During the last decade, Bangladesh's out-of-pocket spending on health care has increased significantly. According to the Bangladesh National Health Accounts (BNHA) 1997-2020 data, such expenditure rose from 62% in 2012 to 68.5% in 2020. Even though the government promised to bring down out-of-pocket health care expenditure to 32% by 2032, it is most likely to remain a pipe dream given the present reality.
Ambulance service is an important part of the total health care services. An ambulance is a vehicle equipped to provide emergency care to sick or injured people and to get them to hospital. Bangladeshi ambulances only have a wheeled stretcher and an oxygen cylinder, and hardly any other equipment. The ambulance menace is just an example of how mismanaged and poorly governed the public health sector is.
Ambulance service costs in modern countries is one of the most variable and least transparent components of health care costs. Medical insurance coverage has a component of transportation of patients. This is a part of insurance because there are many ambulance providers, and they all may have different relationships with different insurance companies.
It's also in part because ambulance rates are generally set according to the services the ambulance is equipped to provide, not necessarily the services actually provided. Some ambulance companies have contact with City Corporation to provide dedicated service to the citizens. Other services providing ambulance companies usually compete for patients. All this combines to create an incredibly complex industry with very little consistency from ambulance to ambulance.
In Bangladesh, particularly in Dhaka, the service is provided by individual owners of an ambulance, but they are united under two ambulance owners' associations -- Bangladesh Ambulance Owners' Welfare Association and Dhaka Metropolitan Ambulance Owners' Cooperative Association. Dhaka Metropolitan Ambulance Owners' Cooperative Association, the largest one, has about 2,700 members.
Both the association keep all ambulances across the country in their grip, and their collusion in the districts also do not let ambulances of other districts take patients away. They have a set of unwritten rules regarding who can take which patient, and it is mandatory for every hospital unit of the associations to follow.
According to a report by a daily newspaper, members of two ambulance owners' associations have combined to form the curtail that operates in every public hospital of the country to make sure that no ambulance from outside their network can take patients to their destinations.
For example, when patients from Dhaka Medical College and Hospital (DMCH) want to go back to their respective hometown, they are forced to use the services of these two associations, paying extra money. If an ambulance from outside the member of the associations somehow carries any patient out of a hospital in Dhaka, the curtail takes half the fare as its cut. This has become the general practice, with the hospital authorities turning a blind eye.
In another instance, an ambulance owner from Kushtia told a newspaper that as soon as patients are taken inside DMCH from ambulances, they are driven out of the hospital premises by the members of these associations to eliminate competition.
A patient's father, who was trying to hire an ambulance to go back to Noakhali from DMCH, said that while an ambulance from Noakhali would cost him Tk3,000 for the ride back home, the ambulances available in DMCH would charge him around Tk6,000.
This is nothing but extortion. That collusion does not let any ambulance from other districts take patients away. For this, the ambulance charges patients double, since they have to make the return trip empty. At a time when people are already left high and dry by their increasing medical bills, the collusion is just increasing their misery.
When asked about "syndicates" ripping off patients, general secretary of Bangladesh Ambulance Owners' Welfare Association, tried to justify the collusive activities. He defends the curtails saying, "Members of our organization have to pay Tk1,500 monthly parking fees and membership fees of Tk200 a month. It takes Tk20-22 lakh to buy an ambulance. If ambulances outside the DMCH are hired, the owners will lose money." Asked about the syndicate, Alamgir Hossain, president of Dhaka Metropolitan Ambulance Owners' Cooperative Association, said this was done to protect ambulance owners from incurring losses.
Interestingly, the ambulance import gets special import duty benefits at the cost of the national exchequer. The government has cut the import duty on ambulances. The import duty is about 31% for the run-off-the-mill ambulances people import. The same vehicle in the microbus configuration has an import duty of about 90%.
In the case of ambulance service, the market mechanism doesn't work properly. For example, if a company sells a consumer product, say, at a higher rate than the market price, chances are it'll find sales drop precipitously. However, when applied to the emergency ambulance industry, they just don't pan out.
This is common to any one individual consumer, ambulances are essentially monopolies. Not only do consumers have no means of price comparison on the spot -- as they usually require ambulances in high-stress, time-sensitive situations -- they often have no control over their ambulance service provider. Consumers have little to no information about the cost of ambulance services at the time they are required to accept them, and they may not even know whether their situations constitute emergencies.
Price controls have always aroused controversy. It may work sometimes during emergencies and war situations for a short period. The experience of Bangladesh regarding controlled prices of sugar, edible oil is very frustrating and against the law of competition.
The ambulance market needs more robust regulations, and has a pretty good way of regulating industries where collusion exists. In some markets regulating prices isn't the possible solution for the wild west of ambulance pricing.
The government may impose heavy penalties for violating the law to form curtailment and cake action under criminal law against the persons barring the non-member ambulance to operate in the market. Any service provider sponsored by the local government or public health department may also play a role in creating competition in the ambulance service market.
Municipalities or public health departments can opt for operating ambulances as a public service. There is reportedly a type of ride-sharing app to call for ambulance services -- it should be widely publicized to get the most benefit out of it.
MS Siddiqui is Non-Government Adviser, Bangladesh Competition Commission.
