying­ healthcare. turn­saving­them­from­economic­catastrophe,­the­terrible
Although­India’s­health­care­system­is­two­types­like­private quality­and­scarce­availability­of­care­in­the­public­sector
and­ public­ sector,­ but­ urban­ areas­ more­ concentrated makes­ people­ choose­ the­ private­ sector­ instead­ (1).­ The
while­65.97%­of­the­total­population­resides­in­rural­areas. public­financing­of­India’s­health­sector­being­historically
According­ to­ World­ Bank­ per­ capita­ government­ health poor­makes­clearer­about­the­existence­of­inefficiency­in
expenditure­of­India­in­the­year­2016,­was­U$­15.95.­The that­ sector.­ Limitation­ of­ government­ expenditure­ has
government­spent­0.93%­of­GDP­in­2016­for­healthcare. added­fuel­to­the­growth­of­the­private­sector­in­India.­
In­ another­ report­ of­ WHO­ in­ India­ 67.78%­ of­ the­ total
health­ expenditure­ in­ 2015­ came­ from­ out-of-pocket
payments.­ The­ public­ financing­ of­ India’s­ healthcare
being­ historically­ poor.­ The­ percentage­ of­ GDP­ share
spent­in­health­sector­by­the­government­has­been­almost
stagnant­over­the­years.
Key words: Healthcare­ financing,­ Government,­ Public
and­Private,­GDP
India­has­a­mixed­health­system­comprised­of­both­public
and­private­sectors,­the­later­being­responsible­for­serving
the­majority­of­the­population.­Most­of­the­private­facilities
of­ the­ country­ are­ concentrated­ in­ urban­ areas,­ while
Figure­1:­Per­capita­government­health­expenditure­and
65.97%­ of­ the­ total­ population­ resides­ in­ rural­ areas.
government­health­expenditure­as­a­share­of­GDP
Furthermore,­the­country­suffers­from­a­shortage­of­health
Source:­World­Bank­Data
workforce.­As­a­consequence,­a­considerable­share­of­the
population­is­deprived­of­access­to­quality­healthcare. According­ to­World­ Bank,­ per­ capita­ government­ health
expenditure­ of­ India­ in­ the­ year­ 2008­ was­ around­ $8.6.
The­infrastructure­of­health­system­in­public­sector­is­separated
Throughout­the­time,­this­amount­increased­to­$15.947­in
into­ 3­ tiers-­ primary,­ secondary­ and­ tertiary­ levels.­ The
2016­(figure­1),­along­with­some­minor­downfalls­in­this
government­ healthcare­ system­ is­ established­ in­ order­ to
augmentation.­ In­ 2012,­ the­ value­ dropped­ to­ $12.97,
deliver­ primarily­ preventive­ and­ curative­ care­ covering
which­was­$13.729­in­the­preceding­year.­Nevertheless,­it
both­rural­and­urban­regions.­The­principle­of­the­foundation
again­started­to­increase­and­reached­to­$15.947­in­2016,
of­government­healthcare­was­to­limit­the­private­practices
which­is­reflected­on­the­upward­sloping­trend­line­of­per
while­paying­the­public­sector­workforce­from government
capita­ heath­ expenditure­ by­ the­ government­ (figure­ 1).
tax­ revenues­ (1).­ Although­ the­ target­ was­ to­ guarantee

119 Global­Healthcare Global­Healthcare 120

However,­ the­ percentage­ of­ GDP­ share­ spent­ in­ health
sector by­ the­ government­ has­ been­ almost­ stagnant­ over
the­years,­even­though­the­nominal­amount­of­the­per­capita
expenditure­ is­ ever-increasing.­This­ percentage­ has­ been
lingering­around­the­same­figure­for­a­long­term.­In­2008,
the­ government­ spent­ almost­ 0.8%­ of­ its­ GDP­ for
healthcare.­Maintaining­the­same­pattern,­this­percentage
stood­to­be­0.93%­in­2016­(figure­1).­This­trend­ascertains
India­as­one­of­the­countries­that­have­been­experiencing
the­lowest­government­spending­in­the­world.Nonetheless,
the­ total­ per­ capita­ health­ expenditure­ in­ the­ 2016­ was
$62.716­which­was­$45.251­in­2010.­On­the­other­hand,
the­total­health­expenditure­as­a­share­of­GDP­of­the­stated
year­ was­ 3.658%.­ Conversely,­ in­ 2000,­ this­ share­ was
4.038%.­­
There­are­a­few­government­programs­running­in­India­in
order­ to­ prevent­ financial­ hardship­ of­ the­ population
regarding­ healthcare.­ The­ latest­ national­ initiative,
Ayushman­ Bharat­Yojana,­ was­ launched­ as­ a­ part­ of­ the
National­health­Policy­2017­with­an­intention­to­achieve
Universal­ Health­ Coverage­ (UHC)­ through­ two
inter-related­ sub-programs-­ Establishment­ of­ Health­ and
Wellness­Centers­and­Pradhan­Mantri­Jan­ArogyaYojana
(PM-JAY).­ According­ to­ Indian­ National­ Health­ Portal,
financial­ protection­ is­ provided­ by­ the­ scheme­ to­ 10.74
crore­ people­ who­ are­ identified­ as­ poor,­ from
disadvantaged rural­ families­ and­ families­ of
occupational­ categories­ of­ urban­ workers’.­ Apart­ from
this,­there­are­other­health­insurance­schemes­in­different
states­ and­ throughout­ the­ country,­ for­ instance,­ Rajiv
Arogyasri­ in­ Andhra­ Pradesh,­ MukhyamantriAmrutam
Insurance­ Scheme­ in­ Gujarat,­ Yeshasvini­ Cooperative
Farmers­ Health­ Insurance­ Scheme,­ and­ Vajpayee
121 Global­Healthcare
Aarogyashree­Scheme­in­Karnataka,­Rashtriya­Swasthya
Bima­Yojana­of­the­Ministry­of­Labor­and­Employment.
Despite­implementing­numbers­of­schemes­and­programs
by­the­government,­the­quality­of­care­has­constantly­been
low­in­public­sector­because­of­the­low­budgetary­allocation.
Consequently,­people­are­tuning­to­private­healthcare.
A­study­discovered­three­determinants­of­people­seeking
private­ healthcare­ in­ India,­ which­ are,­ domination­ of
private sector­ in­ healthcare­ delivery,­ high­ private­ sector
financing­of­healthcare­compared­to­government­contribution,
and­scarce­government­services.­As­claimed­by­a­report­of
WHO­SEARO,­67.78%­of­the­total­health­expenditure­in
2015­ came­ from­ out-of-pocket­ payments­ (3).­ Studies­ on
health­accounts­of­2013-14­found­that­about­4.5%­of­the
total­ population­ of­ the­ country­ suffered­ from
impoverishment­due­to­this­amplified­sum­of­out-of-
pocket­healthcare expenditure,­where­70%­of­the­out-of-
pocket­ payment­ spent­ by­ the­ patients­ are­ spent­ behind
medicines­ (4).­ A­ study­ on­ the­ trends­ in­ out-of-pocket
payments­ and­ catastrophic­ health­ expenditure­ in­ India
from­ 1993­ to­ 2014­ discovered­ households­ that­ are­ most
susceptible­to­catastrophic­expenditure­through­three­key
indicators.­The­study­revealed­that­increase­in­catastrophic
health­expenditure­was­greater­for­the­poor­than­the­rich,
the­proportion­was­highest­among­households­with­older
people­and­the­likelihood­of­catastrophic­health­expenditure
were­also­higher­in­households­headed­by­females­and­in
rural­households.­
Apart­ from­ out-of-pocket­ spending,­ there­ are­ private
health­ insurance­ programs­ in­ India;­ family­ floater­ plans,
top-up­ plans,­ critical­ illness­ plans,­ hospital­ cash­ and­ top
up­policies­being­some­of­those.­Records­of­2015-16­show
Global­Healthcare 122
that,­around­21%­of­the­people­under­insurances­were­covered
by­ private­ insurance­ companies­ (2).­ Due­ to­ the­ huge
amount­ of­ out-of-pocket­ and­ overall­ private­ spending,
India­is­failing­in­attaining­Universal­Health­Coverage,­by
not­being­able­to­establish­equity­in­access­to­healthcare
and­to­demolish­financial­burden.­
References:
1.­ Chokshi­M,­Patil­B,­Khanna­R,­Neogi­SB,­Sharma­J,­Paul­VK,­et­al.­Health­systems­in­India.­J
Perinatol­[Internet].­2016;36(s3):S9–12.­Available­from:­http://dx.doi.org/10.1038/jp.2016.184
2.­ Central­Bureau­of­Health­Intelligence.­National­Health­Profile­2018­[Internet].­New­Delhi;­2018.
Available­from:­www.who.int/classifications
3.­ World­ Health­ Organization­ (WHO).­ Health­ financing­ profile­ 2017­ India­ [Internet].­ 2017.
Available­from:­https://data.worldbank.org/indicator/,
4.­ Bose­M,­Dutta­A.­Health­financing­strategies­to­reduce­out-of-pocket­burden­in­India:­a­comparative
study­of­three­states.­BMC­Health­Serv­Res.­2018;18(1):1–10.­
123 Global­Healthcare
Chapter­11
Healthcare Financing in Cuba
Shahinul­Alam1, Zareen­Tasnim2
Abstract
The­ administrative­ regulator,­ service­ provider­ and
financing­ actor­ of­ the­ health­ system­ of­ Cuba­ is­ the
government­ of­ the­ country.­ The­ primary­ healthcare
focused­health­system­of­Cuba­has­been­able­to­list­the
country’s­ name­ as­ one­ of­ the­ achievers­ of­ Universal
Health­ Coverage­ (UHC).­ A­ national­ health­ system
prevails­in­the­country­which­run­the­healthcare­delivery
system­ encompassing­ Family­ Physician­ Units,
Polyclinics­ and­ Hospitals.­ Involving­ the­ community­ in
healthcare­ delivery,­ the­ Cuban­ health­ system­ has­ made
access­ to­ healthcare­ smoother­ as­ well­ as­ greater.­ The
system­ is­ chiefly­ financed­ by­ the­ government­ through
general­ taxation,­ along­ with­ an­ almost­ non-existent
portion­ of­ OOP­ payment.­ In­ spite­ of­ not­ being­ a
high-income­ country,­ Cuba­ holds­ a­ decent­ figure­ of
healthcare­expenditure,­which­was­around­12.19%­of­the
country’s­ GDP­ in­ 2016.­ By­ enhancing­ community
participation­ in­ healthcare­ provision­ and­ strengthening
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University,Dhaka. Bangladesh.
2. Zareen Tasnim, Research Assistant, Urban Health Research, 25i Green Road. Dhaka.
Bangladesh
Global­Healthcare 124
preventive­healthcare,­Cuba­has­been­able­to­run­a­health
system­ that­ is­ entirely­ funded­ by­ the­ public­ sector.
Although­there­are­a­number­of­drawbacks,­Cuban­health
system­should­undoubtedly­be­taken­as­an­example­for­the
countries­that­are­targeting­to­attain­UHC.­
Key words: Cuba;­ health­ system;­ health­ financing;
Universal­Health­Coverage­(UHC)
The­ health­ system­ of­ Cuba­ is­ worldwide­ recognized­ for
achieving­ Universal­ Health­ Coverage­ (UHC)­ with
sky-scraping­efficiency­within­the­sector.­Since­the­Cuban
socialist­revolution­in­1959,­the­healthcare­system­of­the
country­ started­ to­ build­ up­ targeting­ a­ public-centered
National­ Health­ System­ regulated­ by­ the­ Ministry­ of
Public­Health.­The­National­Health­System­of­Cuba­aims
to­ characterize­ Universal­ Health­ Coverage­ by­ ensuring
equal­access­to­quality­healthcare­for­all­the­citizens­of­the
country.­ For­ its­ astounding­ level­ of­ access­ to­ healthcare,
the­ preventive-care­ based­ health­ system­ of­ Cuba­ is­ well
distinctive­ among­ its­ fellow­ low­ and­ middle-income
countries (LMICs)­(1).­
There­ was­ intense­ disparity­ in­ workforce­ distribution­ in
Cuban­healthcare­system­prior­to­the­revolution­in­1959.
The­lion’s­share­of­the­doctors­used­to­reside­in­the­urban
areas,­ which­ in­ turn,­ was­ the­ reason­ behind­ enormous
number­of­people­not­having­access­to­healthcare(2).­The
provision­ of­ National­ Health­ System­ ensures­ that­ the
entire­population­of­the­country­gets­healthcare­coverage
without­undertaking­any­financial­hardship.­In­the­view­of
this­ fact,­ a­ community­ oriented­ 3­ tier­ healthcare­ system
was­ established­ in­ Cuba,­ which­ is­ comprised­ by­ Family
125 Global­Healthcare
Physician­ Units,­ Polyclinics­ and­ Hospitals.­ These
comprehensive interventions­ are­ put­ into­ operation­ to
extend­healthcare­services­to­the­core­of­the­communities.
Family­ physicians­ are­ in­ charge­ for­ delivering­ primary
care­and­preventive­services­to­the­family­physician­unit
of­the­community(3).­Whereas,­along­with­Primary­Health
Care­ (PHC),­ polyclinics­ provide­ curative­ and
rehabilitative­services with­additional­services according
to­the­health­needs­of­the­communities­those­are­attached
to.­ The­ hospitals­ are­ established­ for­ delivering­ extreme
healthcare­needs­which­the­preceding­two­sectors­cannot
deal­ with.­ Specialized­ hospitals­ and­ research­ institutes
exist­in­order­to­provide­tertiary­care.The­social­security
system­ of­ the­ country­ is­ comprised­ by­ two­ subsystems:
social­security­and­social­welfare.­Protection­for­old­aged,
disabled­ and­ diseased­ persons­ are­ assured­ by­ Social
Security.­Pensions,­grants­for­maternity­leaves­and­subsidies
for­accidents­are­given­through­this­system.­Whereas,­care
for­old­aged­and­disabled­persons­are­guaranteed­in­social
institutions­by­Social­Welfare­program.
The­ entire­ health­ system­ of­ the­ country­ is­ almost
completely financed­through­public­funding;­by­means­of
general­ tax­ revenues,­ where­ all­ healthcare­ facilities­ are
state-owned­ (4).­ Government­ being­ the­ prime­ source­ of
healthcare­financing­in­Cuba,­according­to­World­Bank,­it
spent­ a­ massive­ share­ of­ around­ 89.60%­ of­ the­ total
healthcare­ expenditure­ in­ 2016(5).­ Conversely,­ only
10.31%­ of­ the­ health­ expenditure­ was­ spent­ through
out-of-pocket payments(5).
Global­Healthcare 126

Figure 1: Healthcare expenditure as a % of GDP of Cuba
*Source: World Bank Data
The­country’s­healthcare­expenditure­trend­experienced­a
massive­ growth­ since­ 2000.­ In­ the­ early­ 2000s,­ Cuba’s
total­ healthcare­ expenditure­ lingered­ around­ 6­ to­ 7%­ of
the­country’s­GDP.­Nevertheless,­the­share­grew­at­a­rapid
speed­in­the­succeeding­years.­Cuba­used­up12.19%­of­the
country’s­GDP­in­healthcare­in­2016,­which­is­double­than
that­ of­ the­ share­ of­ GDP­ used­ in­ 2000­ (figure­ 1)
(6).Although­the­expenditure­in­health­grew­over­time,­it
still­ behind­ the­ expenditure­ of­ countries­ with­ higher
income­level,­for­example,­USA­spending­around­17%­of
GDP­in­healthcare.­
127 Global­Healthcare
Figure 2: Per capita health expenditure (US$) in Cuba
*Source: World Bank Data
Analogous­ to­ the­ healthcare­ expenditure­ as­ a­ share­ of
GDP,­ per­ capita­ health­ expenditure­ of­ the­ country­ also
significantly­ augmented­ in­ the­ period­ 2000­ to­ 2016.­As
specified­by­the­World­Bank,­in­2000,­Cuba’s­per­capita
health­expenditure­was­$180.39­(figure­2)­(7).­Following
an­increasing­pattern,­the­healthcare­expenditure­grew­to
around­$970.65­per­capita­(figure­2).­
A­downfall­in­Cuban­health­system­is­that­since­there­is­no
privatization­ of­ healthcare­ and­ the­ health­ work­ force
isexclusively­paid­by­the­government,­a­study­found­that
they­ get­ only­ about­ $20­ as­ their­ monthly­ payment­ (3).
However,­ they­ get­ some­ other­ government­ benefits
resembling­ housing­ and­ food­ subsidies.­ Health­ tourism
has­been­a­huge­source­of­income­to­the­Cuban­government
after­ the­ collapse­ of­ Soviet­ Union.­ For­ this­ concern,­ the
government­has­established­an­association­named­Cubacan
Global­Healthcare 128
Tourism­ and­ Health.­ Two­ tier­ health facilities­ exist­ for Chapter­12
provision­ of­ healthcare­ to­ the­ citizens­ of­ Cuba­ and
healthcare­seeking­foreigners­and­diplomats­(2).­­­

Although­ Cuba’s­ healthcare­ spending­ is­ not­ excessively

high­comparing­to­high­income­countries,­its­health­sector
has­enhanced­health­conditions­and­significant­achievements.
Cuba­holds­record­for­being­the­first­country­to­eliminate Healthcare Financing in Turkey
polio,­ measles­ and­ the­ first­ to­ produce­ a­ vaccine­ for
meningococcus­ B­ meningitis(1).­ Apart­ from­ these,­ the
Shahinul­Alam1,­ZareenTasnim2
country­ has­ an­ impressive­ health­ profile.­ According­ to Abstract
WHO,­in­2015,­the­maternal­mortality­rate­of­the­country The­ health­ system­ of­ Turkey­ has­ successfully­ attained
was­ 41.6­ per­ 100,000­ live­ births.The­ most­ remarkable Universal­ Health­ Coverage­ (UHC)­ through­ an­ exclusive
achievement­ of­ the­ country­ regarding­ current­ global health­ system­ reformation­ program­ under­ which
health­ situation­ is­ the­ enforcement­ of­ Universal­ Health numerous­policies­and­interventions­were­taken­to­tackle
Coverage­and­abolishing­out-of-pocket­payments.­ the­ then-existing­ fragmentations­ within­ the­ system.
Antecedent­ to­ the­ initiation­ of­ the­ revolutionary­ Health
Transformation­ Program­ (HTP),­ Turkey­ was­ suffering
References: with­ severe­ disintegration­ in­ healthcare­ delivery­ among
1.­ Abiyemi­ Benita­ A.­ Health­ for­ all:­ Lessons­ from­ Cuba.­ Perspect­ Public­ Health.
the­population­and­was­lagging­behind­other­Organization
for­ Economic­ Cooperation­ and­ Development­ (OECD)
2016;136(6):326–7.­
2.­ Offredy­M.­The­health­of­a­nation:­Perspectives­from­Cuba’s­national­health­system.­Qual­Prim
Care.­2008;16(4):269–77.­ countries­in­different­health­indicators.­However,­after­the
3.­ Campion­ EW,­ Morrissey­ S.­ A­ Different­ Model-­ Medical­ Care­ in­ Cuba.­ n­ engl­ j­ med.
HTP­commenced­in­2003,­the­scenario­started­to­change.
Among­numbers­of­innovative­and­radical­policies­taken
2013;368(4):297–9.­
4.­ Gericke­ CA.­ Comparison­ of­ health­ care­ financing­ in­ Egypt­ and­ Cuba:­ Lessons­ for­ health
reform­in­Egypt.­East­Mediterr­Heal­J.­2005;11(5–6):1073–86.­ in­the­HTP­era,­the­most­commendable­one­was­the
5.­ The­World­Bank­Data.­Domestic­general­government­health­expenditure­(%­of­current­health­expenditure)
introduction­ of­ purchaser-provider­ split.­The­ Ministry­ of
Health­ became­ the­ single­ purchaser­ of­ healthcare­ from
-­ Cuba­ [Internet].­ Available­ from:­ https://data.worldbank.org/indicator/SH.XPD.GHED.CH.ZS?loca-
tions=CU&most_recent_year_desc=false
6.­ The­World­Bank­Data.­Current­health­expenditure­(%­of­GDP)­-­Cuba­[Internet].­Available­from: both­ public­ and­ private­ providers­ and­ the­ fragmentation
according­to­social­and­economic­classes­diminished.­The
https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=CU&most_recent_year
_desc=false
7.­ The­World­Bank­Data.­Current­health­expenditure­per­capita­(current­US$)­-­Cuba­[Internet].­Available­from: government­funding­for­healthcare­finances­boosted­up­to
https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=CU&most_recent_year_desc=false
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
2. Zareen Tasnim, Research Assistant, Urban Health Research, 25i Green Road. Dhaka,
Bangladesh

129 Global­Healthcare Global­Healthcare 130

almost­75%­of­the­total­health­expenditure­in­2011,­which
was­even­higher­than­that­of­the­average­value­of­OECD
countries.­Although­the­share­of­GDP­spent­in­healthcare
experienced­ an­ expansion­ at­ the­ reform­ era,­ it­ somehow
started­to­decline­slowly­afterwards,­but­again,­the­figures
were­better­than­that­of­the­pre-reform­age.­Nonetheless,
including­some­downturns,­the­health­system­of­the­country
has­still­been­showing­considerable­performances­in­meeting
expected­health­outcomes.
Key words: Turkey;­OECD;­Universal­Health­Coverage
(UHC);­Social­Insurance­Organization.­
The­healthcare­financing­system­of­Turkey­is­an­astonishing
example­ to­ the­ world­ due­ to­ its­ noteworthy­ reforms­ in
2003-2013­ era­ and­ hence­ achieving­ Universal­ Health
Coverage­ (UHC).­ The­ turning­ point­ of­ Turkey’s­ health
system­was­the­introduction­of­the­Health­Transformation
Program­ (HTP)­ in­ 2003,­ which­ was­ put­ into­ action­ in
order­to­overcome­the­existing­fragmentation­in­the­sector.
There­ were­ a­ number­ of­ programs,­ as­ well­ as­ financing
mechanisms­ for­ diverse­ clusters­ of­ the­ population­ in­ the
pre-reform­ period.­ Three­ different­ social­ security
schemes-­ Social­ Insurance­ Organization­ (Sosyal
Sigortalar­ Kurumu, SSK)­ for­ blue­ collar­ and­ private
sector­ workers;­ Social­ Insurance­ Agency­ for­ the
self-employed­ people­ (Ba-Kur)­ and­ Government
Employees­ Retirement­ Fund­ (GERF)­ co-existed­ in­ the
sector,­whereas­the­active­civil­servants’­health expenditure
was­financed­by­the­government­through­the­Active­Civil
Servants­Insurance­Fund­(1).­The­Green­Card­Scheme­was
in­ practice­ for­ delivering­ free­ healthcare­ to­ the­ people
131 Global­Healthcare
outside­formal­health­insurance­programs­(1).­There­were
also­a­very­few­amount­of­private­health­insurances­in­the
country.­ These­ fragmented­ programs­ were­ financed­ by
means­of­general­government­tax­revenues,­social­security
funds­ and­ out-of-pocket­ payments.­ Evidence­ states­ that,
63%­ of­ the­ total­ health­ expenditure­ was­ financed­ by­ the
public­sector­and­a­very­short­potion­was­borne­by­private
insurances,­whereas­27.6%­of­the­expenditures­were­made
through­ out-of-pocket­ payments­ in­ 2000(2).­ SSK­ was
financed­ through­ payroll­ taxes­ by­ both­ employers­ and
employees.­­The­premiums­from­the­beneficiaries­were­the
source­ of­ funding­ for­ the­ Ba?-Kur.­ The­ Government
Employees­Retirement­Fund­(GERF)­financed­healthcare
through­combined­contribution­of­active­civil­servants­and
the­government­budget.­­The­diversified­flow­of­funding
were­a­reason­behind­the­inefficiency,­inequity­and­poor
health­ outcomes­ along­ with­ dissatisfaction­ of­ the­ people
(1).­In­such­chaotic­situation,­numerous­reforms­under­the
Health­Transformation­Program­(HTP)­were­popularized
in­ the­ health­ sector­ of­ the­ country­ to­ improve­ efficiency
and­ establish­ equity.­ According­ to­ the­ Health
Transformation­Program,­the­Social­Security­Institute­was
established­as­the­single­purchaser­of­healthcare­from­both
public­and­private­providers,­Ministry­of­Health­being­the
major­provider.­The­diverse­healthcare­programs­targeting
different­ groups­ of­ the­ population­ were­ equalized­ in­ a
manner­so­that­all­Social­Security­Institute­members­could
get­ equal­ access­ to­ healthcare­ through­ a­ unified­ general
health­insurance­scheme­(1).­Previously,­different­groups
of­ people­ received­ different­ levels­ of­ benefits­ from­ the
packages,­among­which,­the­Green­Card­holders­had­the
Global­Healthcare 132
least­generous­benefits,­which­only­covered­the­in-patient
department­ expenditures.­ The­ expansion­ of­ Health
Transformation­Program­(HTP)­increased­the­expenditures
for­ Green­ Card­ beneficiaries­ almost­ about­ 5­ times.­ ­ In
accordance­ with­ the­ changes­ in­ healthcare­ financing
system,­ changes­ in­ health­ service­ provision­ and­ health
workforce­came­along.­Currently,­preventive­and­curative
services­ are­ provided­ by­ the­ unified­ general­ health
insurance­ scheme­ through­ different­ benefit­ packages.
Emergency­services­along­with­health­promotion­services
are­free­to­all­citizens­throughout­the­country.­The­health
workforce­of­the­country­had­a­36%­boost­during­2002­to
2012­(1).­A­medicine­centered­primary­healthcare­model
was­launched,­according­to­which,­each­family­doctor­is
responsible­ to­ provide­ services­ to­ 4000­ citizens.­ The
family-physicians­are­accountable­to­provide­free­of­cost
primary,­ preventive­ and­ women­ and­ child­ healthcare
services.
After­the­implementation­of­HTP,­along­with­the­existence
of­fiscal­space­for­health­created­through­stable­economic
growth­ in­ that­ period­ (3),­ Turkey­ had­ been­ able­ to
augment­the­public-sector­funding­for­health­to­74.9%­of
total­health­expenditures­in­2011­(1),­which­was­only­63%
in­ 2000­ (4).­ Moreover,­ this­ portion­ was­ 61.3%­ on­ an
average for­ all­ of­ the­ Organization­ for­ Economic
Cooperation­and­Development­(OECD)­countries­in­2011
(1).­The­upturn­in­government­expenditure­reflected­in­the
per­ capita­ expenditure,­ although­ low,­ it­ escalated­ from
US$469­ in­ 2003­ to­ US$1,161­ in­ 2011(1).­ Consequently,
the­ share­ of­ out-of-pocket­ payments­ declined­ from­ 18.9
percent­in­2003­to­15.9­percent­in­2011­(6).­
133 Global­Healthcare
Figure 1: Healthcare expenditure of Turkey as a % of GDP
*Data­are­from­the­Organization­for­Economic­Cooperation­and
Development
The­portion­of­GDP­spent­in­healthcare­of­Turkey­had­a
jump­ during­ the­ reform­ phase.­ As­ claimed­ by­ the
Organization­ for­ Economic­ Cooperation­ and
Development,­the­percentage­share­of­GDP­spent­in­health
was­initially­5.06%­at­the­starting­of­the­reform­period­in
2003­(figure­1).­The­portion­stared­to­increase­simultaneously
with­ the­ continuous­ reforms­ under­ the­ Health
Transformation­ Program­ (HTP),­ and­ ascended­ up­ to
5.53%­in­2009­(6).­Nevertheless­it­initiated­to­tag­along­a
downward­trend­thereafter.­The­share­fell­down­to­4.69%
from­ 5.53%­ within­ 2­ years­ and­ has­ been­ following­ the
same­pattern­since­2009.­In­2016,­the­share­of­GDP­spent
in­healthcare­became­4.31%,­which­was­less­than­half­than
that­of­the OECD average­value­(6),­where­3.4%­accounted
for­ public­ expenditure­ and­ the­ rest­ 0.9%­ was­ spent­ by
private­sources.­Subsequently,­Comparing­to­other­OECD
countries,­ Turkey’s­ per­ capita­ spending­ in­ healthcare­ is
similarly­low.­In­2017­it­was­$1,185.60,­whereas­the­average
spending­ of­ the­ OECD­ countries­ was­ $3,854.40­ in­ that
year­ (6).­ The­ out-of-pocket­ expenditure­ as­ a­ share­ of
health­ spending­ became­ 17.4­ percent­ in­ 2017­ (6).­ Even
Global­Healthcare 134
though,­the­healthcare­spending­had­dropped­slightly­after
2009,­ overall,­ it­ gained­ expansion­ comparing­ to­ the
pre-reform­period.­According­to­World­Bank,­Turkey experienced
a­150%­growth­in­terms­of­per­capita­health­spending­in­the
period­2002­to­2011­(1).­
Although­the­amount­spent­in­health­sector­is­reasonably
short­in­Turkey,­however,­the­country­is­achieving­better
health­outcomes­by­assuring­UHC­for­its­population­than
many­ other­ developed­ countries.­ There­ are­ 1.87
professionally­ active­ physicians­ per­ 1000­ population­ in
Turkey­as­stated­by­OECD­(6).­Per­capita­physician­visits
has­ increased­ twofold­ after­ the­ implementation­ of­ HTP.
There­were­substantial­increase­in­the­utilization­of­maternal
and­child­healthcare­services.­As­a­result,­infant­mortality
was­15­per­1000­live­births­in­2013,­as­stated­by­the­World
Bank.­The­life­expectancy­at­birth­in­Turkey­was­78.1­in
2017­ (6).­ By­ dint­ of­ these­ far-reaching­ changes­ in­ the
health­ sector­ of­ the­ country,­ people’s­ satisfaction­ level
attached­to­this­sector­also­raised­from­39.5%­in­2003­to
75.9%­in­2011­(5).­
References:
1.­ Bump­J,­Sparkes­S,­Tatar­M,­Çelik­Y.­Turkey­on­the­way­of­Universal­Health­Coverage­through
the­Health­Transformation­Program­(2003–13).­1818­H­Street,­NW­Washington,­DC­20433;
2014.­
2.­ MoH,­RSHC­S­of­PH.­Turkey­National­Health­Accounts­1999-2000.­Ankara;­2004.­
3.­ Atun­R,­Ayd?n­S,­Chakraborty­S,­Sümer­S,­Aran­M,­Gürol­I,­et­al.­Universal­health­coverage
in­Turkey?:­enhancement­of­equity.­Lancet.­2013;382:65–99.­
4.­ World­ Bank.­ 2012. World­ Development­ Indicators­ 2012. World­ Development­ Indicators.
Washington,­ DC.­ World­ Bank.­ https://openknowledge.worldbank.org/handle/10986/6014
License:­CC­BY­3.0­IGO.
5.­ Atun­R.­Transforming­Turkey’s­Health­System­—­Lessons­for­Universal­Coverage.­N­Engl­J
Med.­2015;373(14):1285–9.­
6.­ OECD­ (2019),­ Health­ spending­ (indicator).­ doi:­ 10.1787/8643de7e-en­ (Accessed­ on­ 27
September­2019)­
135 Global­Healthcare
Chapter­13
Healthcare Financing in
The United Kingdom
Shahinul­Alam1,­Mohammad­Jahid­Hasan2,
Tahsinul­Abedin3
Abstract
Since­ inception­ of­ National­ Health­ Service­ (NHS)
in1948,­it­provides­care­for­the­United­Kingdom­(England,
Wales,­Scotland­and­Northern­Ireland)­with­minimal­pay.
The­ health­ systems­ are­ funded­ by­ the­ UK­ Government
through­ general­ taxation­ and,­ to­ a­ much­ lesser extent,
through­ user­ charges.­ It­ explains­ that­ the­ rate­ of­ out-of-
pocket­(OOP)­expenses­are­remarkably­insignificant­in­the
UK.­As­per­the­statistics­of­2017,­merely­16%­of­the­total
health­expenditure­in­the­UK­was­paid­through­OOP­out-
lays,­ whereas­ a­ massive­ 79%­ was­ comprised­ by­ gov-
ernment­funding.­Each­country­has­its­own­NHS­of­vary-
ing­size,­where­England­serves­as­largest­NHS dedicat-
ed­to­the­country.­Despite­lack­of­coverage­of­Optometry
services,­co-payment­in­dental­services­and­issue­of­user
1. Dr. Shahinul Alam MBBS. MD. FCPS, Professor, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University Dhaka. Bangladesh.
2 Dr. Mohammad Jahid Hasan, MBBS, MPH, Executive Director, Pi Research Consultancy
Center. Dhaka. Bangladesh
3. Tahsinul Abedin, Department of Computer Science and Engineering, The University of Sydney,
NSW. Australia
Global­Healthcare 136
fees­and­medicine­cost­in­fewer­instances,­still­it­is­consid-
ered­one­of­the­best­health­care­serving­system among­the
developed­countries.­Every­fiscal­year­UK­govt.­expends
in­ an­ average­ £155.6­ billion­ which­ was­ around­ 10%­ of
GDP.­Although­opinion­exists­to­increase­the­health­care
budget­and­prolonged­waiting­time­to­access­NHS,­still­it
is­ a­ leading­ health­ care­ system­ around­ the­ Globe­ which
have­ promised­ to­ ensure­ public­ spending­ efficiently­ to
meet­health­needs­of­every­citizen.
Key words: Health­ financing;­ UK;­ OOP­ expense;
National­Health­Service­(NHS).
The­ healthcare­ system­ in­ The­ UK,­ commonly­ known­ as
National­Health­Service­(NHS),­is­a­public­funded national
health­care­system.­The­NHS­is­responsible­to­provide­free
of­ cost­ healthcare­ services­ to­ the­ care­ seekers,­ except
some­of­the­specific­services.­It­is­testified­to­be­the­best
in­ delivering­ health­ care­ services­ compared­ to­ 10­ other
most­developed­countries­in­the­world­in­a­recent­report
published­by­the­Commonwealth­Fund.­A­total­of­5 criteria
were­ selected­ for­ the­ ranking­ including­ care­ process,
access­ to­ health­ care­ services,­ administrative­ efficiency,
equity­and­healthcare­outcomes,­and­the­health­system­of
UK­topped­on­care­process­and­equity­(1).
There­are­differences­in­the­structure­of­NHS­in­the­four
countries-­England,­Wales,­Scotland­and­Northern­Ireland.
Whereas­the­NHS­in­England­and­Northern­Ireland­has­a
‘purchaser-provider­split’,­while­Wales­and­Scotland,­has
Local­Health­Boards­for­both­the­financing­and­delivery­of
healthcare.­ General­ taxation­ and­ National­ Insurance
contributions,­ that­ is,­ the­ government­ spending,­ is­ the
main­ source­ of­ health­ care­ financing­ in­ NHS,whereas­ a
137 Global­Healthcare
very­short­amount­comes­from­the­patients’­charges­which
are­excluded­from­the­NHS­coverage­and­costs­of­privately
organized­ care.­ A­ source­ of­ income­ for­ the­ NHS­ in
England­is­prescription­charges,­which­was­£9­per­item­in
2017.­ Total­ healthcare­ expenditure­ In­ the­ UK­ has­ an
upward­trend.­In­2000,­total­healthcare­expenditure­in­the
UK­ was­ 5.97%­ of­ its­ GDP.­ Following­ an­ increasing
pattern, in­the­year­2016,­the­total­healthcare­expenditure
as­a­share­of­GDP­of­the­UK­reached­9.8%.­Even­though
there­were­some­minor­falls,­the­overall­trend­of­per­capita
healthcare­ expenditure­ in­ the­ UK­ is­ similarly­ upward
sloping.­ Per­ capita­ health­ expenditure­ was­ $1674.018­ in
2000,­which­increased­to­$3958.019­in­2016.­In­2016-17,
per­capita­health­expenditure­was­£2331­in­Scotland­being­the
highest­ among­ the­ four­ countries;­ contrarily­ the­ figure­ was
£2137­per­capita­for­England,­which­was­the­lowest.­However,
the­ total­ expenditure­ on­ health­ in­ England,­ Scotland,
Wales­ and­ Northern­ Ireland­ was­ respectively­ £118101,
£12600,­£6950­and­£4176.­
Figure 1: Sources of Healthcare Expenditure in 2017, UK
Source: Office for National Statistics - UK Health Accounts
Global­Healthcare­138
Since­NHS­is­a­tax­funded­national­healthcare­system,­the
prime­ share­ of­ healthcare­ spending­ is­ done­ by­ the
government.­ In­ 2017,­ total­ government­ expenditure­ on
healthcare­ was­ £155.6­ billion,­ which­ accounted­ for­ 79%
of­ the­ total­ healthcare­ expenditure­ (2).­ The­ portion­ of
government­ spending­ has­ more­ or­ less­ been­ stable­ since
2013,­ after­ falling­ from­ 84.4%­ of­ contribution­ in­ 2012.
Almost­96%­of­government­spending­includes­preventive
care­expenditures,­curative­and­rehabilitative­care­expenses,
health­related­long-term­care­costs­and­costs­for­medical
goods­(2).­The­residual­share­of­4%­is­primarily comprised
of­ancillary­services­and­health­sector­governance­(2).
The­remaining­21%­was­financed­by­the­non-government
arrangements,­ which­ was­ £41.8­ billion­ in­ total­ (2).­ The
non-government­ expenditure­ comprised­ off­ our
categories­voluntary­health­insurance,­charitable­financing,
and­enterprise­financing and­out-of-pocket­expenditure. Of
all­ then­ on-government­ sources,­ out­ of­ pocket
payments­held­the­largest­cut,­16%­of­the­total­spending,
which­was­£31.5­billion­(2).­The­highest­OOP­spending­is
spent­for­pharmaceuticals­in­the­UK,­which­accounted­for
4%­of­the­total­OOP­spending.­A­World­Bank­study­found
that,­only­0.5%­of­the­population­in­the­UK­has­to­spend
more­ than­ a­ quarter­ of­ their­ income­ as­ out-of-pocket
expenditure­ in­ healthcare.­ On­ the­ other­ hand,­ voluntary
health­ insurance,­ charitable­ financing­ and­ enterprise
financing­ accounted­ for­ 3%,­ 2%­ and­ less­ than­ 1%
correspondingly­(2).­Among­the­government­sponsored
services,­nearly­half­of­the­care­was­provided­in­hospitals
(2).­In­private­sector,­long-term­care­expenses­and­medical
goods­spending­accounted­for­respectively­30%­and­29%
share­of­expenditure­in­2017­(2).
139 Global­Healthcare
The­above-mentioned­data­have­been­calculated­using­the
System­ of­ Health­Accounts­ 2011­ framework.There­ were
few­changes­in­this­accounting­process­from­the­previous
one­which­brought­upon­interesting­variations­in­the­UK
healthcare­ expenditure­ statistics­ and­ global­ rankings.­As
claimed­ by­ previous­ calculations,­ in­ the­ year­ 2014,­ the
healthcare­spending­of­the­UK­was­8.7%­of­the­country’s
GDP,­ however,­ the­ recent­ revision­ of­ the­ spending­ by
Office­ for­ National­ Statistics­ with­ the­ 2011­ accounting
rules­ have­ revealed­ that­ the­ healthcare­ spending­ in­ the
UKwas­actually­9.8­%­of­the­GDP­(3).­The­changes­in­the
accounting­process­resulted­in­such­rise­in­the­healthcare
spending­of­the­UK.­The­introduction­of­a­new­accounting
system­ played­ a­ crucial­ role­ in­ improving­ the­ UK’s
position in­the­international­ranking.­Prior­to­the­revision,
the­ UK’s­ health­ spending­ as­ a­ percentage­ of­ GDP­ was
lower­ compared­ to­ both­ Organization­ for­ Economic
Cooperation­ and­ Development­ (OECD)­ and­ European
Union­ (EU)­ countries’­ averages,­ whereas­ it­ is­ now
estimated­ higher­ than­ both­ of­ the­ average­ values(3).­ A
substantial­ amount­ of­ this­ increased­ amount­ is­ due­ to
re-classifying­ publicly­ funded­ social­ care­ as­ healthcare
spending,­ which,­ previously was­ not­ included­ under­ this
category(4).
Although­the­new­statistics­have­changed­the­UK’s­global
position­regarding­healthcare­spending,­according­to­some
studies,­it­does­not­imply­that­the­current­spending­is­just
‘the­most­desirable­level­of­spending’­(3).­In­this­regard,
the­Association­of­British­Pharmaceutical­Industry­mentioned
that­ the­ government­ healthcare­ spending­ should­ be
increased­to­11.3%­of­the­GDP,­which­is­the­average­of­G7
spending(5).­
Global­Healthcare 140
Despite­being­one­of­the­finest­healthcare­systems­in­the Chapter­14
world,­ NHS­ still­ lacks­ efficiency­ in­ some­ sectors.­ With
increasing­population,­increased­healthcare­demand­along
with­longer­waiting­time­are­becoming­huge­obstacles­in
NHS’s­ functioning;­ since­ the­ system­ allegedly­ has­ been

Healthcare Financing in
suffering­from­staff­scarcity.­Evidence­showed­that­NHS
employs­less­doctors­as­well­as­fewer­nurses­than­that­of
average­ OECD­ figures­ (6).­ In­ 2015,­ there­ were­ only­ 2.6 The United States of America
hospital­beds­per­1,000­populations.
Shahinul­Alam1,­Muhammad­Abdul­
References:
Baker­Chowdhury2
1.­ Gulland­A.­NEWS­UK­has­best­health­system­in­developed­world­,­US­analysis­concludes. Abstract:
Health­care­in­The­United­States­(US)­is­technologically
2017;3442:3442.­Available­from:­http://dx.doi.org/doi:10.1136/bmj.j3442

advanced­but­extremely­expensive.­It­includes­a­vast­range
2.­ Cooper­J.­Healthcare­expenditure­,­UK­Health­Accounts?:­2019;(June):1–28.­

of­ complex­ interrelationships­ among­ those­ who­ receive,

3.­ Appleby­J,­Gershlick­B.­Keeping­up­with­the­Johanssons?:­How­does­UK­health­spending
compare­internationally??­2017;3568:1–10.­Available­from:

provide,­ and­ finance­ care.­  Health­ care­ expenditure

http://dx.doi.org/doi:10.1136/bmj.j3568

increased­sharply­in­the­US­over­the­past­few­decades.­In
4.­ Appleby­J.­Is­the­UK­spending­more­than­we­thought­on­healthcare­(­and­much­less­on
social­care­)?­2016;3094(June):4–7.­Available­from:­http://dx.doi.org/doi:10.1136/bmj.i3094

5.­ Iacobucci­G.­NEWS­UK­spent­9­.­9­%­of­GDP­on­healthcare­last­year­,­official­figures­show. 1970,­the­US­spent­7.2%­of­GDP­on­health­care.­By­2010,

2017;2080:2080.­
it­increased­to­17.9.­The­per­capita­healthcare­expenditure
6.­ Charlesworth­A,­Bloor­K.­70­years­of­NHS­funding?:­how­do­we­know­how­much­is
enough??­2018;2373(June):1–6.­ is­ higher­ in­ the­ United­ States­ than­ in­ other­ countries;
moreover,­ the­ percentage­ gross­ domestic­ product­ (GDP)
spent­on­health­care­is­substantially­higher­than­that­in­any
other­ nation.­ In­ 2018­ the­ United­ States­ spent­ 16.9%­ of
GDP­ on­ health­ care­ compared­ to­ the­ next­ highest
Organization­ for­ Economic­ Cooperation­ and
Development(OECD)­ countries,­ including­ Switzerland
(12.2%­ of­ GDP)­ and­ France,­ Germany,­ Sweden,­ and
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.

2. Muhammad Abdul Baker Chowdhury, MPH, MPS, M.Sc., Clinical Biostatistician, Department of
Emergency Medicine, University of Florida College of Medicine, PO Box 100186, Gainesville, FL

141 Global­Healthcare Global­Healthcare 142

Japan­ (each­ about­ 11%),­ while­ the­ average­ of­ the­ 35
OECD­ countries­ (OECD35)­ was­ 8.8%.­ Even­ though­ the
United­States­spends­more­on­health­care­per­person­than
any­ other­ country,­ still­ there­ are­ large­ number­ of­ people
are­ uninsured­ or­ underinsured.­ The­Affordable­ Care­Act
which­became­effective­in­2014­improved­access,­affordability,
and­ quality­ of­ medical­ care­ through­ both­ public­ and
private­sector­funding­still­there­are­a­large­number­of people
do­not­have­any­source­of­health­care­financing­rather­than
out­of­pocket­expenditure.­­
Key words: Healthcare­financing;­USA;­Medicare;
OECD;­Medicaid

The­ United­ States­ (US)­ has­ been­ holding­ its­ position

among­ the­ Organization­ for­ Economic­ Cooperation­ and
Development­ (OECD)­ countries,­ as­ well­ as­ in­ the­ world
for­spending­the­highest­share­of­GDP­on­health­care­for­a
long­ period­ of­ time.­ However,­ despite­ having­ such­ an
enormous­amount­of­spending,­the­health­sector­in­the­US
has­been­constantly­showing­poor­performances­comparing
to­other­OECD­countries.­In­the­US,­indicators­like­cancer
rate,­low­birth­weight­rate,­infant­mortality­rate,­and­years
of­life­lost­are­higher­than­that­of­the­median­OECD values.
The­ life­ expectancy­ at­ birth­ declined­ 0.1­ years­ between
2015­and­2016,­which­is­the­first­time­since­1993.­Among
the­OECD­countries,­US­offers­the­least­healthcare­coverage
to­the­citizens­of­the­country.­The­health­sector­prices­are
higher­ than­ other­ countries­ having­ high­ healthcare
expenditures.­­
Figure 1: Healthcare expenditure as a % of GDP in US
*Source: World Bank Data
The­ healthcare­ expenditure­ in­ the­ USA­ is­ substantially
higher­than­any­other­country­in­the­world.­Although­the
growth­rate­did­not­increase­much­since­2010,­the­country
has­ been­ spending­ a­ very­ high­ percentage­ of­ its­ GDP
(Figure­1).­According­to­OECD,­the­healthcare­expenditure
as­a­share­of­GDP­in­the­USA­was­17.1%­in­2017,­which
was­significantly­higher­than­the­OECD­average­of­8.8%
(1).­The­per­capita­expenditure­in­2017­was­$10,206­(1).­
The­financing­of­the­health­sector­in­the­US,­not­having
any­ particular­ mechanism,­ operates­ in­ a­ mixed­ system,
which­can­be­portrayed­as­a­hybrid­structure.­The­system
is­ characterized­ by­ the­ contribution­ of­ both­ public­ and
private funding.­ The­ public­ funding­ runs­ the­ largest

143 Global­Healthcare Global­Healthcare 144

government­ health­ insurance­ programs-­ Medicare­ and
Medicaid,­ along­ with­ some­ other­ government­ programs,
such­ as­ State­ Children’s­ Health­ Insurance­ Program,
Children­ and­ Youth­ with­ Special­ Health­ Care­ Needs,
Veterans­ Health­ Administration,­ Indian­ Health­ Service,
Refugee­ Health­ Promotion­ Program,­ etc.­ On­ the­ other
hand,­private­health­insurance­programs­and­out-of-pocket
payments­comprise­the­private­health­care­programs.­
Medicare,­which­is­a­national­insurance­program­primarily
targeted­ for­ elderly­ people­ who­ are­ aged­ over­ 65,­ along
with­people­with­disabilities,­is­financed­by­the­Medicare
Trust­ Fund.­ The­ Medicare­ Trust­ Fund­ encompasses­ two
distinct­ funds-­ Hospital­ Insurance­ Trust­ Fund­ (HI)­ and
Supplementary­ Medical­ Insurance­ Trust­ Fund­ (SMI).
Payroll­ taxes­ on­ earnings­ and­ income­ taxes­ on­ Social
Security­benefits­finance­the­HI­Trust­Fund,­whereas­The
SMI­Trust­Fund­is­funded­through­general­tax­revenue­and
the­ premiums­ paid­ by­ the­ enrollees.­ The­ Centers­ for
Disease­ Control­ and­ Prevention­ (CDC)­ estimated­ that
Medicare­accounted­for­22.1%­of­total­health­care­spending
in­2016.­The­growth­rate­of­personal­healthcare­cost­was
5%­for­Medicare­from­2006­to­2016­(1).­In­total,­$625.3
billion­ was­ spent­ behind­ personal­ healthcare­ through
Medicare­in­the­latter­year­for­56.8­million­enrollees­(1).
Medicaid­is­a­joint­program­by­federal­and­state­governments
that­ supports­ mainly­ the­ low-income­ people.­ Medicaid
spending­is­primarily­funded­by­Federal­and­State­general
revenues.­At­times,­local­government­revenues­are­necessary
to­ finance­ a­ percentage­ of­ the­ expenditures.­ In­ 2016,
Medicaid­ paid­ 17.8%­ of­ total­ healthcare­ expenditure­ of
the­ country­ (1).­ During­ 2006–­ 2016­ periods,­ the­ annual
growth­ rate­ for­ personal­ healthcare­ expenditures­ for
145 Global­Healthcare
Medicaid-state­ and­ Medicaid-federal­ was­ respectively
4.3%­and­7%­(1).­In­2016,­personal­healthcare­expenditure
through­ Medicaid­ was­ $505.2­ billion­ (1).­ 13.1%­ of­ the
adults­were­recorded­to­be­under­the­coverage­of­Medicaid
in­2017­(1).­
Unlike­most­of­the­developed­countries,­the­health­system
is­not­entirely­funded­by­government­arrangements­in­the
USA.­A­huge­portion­of­health­care­expenditure­is­borne
by­private­insurance­companies,­which­was­35.1%­of­total
healthcare­ expenditure­ in­ 2016­ (1).­ Mostly,­ private
insurances­ are­ bought­ by­ employers.­The­ employers­ pay
the­ premiums­ on­ behalf­ of­ their­ employees,­ sometimes
cutting­ a­ portion­ of­ their­ employees’­ wages­ intended­ for
the­ premiums.­ The­ government­ also­ subsidizes­ these
insurances­to­some­extent.­Apart­from­the­employee­market,
people­ too­ buy­ insurance­ policies­ themselves,­ not­ being
under­any­firm.­Out-of-pocket­payments­constitute­a­large
part­of­the­healthcare­expenditure­in­the­USA.­­
The­Affordable­Care­Act­(ACA)­is­one­of­the­most­revolutionary
acts­ in­ the­ health­ sector­ of­ the­ US­ enacted­ to­ improve
access,­affordability,­and­quality­of­medical­care­through
both­ public­ and­ private­ sector.­ The­ key­ provision­ of­ the
ACA­was­to­reduce­the­uninsurance­rate­among­specific
populations­ including­ youngest­ adults,­ low-income
families (income­ below­ 138%­ of­ the­ federal­ poverty
level),­and­individuals­with­pre-existing­conditions.­After
the­ full­ implementation­ of­ the­ACA,­ a­ rapid­ decrease­ of
about­9­million­uninsured­people­than­its­preceding­year
was­recorded­in­2014­(2).­However,­still­a­massive­portion
of­ the­ population­ is­ uninsured­ in­ the­ USA.­ Currently,­27
million­ Americans­ are­ not­ under­ any insurance­ program
Global­Healthcare 146
even­after­the­expansion­of­coverage­due­to­the­ACA­(3).
Furthermore,­it­is­seen­that­the­majority­of­the­uninsured
people’s­annual­income­is­mostly­below­the­poverty­line
(3).Those­who­cannot­get­coverage­by­all­the­aforementioned
sources­have­no­other­choice­than­to­pay­their­healthcare
costs­through­out-of-pocket­payments.­
Figure 2: Per capita out-of-pocket expenditure in USA (US$)
*Source:­World­Bank­Data
In­ 2016,­ reportedly­ 12.4%­ of­ the­ total­ healthcare
expenditure was­paid­out-of-pocket­(1).­The­amount­spent
out-of-pocket­is­following­an­increasing­trend­in­the­USA
(figure­ 2).­ In­ 2010,­ per­ capita­ out-of-pocket­ expenditure
was­ $971.167­ in­ the­ USA,­ which­ gradually­ increased­ to
$1094.227­in­2016.­The­prime­cause­of­high­out-of-pocket
expenditure­in­the­USA­is­the­direct­payment­in­absence­of
coverage­for­the­uninsured.­Apart­from­that,­the­high­cost
sharing­requirements­boost­up­the­out-of-pocket­payments.
147 Global­Healthcare
In­Medicare,­20%­co-insurance­rate­for­physician­services
and­no­out-of-pocket­ceiling­cause­increase­in­the­out-of-
pocket­expenditure.­In­the­case­of­private­insurances,­the
deductibles­have­risen­dramatically­in­recent­years­with­a
2.5-fold­ increase­ resulting­ it­ to­ be $1478­ in­ 2016­ which
was­ $602­ in­ 2005.­ The­ high­ amount­ of­ out-of-pocket
payments­generally­pushes­people­towards­bankruptcies.
Medical­ bills­ were­ found­ as­ the­ leading­ cause­ of
bankruptcy in­the­US­in­a­2014­survey­(4).­
Regardless­of­being­the­country­with­the­highest­percentage
of­spending­on­health­sector­with­a­figure­more­than­double
than­ that­ of­ the­ average­ spending­ of­ the­ other­ OECD
countries,­ the­ US­ is­ far­ behind­ in­ case­ of­ health­ sector
outcomes along­with­having­high­out-of-pocket­payments.­­
References:
1.­ National­Center­for­Health­Statistics.­Health,­United­States,­2017:­With­special­feature­on­mor-
tality.­Hyattsville,­MD;­2018.­
2.­ Majerol­M,­Newkirk­V,­Garfield­R.­The­Uninsured?:­A­Primer­Key­facts­about­health­insur-
ance­and­the­uninsured­in­the­era­of­health­reform.­2015.­
3.­ Dickman­ SL,­ Himmelstein­ DU,­ Woolhandler­ S.­ Series­ America?:­ Equity­ and­ Equality­ in
Health­ 1­ Inequality­ and­ the­ health-care­ system­ in­ the­ USA.­ Lancet­ [Internet].
2017;389(10077):1431–41.­Available­ from:­ http://dx.doi.org/10.1016/S0140-6736(17)30398-
7
4.­ Austin­DA.­Medical­debt­as­a­cause­of­consumer­bankruptcy.­Maine­Law­Rev.­2014;67:1(204).­
Global­Healthcare 148
Chapter­15
Recommendation for a Better
Healthcare Financing System
for Bangladesh
Shahinul­Alam1,­Zakiul­Hasan2,­Shah
Mohammad­Fahim3,­Zareen­Tasnim4
Abstract:
Health­ sector­ is­ being­ financed­ by­ government,­ foreign
donors,­NGOs,­and­households.­The­participation­of
government­for­health­care­financing­is­one­third.­Whereas
the­house­hold­expenditure­through­Out-of-pocket­(OOP)
payments­ranges­from­64­to­71.82%­leading­to­catastrophic
health­ expenditure.­ Health­ budget­ is­ around­ 5­ %­ of­ the
total­ budget­ of­ the­ country­ with­ spending­ rate­ of­ 90%.
Universal­Health­Coverage­(UHC)­is­yet­to­be­addressed.
Social­coverage­and­health­insurance­is­in­primitive­stage.
1. Professor Dr. Shahinul Alam MBBS. MD. FCPS, Department of Hepatology, Bangabandhu
Sheikh Mujib Medical University, Dhaka. Bangladesh.
2. Dr. Md. Zakiul Hassan MBBS, Assistant Scientist , Emerging Infections, Infectious Diseases
Division, 68 Shaheed Tajuddin Ahmed Sarani | Mohakhal| Dhaka 1212 | Bangladesh
3. Dr. Shah Mohammad Fahim, MBBS, MPH, Research Investigator , Nutrition and Clinical
Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh
(icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
4. ZareenTasnim, Research Assistant, Urban Health Research, 25i Green Road. Dhaka,
Bangladesh
149 Global­Healthcare
In­ response­ to­ unmet­ need­ and­ challenges­ in­ health­ care
financing­ health­ budget­ should­ be­ 15%­ of­ total­ budget,
OOP­ should­ be­ reduced­ to­ 32%.­ Social­ coverage,­ health
insurance­ may­ be­ expanded­ to­ all­ government­ and
non-government­ employee,­ garments­ worker,­ family
members­ of­ nonresident­ Bangladeshi­ by­ contribution­ of
employee­ and­ employers­ and­ also­ by­ public­ private
partnership.­ ­ UHC­ will­ have­ to­ be­ ensured­ for
every­ person, everywhere­ completely­ by­ government
financing.­Though­good­governance­is­a­big­question­to­be
solved.­We­still­hope­these­are­achievable­by­2030.
Key words: Health­ financing;­ health­ budget;­ universal
health­coverage;­social­coverage;­health­insurance;­health
system.
The­ prime­ actors­ of­ healthcare­ financing­ in­ Bangladesh
are­ the­ government,­ foreign­ donors,­ NGOs,­ and
households.­ Financial­ flow­ for­ the­ public­ sector­ derives
from­ general­ tax­ revenues,­ foreign­ development­ funds,
and­ corporations­ and­ autonomous­ bodies,­ which­ are
channeled­ by­ the­ Ministry­ of­ Finance­ (MoF)­ to­ the
Ministry­of­Health­and­Family­Welfare­(MoHFW)­(1).­On
the contrary,­ for­ buying­ healthcare,­ households­ or
individuals­ contribute­ from­ their­ own­ pocket,­ in­ other
words,­through­Out-of-pocket­(OOP)­payments.­Although
Bangladesh­achieved­number­of­triumphs­in­health­sector
lately,­the­scenario­of­financing­is­not­satisfactory.
Unlike­most­developed­countries­in­the­world,­the­government
of­Bangladesh­has­minimal­contribution­in­the­health­sector
Global­Healthcare 150
funding.­As­reported­by­the­Healthcare­Financing­Strategy
2012-2032,­the­government­budget­for­public­facilities­in
2012­was­26%­of­total­health­expenditure,­contrarily­OOP
expenditure­accounted­for­64%­of­it­(2).­The­government
set­ the­ target­ to­ decrease­ the­ share­ of­ OOP­ payments­ to
32%,­slightly­increase­the­government­budget­to­30%,­and
introduce­social­health­protection­schemes­which­intended
to­account­for­32%­of­total­health­expenditure­within­2030
(2).­ However,­ instead­ of­ moving­ forward­ according­ the
proposed­ strategy,­ the­ scenario­ has­ been­ degrading­ ever
since.­ According­ to­ the­ World­ Bank,­ the­ share­ of­ OOP
payments­ rose­ to­ 71.82%­ of­ total­ health­ expenditure­ in
2016.­ Meanwhile,­ in­ 2016,­ government­ contribution
dropped­ to­ 18%­ of­ the­ total­ health expenditure.
Budgetary­allocation­for­health­has­been­decreasing­for­a
long­term,­whereas­the­government­is­expected­to­be­allotting
a­fair-share­of­the­national­budget­in­favor­of­establishing
an­ efficient­ health­ system­ of­ any­ country­ (3).­ Moreover,
the­MoHFW­is­not­even­being­able­to­utilize­the­allocated
budget­fully­and­leaving­a­substantial­amount­unspent;­let
alone­the­size­of­the­share.­We­highly­recommend­that­the
government­should­look­into­increasing the­share­of­health
budget­through­creating­fiscal­space­for­health.
Although­ the­ public­ sector­ infrastructure­ is­ splendidly
designed­for­delivering­healthcare,­due­to­having­extremely
scarce­ government­ budget­ allocated,­ the­ government
health­facilities­of­the­country­are­in­underprivileged­state.
Public­ medical­ facilities­ are­ afflicted­ with­ severe­ human
151 Global­Healthcare
resource­shortage,­along­with­lack­of­physical­and­technological
resources­(4).­In­the­World­Health­Report­2006,­the­WHO
announced­ Bangladesh­ as­ one­ of­ the­ countries­ that­ are
suffering­ from­ critical­ shortage­ of­ health­ workforce­ (5).
According­to­evidences,­Bangladesh­has­only­0·5­doctors
and­ 0·2­ nurses­ per­ 1000­ people­ (3).­ In­ 2018,­ there­ were
103,743­ sanctioned­ posts­ under­ Directorate­ General­ of
Health­Services­under­the­MoHFW,­out­of­which,­27.72%
posts­ were­ allegedly­ vacant­ (6,7).­ Out­ of­ ­ 25,980
sanctioned­ posts­ for­ doctors,­ only­ 20,914­ posts­ were
filled,­keeping­a­vacancy­rate­of­19.50%­in­2018,­which
increased­ from­ a­ 17.56%­ vacancy­ rate­ in­ 2017(6).­ The
population-bed­ ratio­ in­ public­ sector­ is­ severely­ low,
which­was­3.24­beds­per­10,000­people­in­2018­(6).­Most
of­the­primary­healthcare­facilities­are­enduring­resource
scarcity,­ being­ able­ to­ utilize­ a­ short­ portion­ of­ the
allocated­budget­due­to­technical­hassles.­Only­60.9%
of­ the district­ and­ Upazila­ health­ facilities­ have­ all­ six
equipment­ items­ considered­ basic­ to­ providing­ quality
health­services­(8).­Moreover,­only­18%­of­Upazila­Health
Complexes­ have­ x-ray­ machines­ that­ are­ functional­ (8).
Absence­of­need­based­resource­allocation­is­causing­such
inefficiency­in­the­government­health­sector.­We­therefore
recommend­ that­ the­ government­ should­ increase­ the
allocation for­ health­ budget­ to­ tackle­ the­ workforce
deficiency and­inadequacy­of­healthcare­equipment.­­
As­ a­ consequence­ of­ an­ inefficient­ and­ dissatisfactory
public­ health­ sector,­ people­ of­ the­ country­ have­ turned
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towards­ the­ comparatively­ qualified­ private­ sector.
Although,­ this­ sector­ also­ suffers­ from­ inadequate
resources.­ The­ cost­ of­ healthcare­ services­ in­ the­ private
sector­ is­ extremely­ high­ partly­ due­ to­ the­ quality­ of­ the
service,­and­partly­because­of­the­profiteering­tendency­of
the­ providers­ of­ private­ sector.­ Nevertheless,­ healthcare
cost­in­the­private­sector­has­to­be­paid­by­the­consumers
from­ their­ own­ pocket,­ which­ account­ for­ more­ than
two-third­of­the­total­healthcare­expenditure.­As­a­result,
people­from­only­higher­economic­background­can­afford
the­services,­and­people­from­lower­economic backgrounds
has­ to­ experience­ impoverishment­ for­ trying­ pay­ the
expenditures.­ Furthermore,­ hardly­ any­ pre-payment
mechanisms­are­existent­in­the­country.­The­government
has­intended­to­launch­healthcare­protection­schemes,­for
which­the­government­is­currently­running­a­pilot­project
as­ a­ social­ health­ protection­ scheme­ named­ Shasthyo
Shuroksha­ Karmasuchi­ (SSK)­ which­ is­ only­ for­ people
below­the­poverty­line­(2).­In­order­to­reduce­the­excessively
high­OOP­payments­and­save­the­vulnerable­from­falling
into­ impoverishment,­ the­ government­ should­ scale-up the
health­ protection­ schemes­ and­ include­ people­ from­ vast
range­ of­ economic­ background­ (9).­ Furthermore,­ Health
Equity­Funds­are­suggested­for­the­people­who­contribute
to­the­nation’s­economy­highest,­for­example­government
employees,­teachers,­garment­workers,­and­migrant­earners
(9).­ On­ the­ other­ hand,­ we­ suggest­ that­ basic­ primary
healthcare­preventive­and­curative­services­can­ be­ made
free­ of­ cost­ the­ entire­ population­ by­ the­ government.
153 Global­Healthcare
Commitment­ for­ Universal­ Health­ Coverage­ (UHC)­ for
every­ person­ everywhere­ is­ waiting­ to­ be­ fulfilled.­ The
country­is­far­away­from­that.­The­pilot­project­as­a­social
health­ protection­ scheme­ named­ Shasthyo­ Shuroksha
Karmasuchi­ (SSK)­ may­ have­ expand­ whole­ over­ the
country.
The­emergency­health­care­should­be­provided­by­the public
hospital­at­everywhere­for­every­person.­Bangladesh­is­a
country­ where­ there­ are­ huge­ number­ of­ road­ traffic
accident­every­day.­Anybody­may­have­to­confront­any
emergency­ condition,­ at­ anytime,­ anywhere­ but­ the
emergency­ management­ regarding­ manpower,­ logistics
and­financial­support­is­negligible­at­primary­and­secondary
health­ care­ center.­ So­ special­ attention­ to­ develop
emergency­health­care­up­to­the­mark­necessitates­financial
allocation.
Bangladesh­has­gained­praise­from­around­the­world­for
its­ impressive­ performance­ in­ maternal­ and­ child­ health
care.­ The­ United­ Nations­ has­ admired­ Bangladesh­ for
reaching­ towards­ goal­ 4­ from­ the­ Millennium
Development­Goals­(MDGs)­in­child­mortality­in­2010.­In
last­ couple­ of­ decades,­ under-5­ child­ mortality­ rate­ in
Bangladesh­ has­ declined­ from­ 144­ to­ 41­ per­ 1000­ live
births­ (3).­The­ maternal­ mortality­ rate­ also­ had­ a­ drastic
drop.­ Nonetheless,­ all­ and,­ the­ working­ age­ population
will­ transform­ into­ the­ aged­ population­ in­ near­ future.
Since­ NCDs­ are­ responsible for­ 87%­ disease­ burden
among­ people­ aged­ more­ than­ 60,­ the­ risk­ of­ aged
population­ and­ NCDs­ will­ arrive­ concurrently­ in
Global­Healthcare 154
Bangladesh.­ The­ government­ should­ emphasize­ on
blocking­ incoming­ risk­ associated­ with­ the­ transition­ by
taking­ proper­ measures­ towards­ geriatric­ care­ and
handling­ NCDs­ (9).­ Government­ of­ Bangladesh­ has
already­ started­ taking­ interventions­ in­ order­ to­ tackle
emerging­risks­of­NCDs­by­establishing­NCD­control­unit
within­ the­ Directorate­ General­ of­ Health­ Services­ (9).
Government­took­further­steps­to­combat­NCDs­through
establishing­NCD­corners­in­Upazila­Health­Complexes­in
2012­ with­ a­ view­ to­ providing­ preventive­ and­ curative
services­for­common­NCDs­and­related­conditions­such­as
cardiovascular­ diseases­ (CVDs),­ diabetes­ and­ chronic
respiratory­ diseases­ (asthma­ and­ chronic­ obstructive
pulmonary­ disease)­ and­ screening­ for­ certain­ cancers.
However,­ studies­ found­ that­ the­ NCD­ corners­ functions
poorly­facing­challenges­including­lack­of­trained­human
resources,­inadequate­equipment­and­laboratory­facilities,
inadequate­ logistics­ and­ drug­ supplies,­ lack­ of­ proper
recording­ and­ reporting,­ coordination­ or­ communication
between­NCD­corners­and­NCD­unit­of­DGHS­and­lack­of
proper­guidelines­and­standard­operating­procedure­(10).
It­ is­ suggested­ that­ government­ should­ allocate­ enough
financial­flows­to­improve­the­infrastructure­and­upgrade
the­equipment­of­the­NCD­corners­(10).­
Health­insurance,­social­coverage­for­health­care­financing
is­ at­ neonatal­ stage­ in­ Bangladesh.­ Country­ like­ Turkey
and­ Malaysia­ could­ confront­ this­ situation.­ Health
insurance­by­contribution­employer­and­employee­may­be
155 Global­Healthcare
of­ benefit­ for­ health­ care­ financing.­ It­ could­ be­ adopted
both­in­private­and­public­sector.­It­is­partially­practiced­at
present­situation.­It­could­be­expanded­by­compulsory
status­to­reduce­the­catastrophic­health­expenditure.­
The­ nonresident­ Bangladeshi­ (NRB)­ and­ their­ family
members­may­be­included­in­a­“Health­Scheme”­by public
private­ partnership.­ The­ social­ health­ protection­ scheme
named­ Shasthyo­ Shuroksha­ Karmasuchi­ (SSK)­ may
imposed­ in­ garments­ sector,­ the­ highest­ revenue­ earning
sector­ for­ their­ worker­ financed­ by­ the­ owner­ and­ from
public­financing.
The­ budgetary­ allocation­ for­ emerging­ and­ reemerging
communicable­disease­could­not­be­ignored­in­the­era­of
COVID­19.­A­strong­preparedness­for­outbreak­is­never­to
be­ forgotten­ for­ the­ health­ sector.­ Huge­ infrastructures,
health­care­workers,­logistics,­training­are­the­urgent­need.
Funding­for­the­research­of­public­health­issue­is­not­to­be
forgotten.
Above­ these­ a­ good­ governance­ will­ not­ only­ enlighten
the­ health­ care­ financing­ but­ also­ lead­ the­ full­ team­ to
achieve­the­target­without­corruption.
The­constant­record­of­low­budgetary­allocation­for­health
sector­ is­ generating­ more­ financial­ catastrophes­ through
high­OOP­payments.­Inefficient­and­inadequate­financial
allocation­ and­ unskilled­ workforce­ are­ hindering­ the
function­ of­ the­ healthcare­ system.­ Treatment­ costs­ are
rising­due­to­increased­use­of­private­healthcare.­The­government
Global­Healthcare 156
of­Bangladesh­is­obliged­to­ensure­healthcare­services­for­all
the­citizens­of­the­country­by­the­constitution.­Hence,­the
government­ should­ prioritize­ healthcare­ financing,
earmark­ essential­ amount­ of­ funding­ for­ the­ needed
segments­and­utilize­the­available­resources­as­recommended
to­bring­Bangladesh­out­of­the­chaos­of­inefficiency.
The­budgetary­allocation­for­health­care­financing­should
be­ 15%­ of­ the­ total­ budget.­ OOP­ should­ be­ reduced­ to
32%.UHC­ should­ be­ free­ of­ cost­ for­ every­ people,
everywhere.­ Expansion­ ShasthyoShurokshaKarmasuchi
(SSK)­ for­ people­ of­ terminal­ end­ may­ be­ expended­ to
whole­over­the­country.­Health­insurance­for­all government
worker­ could­ be­ ensured.­ Contribution­ employee­ and
employer­may­be­good­option­of­social­coverage­at­private
sector.­Nonresident­Bangladeshi­and­their­families­may­be
under­ the­ umbrella­ of­ medical­ insurance­ by­ public­ and
private­ partnership.­ Inclusion­ of­ garments­ worker­ in
separate­scheme­may­be­an­incentive­for­them.­Profession
with­ the­ risk­ of­ physical­ risk­ may­ be­ under­ insurance
system.­Health­research­may­be­smartly­funded­to confront
the­ unknown­ challenges­ of­ public­ health­ issues.
Assignment­of­the­Community­Clinic­would­be­as­preventive
measures.­A­clear­policy­and­financing­for­Upazila­Health
Complex­to­meet­the­emergency­and­primary­care­is­still
possible, district­Hospital­for­specialized­care­and­intensive
care,­ Medical­ College­ Hospital,­ University­ Hospital
should­ serve­ for­ academic­ purpose­ only­ with­ referral
system.
157 Global­Healthcare
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