All the healthcare systems across the world have benefits and drawbacks, and we can learn from them to design what is suitable for us. We must ensure that the outcome is in our favour.
The existing system is fragmented, but many services are already provided which are not reported in a formalized manner. Any innovation in the entire eco-system will require a vision and a strategy which must be broken down to achievable goals. So, coming back to the country’s vision in achieving universal health coverage by 2032, some basic tenets need to be set.
Primary care
Primary care should be at the core of any reform. When primary care is given throughout the course of a person’s life, it can meet 80-90% of the individual’s health needs.
It begins even before a person is born. The journey starts from providing health education to the population to increase health-seeking behaviour, ensure antenatal care to the expecting mother and provide safe delivery of the child, complete the vaccination of the newborn, continue providing health care for preventive and curative diseases, generate awareness to prevent noncommunicable diseases (NCD), and if affected, then continue management of NCDs to avoid progressive complications from it.
The healthier we keep our population, the less the expense to cover the entire population and ease the burden on the system.
Insurance
Health insurance is a tool where the core objective is risk pooling to create the potential for redistribution of funds more equitably. Pooling the fund allows the higher costs of the less healthy to be offset by the relatively lower costs of the healthy.
The key factor is the average health care costs of the enrollees included; if the number of healthy individuals are higher in the pool, then it will keep the insurance premium stable. This is where a robust primary care can act as the gatekeeper by providing affordable, preventive, and promotive care to keep the people healthy and not run up insurance costs.
In Bangladesh, the informal sector employment is high which does not justify risk pooling of funds, but worldwide, the social protection scheme has universally shown to be effective to gradually reduce out-of-pocket expenditure.
Currently, there is fragmentation in fund pooling in the government with its many schemes for the government employees and the vulnerable; some private sector companies and NGOs also provide health benefits to their employees. Although that contribution altogether is still inadequate for over 170 million people, when pooled with additional taxes from tobacco, beverages, or other surplus duties, we may have a substantial fund earmarked as some form of medical financial assistance program that might protect the most vulnerable.
However, once an insurance scheme is launched and if it is made free, health care costs will overall go up because the health-seeking attitude will change. Also, any radical change in the system will be impossible without expanding the number of health human resources to provide the care.
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The pharmaceutical industry
The country’s pharmaceutical industry is not rich enough yet to run research and invent medicines, but the sector is enriched in Bangladesh and is fulfilling the domestic demand of all essential drugs at affordable prices.
Local pharmacies are the first point of contact for many people; we can also formalize this sector as caregivers with proper guidelines and accountability. The speed of health care infrastructure expansion might be slower than many other sectors in the country, but the need is there, and it will happen.
Up-and-coming medical colleges can be built in rural areas, which will have various advantages. The rural people will have access to health care, primary care coverage will be expanded, enrollment of a higher number of medical students will be possible, economic activities will be created in the region, and building the infrastructure might cost less due to inexpensive land area.
E-health
Enriching the e-health system through telemedicine support and referral is also a smart step forward in scaling up access. The pandemic broke all the traditional cultures of health care delivery. Overnight, surveillance and patient care were moved to virtual platforms in real time with the help of information technology and the coordination of multiple stakeholders.
Digital platforms can establish a myriad of integrated activities that can be implemented simultaneously to drive the development of health institutions, ensure on-time service delivery by the health workforce, patient engagement, adherence to protocols, and surveillance of disease clusters. This may reduce the layers of bureaucracy and help in faster decision making.
At the same time providers can be held accountable for the service quality. By population size, Bangladesh is a big country and health system activities need decentralization to drive development. Ultimately a healthy, productive population will be the backbone for an economically strong nation and for that, the human capital needs nurturing.
A very famous doctor in the US, recently appointed by the US president as the White House Covid response coordinator had stated: “Outcomes matter more than the system. Health systems should be judged not by how they are organized but by what they produce. How well does it do what a health care system ought to do?”
Bangladesh handled the pandemic far better than many developed nations by taking the right strategic decision at the different phases of the pandemic and it was done through a concerted effort by the public, private, and development sector. It will be disheartening if we return to the pre-pandemic state of the health sector when it is evident that given the right focus and intention, we can get things right.
Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Master’s in Health Care Leadership.
