What can we learn about universal health coverage from global experiences?

 

Resource Allocation and Utilization Critical for Achieving UHC in Bangladesh

Allocating sufficient resources to the health sector and ensuring their proper utilization are vital for achieving universal health coverage (UHC) and meeting the Sustainable Development Goals (SDGs). Many countries are reforming their health sectors by customizing healthcare financing and payment methods for providers. Global experiences demonstrate that increasing resources for health, enhancing spending efficiency, adopting appropriate provider payment methods, and implementing supply-side cost-sharing are crucial steps toward UHC. For instance, in 2021, Thailand allocated 13.5% of its government spending to health, while Turkey, Sri Lanka, and Vietnam allocated 11.5%, 9.5%, and 9% respectively. Out-of-pocket (OOP) health expenditures in these countries were significantly reduced due to various strategic reforms.

Bangladesh, however, allocated only 5.19% of its proposed national budget—Tk 41,407 crore—to the health sector for FY2024-25. This allocation has been stagnant at around 5% for over a decade. In 2020, Bangladesh's current health expenditure per capita was $50.66, with government health expenditure at $9.1 per capita, according to the World Bank. These figures are low compared to other Asian countries, despite achieving some MDGs at a low cost. However, financial protection in healthcare and meeting SDG targets remain significant challenges.

The low public financing share is reflected in the limited use of public health facilities, which provided only about 12% of total health services in 2022. Formal private healthcare providers accounted for 29%, while informal providers dominated with 59%. Additionally, patients received 93% of their medicines from private pharmacies, contributing to over 60% of total OOP expenditure on medical goods in 2020. The overall OOP health expenditure was 68.5% of total health expenditure.

Inefficiencies in Budget Utilization

Bangladesh's budget preparation lacks the economic evaluation seen in other countries, and budget spending does not always ensure the implementation of cost-effective interventions. In 2022, the health budget utilization rate was only 78%, hindered by lengthy procurement processes, limited managerial capacity, rigid financial rules, frequent manager transfers, inadequate monitoring, and lack of financial autonomy in public health facilities.

Health Care Financing Strategy and Future Directions

Bangladesh's first Health Care Financing Strategy (2012-32) aimed at UHC by increasing budgetary allocation, improving financial management efficiency, establishing health protection schemes, and initiating mandatory health insurance for formal sector employees. A recent review emphasized the need for increased public financing, revisiting financial management rules, strategic purchasing, and accrediting the private sector.

Countries like Sri Lanka, Thailand, the Philippines, Indonesia, Turkey, and India have transitioned from input-based to outcome-based payment approaches, successfully increasing coverage and reducing catastrophic health spending. Bangladesh needs to immediately focus on designing effective healthcare financing mechanisms and provider payment methods. This includes increasing funds for medical goods and enhancing medicine availability in public facilities, which could reduce OOP expenditure significantly.

Multi-Sectoral Collaboration and Efficiency

Bangladesh has achieved "good outcomes at a low cost" partly due to improvements in literacy rates, poverty reduction, social safety nets, and other social determinants of health. Investments in public health and social determinants can be highly cost-effective. Therefore, planned investments should not be limited to the health sector but should involve coordinated efforts across different ministries to attain the SDGs by 2030 and the goals of the Perspective Plan by 2041.

Conclusion

Increasing efficiency in the public sector is crucial for enhancing budget allocation and healthcare financing coverage. However, achieving UHC requires not only increased efficiency but also substantial allocation increases in the public sector. Bangladesh should gradually introduce outcome-based payments and strategic purchasing in the private sector. A comprehensive master plan for health, incorporating future allocations, spending modalities, necessary reforms, and integration with other policies, is essential. We hope to see these reflections in future national budgets.

Nahid Akhter Jahan is a professor at the Institute of Health Economics, University of Dhaka.