The Dhaka Forum (TDF) jointly organized a roundtable discussion “Accessible and Affordable Healthcare in Bangladesh” in collaboration with the Southeast Bank at Policy Research Institute Conference Centre in Dhaka on the 6th August 2016.

The Programme was attended by renowned doctors, health experts, founders of famous private hospitals, academicians and field level people. Especially Dr. Hossain Zillur Rahman, Former advisor of caretaker government, Dr, Zafarullah Chowdhury , Trustee, Gonoshasthya Kendra, Dr. Rashid-E-Mahbub, Former president of BMA, Mr. Mahbub Jamil, Former advisor of caretaker government, Mr. Nasir Uddin, Former Health Secretary, Dr. A M Shamim, Managing Director, Labaid Group, Prof. Dr. Md. Firoz Khan, Nephrologists, M. Khondaker Abu Ashrafe, Managing Director, Prescription Point, Dr. Simin Akter , Health management expert and Dr. Rafiqul Haque of BRAC.

TDF president Dr. Salehuddin Ahmed chaired the session and briefed about the objective of TDF and their work. Prof Muzherul Huq presented a keynote paper.

In his presentation, Prof Muzherul raised various issues of health sector in Bangladesh which need to be addressed to achieve the sustainable development goal (SDG) number 3.8 by 2030.

According to goal number 3.8, 'achieve UHC, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all'.

In Bangladesh, out of pocket (OOP) health expenditure is 64 per cent while household OOP expenditure is more than 20-30 per cent which indicates problem over financial protection for healthcare.

Bangladesh is among 57 countries facing an acute health Human Resources (HR) crisis. The formal health workforce (doctors, dentists, nurses) is mostly concentrated in urban areas.

The doctor to population ratio is 1 per 1,500 people in urban areas and 1 per 15,000 in rural areas.

Currently, there are 3.8 physicians, 1.15 nurses, 0.38 paramedics and community health workers (CHW) for per 10,000 people. But the recommended ratio for Physician: Nurse: Paramedic is 1:4:8 (Public + Private).

There is also discrimination in healthcare services and health quality among men and women, rural and urban areas, literate and illiterate and rich and poor. The risk of mortality is double among poor children. Death among the rich families is 38 per thousand while it is 78 in poor families.

Bangladesh needs to increase GDP investment in health sector and make the upazila and union healthcare facilities functional to bring 66 per cent of the rural population under health coverage to achieve universal health coverage (UHC) target.

There is no data on how many urban and rural people are out of health coverage in Bangladesh, but the rate is 56 per cent across the globe.

Bangladesh invests 0.74 per cent of GDP and 5.1 per cent of the national budget in health sector, per capita total health spending US$ 27 or 1.4 per cent of public health expenditure against a recommended $ 54 for a basic minimum package of care. Per capita government spending is US$ 9.7 here.

India spends $ 59 of which government spends $ 18.3 while Nepal $ 33 of which government spends $ 13 and Pakistan spends $ 30 of which government spends $ 8.0. Disorganized outpatient services, unavailability of doctors and improper distribution and abuse of medicines prevail in upazila health complexes.

There are 612 public hospitals while 128 at secondary and tertiary levels and 484 at upazila and union levels, with 46,964 functional hospital beds.

On the other hand, there are 4,280 private hospitals, 9,061 diagnostic centers and 74,620 hospital beds in the private sector.

There are 424 upazila health complexes (10-51 bed) and 75 upazila health offices and trauma centers (20-31 bed). For 31 beds, there are nine doctors, but 14 have been posted. For 50 beds, there are 21 doctors, but 35 are posted. In both cases, only three doctors are available, said Dr Muzherul.

Of the nine doctors, four are consultants at while 10 out of 21 are consultants at upazila level.

"We don't need so many specialised hospitals in cities. If these were located in upazilas, pressure on tertiary hospitals would have been reduced," he said.

Power and Participation Research Centre (PPRC) executive chairman and former advisor of caretaker government Dr. Hossain Zillur Rahman said public health infrastructures in rural areas are unutilized. But coercive measure can keep the physicians in villages.

He said the reason for high OOP is due to unusual increase in medicine prices. The influence of pharmaceutical companies has increased many times. Besides, unholy nexus and unethical promotion of pharmaceuticals are some of the reasons for increase in OOP. There needs to be emphasis on mapping of accidents, cancers and other non communicable diseases. He noted that the recognition of the doctors is severely affected by existing social and political environment. That's why they stay in the cities in the name of attachment with various hospitals around the capital by using high political connections.

Waste management, sanitation needs to be taken into account.

Former president of Bangladesh Medical Association (BMA) Dr Rashid E Mahbub said that the major problem of UHC is who will give money. Bangladesh has the capacity to implement UHC, but it is not possible overnight.

The government structures are not functioning properly while there is no monitoring in the private sector investment to control quality and fraudulent practice. There are many private medical colleges but mostly vacant cause no one goes there to take service. Europe and USA has medical insurance and we need to learn from them.

People own government hospital and has some rights on it but private hospitals won’t give that treatment without money.

Dr Zafarullah Chowdhury of Gana Shastha Kendra pointed out that there is only 1000 anesthetist in Bangladesh. There is a dearth. We need to train more people to be anesthetist. Bangladesh has a growing aging population and physiotherapist should be given more importance. There should be General Practice (GP) system in the ward level.

The primary healthcare in urban areas has not been ensured due to conflict between local government and health ministries, he said.

Mr. Nasiruddin said we have to recognize the importance of healthcare center in every union to ensure healthcare services for the common people. To keep the doctors, maintain equipments and logistics, at the upazilla and local levels, is a major challenge. The union level health facilities can be a focal starting point, he said.

Dr. Shamim has indicated that there is no career planning for the doctors of our country. If we could ensure better future prospects, doctors will be interested to stay in remote areas of the country. In pharmaceutical businesses 35% cost is incurred for marketing and promotional activities. The situation is unacceptable. He thought that if we could take proper action against the unethical activities of doctors the pharmaceutical companies, cost will come down for the benefits of the common people.

Mr. Khondaker Abu Ashrafe said that in most of the community clinics or upazilla health complex the machines are faulty; there is no ambulance and other facilities. The technicians willingly keep essential services away from the patients for getting commission from the private clinics. We need to come out of this malpractice and the government must make strict policy to stop this. He also mentioned that we should focus on the quality of medicine.

Dr. Md. Firoz Khan pointed out that we have not yet got a proper health policy and health planning. General people always criticize the doctors but we should think that doctors are not solely responsible to make the health policy or run the administration. He also expressed the urgency of proper career planning of doctors.

Mr. Mahbub Jamil said that the civil surgeons do not have any authority. If we could give authority to them many problems can be solved easily, like doctors would have stayed in the remote areas and also there would be sufficient medical equipments in the rural health centers.He also emphasized on training program for the technicians and people who have medicine stores.

Dr. Simin Akter highlighted the fact that patients must be aware of their rights and how government, doctors, and the social actors play an important role. End of result can be measured by patient satisfaction .We need to make sure that ethical practice is ensured.

Dr. Salehuddin Ahmed concluded the seminar by saying that we as a country need to move on despite all the problems the country faces. He pointed out the key factors. Health budget needs to increase to 10% from 5%.Upazila healthcare needs to be functional. Private sector also needs to come forward. Union level needs to be considered instead of Upazila. Manpower projection must be considered.

The round table up with the following margin recommendations:

(a) Allocation for the health sector in the budget should be increased to minimum 10% of total budget.

(b) Upazila health care system should be more functional. Adequate number of health professionals should stay there and provide services. Private providers of health services should also be rationalized and monitored by the government.

(c) Referral Service should be introduced from the upazila level. So that complex cases can be handled by specialists at the appropriate hospitals and health centers.

(d) Health insurance scheme should be assessed. To stat with some model cases can be examined.

(e) At Union level, the health centers, union Community health clinics should be made more functional and active.

(f) There is no projection of manpower requirement in health sector, which should be considered immediately by the government and other appropriate agencies.

(g) All health facilities from union level to national level should be integrated.

Vote of thanks was given by Ambassodor Shahed Akhtar , on behalf of the Dhaka Forum ,to all the participants for their valuable time and active participation in the roundtable. He thanked the Southeast Bank for their cooperation. The support of the Policy Research Institute (PRI) was also acknowledged by him.