Over the five decades after the independence Bangladesh has made notable progress in a number of key health indicators, but the lack of mass people’s affordability and access to quality healthcare, especially for non-communicable diseases, has undermined the sector’s advancements.
The health sector had the lowest priority in terms of government investment while corruption in health financing also appeared as an obstacle to the improvement of the health system, which is largely urban-centric and availed at people’s own expense.
When the first census was carried out in 1974 after Bangladesh was born in 1971, the population’s life expectancy at birth was merely 46.2 years, which has climbed to 72.3 years, according to the latest Bangladesh Bureau of Statistics data released in 2018.
The infant mortality rate for every thousand live-births was 153 in 1974, but it was 22 in 2018 while the maternal mortality rate per 1,00,000 live-births was 478 in 1991, which came down to169 in 2018.
Family planning services improved quite significantly, with lifting the contraceptive prevalence ratio from 7.7 per cent in 1975 to 63.1 per cent in 2018.
While every woman on an average produced 6.2 children in 1974, the rate was 2.05 in 2018.
Other health indicators, too, demonstrate the improvement in the health status of the Bangladesh population.
The safe drinking water coverage increased from 56 per cent in 1981 to 98 per cent in 2018 and the sanitation coverage from 6.1 per cent in 1981 to 78 per cent in 2018.
There was one doctor per 14,163 people in 1974 but the situation improved with one doctor per 1,581 in 2018.
There was one hospital bed for 5,651 population in 1974 while one bed was available for 1,169 people in 2017.
Bangladesh received international recognition for its healthcare progresses and did comparatively better in South Asia.
World-famous British medical journal The Lancet in a study in 2018 said that Bangladesh was ahead of India, Pakistan, Nepal and Afghanistan in providing access to quality healthcare to citizens.
It ranked Bangladesh 133rd among 195 countries in terms of providing access to quality healthcare.
Bangladesh, however, was behind Sri Lanka and China in the region.
The Lancet study revealed that Bangladesh had seen improvement in healthcare access and quality since 1990, with its Healthcare Access and Quality index score increasing from 17.8 in the year to 47.6 in 2016.
The average South Asian HAQ index score was 40.4 in 2016 while the value was 23.8 in 1990.
The rate of improvement in Bangladesh was better than its South Asian neighbours.
India’s HAQ index score was 24.7 in 1990 and 41.2 in 2016, Pakistan’s 26.8 in 1990 and 37.6 in 2016 while, despite the gains, Bangladesh continued to lag behind China with 48 and Sri Lanka with 71 in 1990.
Myanmar ranked 143rd, India 145th, Nepal 149th, Pakistan 155th and Afghanistan 191st in terms of the HAQ index score.
Although Bangladesh has achieved better healthcare progresses compared to India and Pakistan there is no room for complacence, said experts.
They pointed to the high out-of-pocket expenditure for healthcare services in Bangladesh, which is the highest in South Asia.
According to the latest reports of the government Health Economics Unit, people in Bangladesh have to bear 67 per cent of their medical bills.
The out-of-pocket medical expenses of fellow South Asians are far below that of Bangladeshis, 18 per cent for the Maldivians, 25 per cent for the Bhutanese, 47 per cent for the Nepalese, 56 per cent for the Pakistanis and 62 per cent for the Indians.
The government allocation for health in the budget remains low. The current health allocation of GDP’s 2.34 per cent puts Bangladesh at the bottom among the South Asian countries, according to the World Bank.
A study conducted by the ICDDR,B and BRAC’s James P Grant School of Public Health and published in 2019 showed that 68.9 per cent of the country’s citizens found it hard to bear their medical bills, with the annual average bill per household Tk 40,000 and the lowest being Tk 18,000.
While mass people struggle to afford quality health care, people from the affluent section go abroad even for simple medical needs, draining out huge foreign currencies, said public health experts.
India or other Asian countries like Thailand, Malaysia and Singapore are alternative destinations for treatment for them.
The unavailability of healthcare services for critical diseases like cancer, kidney diseases, heart complications and brain diseases compel people to go to private or overseas hospitals for treatment on own finance.
According to WHO statistics, at least 5,72,600 people in Bangladesh die premature deaths annually due to non-communicable diseases.
Non-communicable diseases are estimated to account for 67 per cent of all deaths, the WHO says.
Cardiovascular complications top the list of deaths caused by non-communicable diseases, accounting for 31 per cent of total deaths in Bangladesh.
Besides, communicable diseases and maternal, perinatal and nutritional conditions cause 26 per cent of deaths, cancer 12 per cent, chronic respiratory diseases 10 per cent, diabetes 3 per cent, other non-communicable diseases 12 per cent and injures 7 per cent.
‘But the pace at which the burden of non-communicable diseases is growing, the healthcare facilities for tackling them are not developing in the country,’ said public health expert Quazi Quamruzzaman.
‘Most of the private hospitals are making money cashing in on the critical diseases,’ he observed.
Nutrition is another sector where Bangladesh lags behind its neighbours.
According to the UN Food and Agriculture Organisation, Bangladesh is among the 29 countries facing the challenges of multiple forms of malnutrition — under-nutrition, over-nutrition and micronutrient deficiencies.
According to the State of Food Security and Nutrition in the World 2019, 14.7 per cent of people in Bangladesh, 2.42 crore, are under-nourished.
Among the under-5 children in Bangladesh the rate of stunting is 36.2 per cent, the rate of wasting 14.4 per cent and the rate of overweight 1.6 per cent while among the adults the rate of obesity is 3.4 per cent and the rate of anemia among women in the 15-49 age bracket is 39.9 per cent.
At least 22.6 per cent of babies are born in Bangladesh with low birth-weight, below 2.5 kilograms.
The major causes of low birth-weight are premature birth, poor nutritional status and inadequate nutritional intake during pregnancy, and intrauterine growth restriction caused by early marriage.
In Bangladesh at least 59 per cent of marriages occur when the brides are yet to reach 18.
Bangladesh’s highest civilian Ekushey Padak-winner Quazi Quamruzzaman noted that despite progress in some indicators, the Bangladesh health system was not yet well-managed to ensure an efficient and cost-effective healthcare delivery system.
The backbone of the healthcare system — the primary healthcare system — is yet to be set up on a community-based general practitioner system that could handle 80 per cent of patients, Quamruzzaman said.
The GP system ensures a proper referral linkage between the patients and the secondary- or tertiary-level care when they are in need of such services, thus reducing healthcare cost and making the health service system efficient, said Quamruzzaman, also a freedom fighter.
The unregulated medicine market and medical test business in the private sector are also two major undesirable phenomena in Bangladesh as the primary care system are not well-regulated and well-monitored.
Quamruzzaman said that despite having an excellent health system setup in Bangladesh, the COVID-19 pandemic exposed the vulnerability of the system’s inadequate infrastructure, inefficient management system and corruption.
According to health economist and Dhaka University professor Rumana Huque, while the health sector needs more government investment it is imperative to rid the health-financing management system from leakage and corruption.
Bangladesh still invests more in curative care, but the focus now should be on preventive care to check the growing burden of non-communicable diseases that cause 67 per cent of deaths in Bangladesh, which are largely attributable to lifestyle, diet and behaviour, she observed.
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