TERM PAPER

ON
HEALTH SECTOR IN BANGLADESH AND SCOPE OF
IMPROVEMENT

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 TERM PAPER
ON
HEALTH SECTOR IN BANGLADESH AND SCOPE OF IMPROVEMENT

Submitted to Submitted by
Md.Jillur Rahman Md.Rakinul Haque Chowdhury
Lecturer ROLL NO:B-120401092
Jagannath University, Session: 2012-2013
Department of Economics Department of Economics

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 Certificate approval

The project report title “HEALTH SECTOR IN BANGLADESH AND SCOPE OF

IMPROVEMENT” submitted as partial requirement of BSS program.

This project term paper has been prepared by MD.Rakinul Haque Chowdhury Roll:
B-120401092 session: 2012-2013, Department of BSS, “health sector in
Bangladesh” Jagannath University, Dhaka.

This project report is approved and accepted in quality form.

………………………………………………
Md.Jillur Rahman
Lecturer
Jagannath University,
Department of Economics

Letter of Transmittal

Date:

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Md.Jillur Rahman
Lecturer
Department of Economics,
Jagannath University, Dhaka.

Subject: submission of term paper on “HEALTH SECTOR IN BANGLADESH AND

SCOPE OF IMPROVEMENT”.

Dear sir,
I beg most respectfully to state that I am a student of Jagannath University in BSS
final year. I would like to submit this term paper which is given by you. I don’t
submit this term paper anywhere, anyone except you, it is only for you.
I, therefore, pray and hope that you would be kind enough to grant my term
paper and oblige thereby.

I remain sir,
Your mot obediently,
MD.Rakinul Haque Chowdhury
ROLL NO: B-120401092
Session: 2012-2013

Certificate of the Supervisor

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This Paper certifying that the term paper on “HEALTH SECTOR IN BANGLADESH AND

SCOPE OF IMPROVEMENT” is the record of work done by, Md.Rakinul Haque chowdhury
in the requirements for BSS degree of Economics Department, Jagannath University, Dhaka.

The preparation of this paper has been carried out under my supervision.

Md.Jillur Rahman
Lecturer
Department of Economics
Jagannath University
Dhaka-1100

Acknowledgement

All praise to be Allah to whom all Dignity, Honor and Glory are due, the lord of the
world, The Almighty Omnipotent for his favor to me in completing this internship
report.

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For most it gives me immense pleasure to express my sincerest gratitude and
sense of my most honorable supervisor lecturer Jillur Rahman Jagannath
University for his kind approval of my work on the project along with his
important direction.

Also, I would like to express my best regards to my beloved friends, teachers and
brothers for their unlimited love and encouragement.

TABLE OF CONTENT PAGE NO

Abstract 07
SL. NO. CHAPTER : ONE
1.1 Introduction 07
1.2 Statement of the research problem 08
1.3 Objectives 08
1.4 Limitations of study 09
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1.5 Background of the study 09

CHAPTER : TWO
2.1 Literature review 11
2.2 Methodology of study 14
2.3 Research on health system 16
2.4 Sample design 16
2.5 Sample size 17

CHAPTER : THREE
3.1 Present condition of health sector in Bangladesh 17
3.2 Health policy in Bangladesh 18
3.3 Institute of health economics 20
3.4 Healthcare Industry in Bangladesh 20

CHAPTER : FOUR
4.1 Health Financing in Bangladesh 22
4.2 Who pays for health care in Bangladesh 22
4.3 Economic problems in health issue in Bangladesh 25
4.4 Health system in Bangladesh: Challenges and 28
opportunities

CHAPTER : FIVE
5.1 Conclusion 30

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5.2 Reference 30

Abstract
The health system of Bangladesh relies heavily on the government or the public
sector for financing and setting overall policies and service delivery mechanisms.
Although the health system is faced with many intractable challenges, it seems
to receive little priority in terms of national resource allocation. According to
the World Health Organization (WHO 2010) only about 3% of the Gross Domestic
Product (GDP) is spent on health services. However, government expenditure on
health is only about 34% of the total health expenditure (THE), the rest (66%)
being out-of-pocket (OOP) expenses. Inequity, therefore, is a serious problem
affecting the health care system. Based on a review of secondary data, the paper

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assesses the current challenges and opportunities of the health system in
Bangladesh. The findings suggest that although the health system faces
multifaceted challenges such as lack of public health facilities, scarcity of
skilled workforce, inadequate financial resource allocation and political
instability; Bangladesh has demonstrated much progress in achieving the
health-related Millennium Development Goals (MDGs) especially MDG 4 and
MDG 5. Although the country has a growing private sector primarily providing
tertiary level health care services, Bangladesh still does not have a
comprehensive health policy to strengthen the entire health system. Clearly,
the most crucial challenge is the absence of a dynamic and proactive stewardship
able to design and enforce policies to further strengthen and enhance the overall
health system. Such strong leadership could bring about meaningful and effective
health system reform, which will work more efficiently for the betterment of the
health of the people of Bangladesh, and would be built upon the values of equity
and accountability.

CHAPTER: 1
1.1 INTRODUCTION
Health Economics is an applied field of study that allows for the systematic and
rigorous examination of the problems faced in promoting health for all. By
applying economic theories of consumer, producer and social choice, health
economics aims to understand the behavior of individuals, health care providers,
public and private organizations, and governments in decision-making.
*Health economists apply the theories of production, efficiency, disparities,
competition, and regulation to better inform the public and private sector on the
most efficient, cost-effective and equitable course of action. Such research can
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include the economic evaluation of new technologies, as well as the study of
appropriate prices, antitrust policy, optimal public and private investment and
strategic behavior.
*Bangladesh, adhering to its remarkable performances in achieving the
Millennium Development Goals way ahead of neighboring countries, has also
expressed its willingness to do the same with regard to achieving the SDGs as
well. As part of the nation’s commitment to achieving the SDGs, the current
government took the agenda of healthcare development with utmost importance
and has adopted relevant policies to improve the national health indicators.
*An integral part of the government’s ‘Vision 2021’ engulfs the national goal of
ensuring a healthy population through widespread access to healthcare facilities.
However, how far has the nation managed to do so is definitely an area of
concern and contemplation.
*Bangladesh over the course of its post-independence period has come a long
way in stimulating healthcare development within its economy.
*A country which once had a huge portion of its population being malnourished
following insufficient nutritional intake, has somewhat managed to reverse the
scenario at present. The life expectancy at birth has surged by more than 53%
over the last 45 years revealing significant development in healthcare facilities
over time. According to the World Health Organization (WHO), Bangladesh is
ahead of most of its neighboring nations when it comes to its national life
expectancy at birth. For instance, the life expectancy at birth in the country is 72
years on average which is more than by a couple of years compared to that of
India and Pakistan having life expectancy at birth figures of 68.5 and 67 years
respectively.
*Moreover, the country displayed impressive performance in safeguarding and
improving maternal and infant lives. The maternal mortality rate in Bangladesh
has also experienced a declining trend as the rate was curbed by more than 70%
over the last 30 years. At present, maternal mortality rate in the country is
estimated to be around 176 per 100,000 live births. Moreover, according to the
WHO the maternal mortality ratio between 2000 and 2015 in Bangladesh
dropped from 339 to 176 maternal deaths per 100,000 live births while the
corresponding lifetime risk of maternal death declined from 1.49% to 0.421%.
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*The country has also taken effective initiatives in ensuring praiseworthy infant
and neonatal health protection as reflected by sharp declines in the associated
death rates. Infant mortality rate in the country has gone down by almost 75%
over the last three decades or so.
*At present, infant mortality rate in Bangladesh overs around 31 deaths per 1000
live births as compared to India, Pakistan and Sri Lanka having corresponding
rates of 38, 66 and 8 per 1000 live births respectively. The current neonatal death
rate in Bangladesh, according to UNICEF, is around 23 deaths per 1000 live births
which is 50% and 17.86% less compared to that in Pakistan and India respectively.
Furthermore, loss of lives due to communicable diseases and maternal, prenatal
and nutrition conditions has also reduced in the country by more than 33% in
between 2000 and 2012. However, Bangladesh despite being slightly better off in
this matter compared to Pakistan, the country ways behind than India and Sri
Lanka which is a matter of concern.
* In the fields of health and nutrition in Bangladesh, the country is yet to match
global standards which would have potentially aided the nation in leapfrogging
into the elite list of upper middle income countries in near future. The health
sector in particular has been accompanied by inefficiencies arousing from
multiple directions. One of the major factors inhibiting the potential growth of the
healthcare sector in Bangladesh is the country’s insufficient fiscal allocation for
the sector. The country has been incompetent in matching the prescriptions made
by the WHO in terms of allocating at least 15% per cent of the total fiscal budget
for the health sector in order for it to flourish at a brisk pace. In contrast, the
current allocation for the health sector as declared in the proposed national
budget is just a little more than 4% of the total budget size. Moreover, this
allocation, contradicting the increasing trends over the last one and half decades,
has in fact declined by around 1,300 cores taka as compared to the last fiscal year.
Such downsizing of the healthcare development budget may potentially impose
adverse consequences on the socioeconomic indicators of the economy since
returns on public expenditure on healthcare is believed to be important in the
sense that it can even outweigh the public returns on education.
*Apart from inadequacy of public allocation, the healthcare sector of the country
is engulfed by numerous problems. For instance, the number of doctors per

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capita in Bangladesh is considerably lower than the number required. It is
believed that Bangladesh requires around 500,000 doctors to meet the healthcare
requirements of the population. However, in reality, the country only has around
45,000 doctors of which merely 3-4 thousand are specialists. Such scarcity in the
form of doctors and trained nurses have often led to patients facing adverse
consequences following inappropriate diagnosis and treatment provided by non-
doctors in the form of attendants, ward boys, and other untrained frauds,
especially in the rural areas. In 2013, more than 30,000 doctors passed the MBBS
degree in the country out of which only 9,000 of them were fortunate enough to
be hired by the government.
*Thus, the government has a huge role to play in accommodating the remaining
doctors and providing further trainings which would not only curb the demand
supply deficit within the country but would also enhance the overall quality of
healthcare services. Quality of healthcare services is another factor that has
coupled with the inadequate availability of doctors in the country, undermining
the development of the heath sector as a whole. Lack of expertise and modern
technology embodied medical machinery has also led to loss of revenue as
patients, having no other alternative, are forced to fly oversees in quest of
relatively superior quality of health services. It has been estimated that 90% of
the total revenue generated from health tourism in Thailand is contributed by
patients of Bangladeshi origin.
Thus, in order to partially achieve the SDGs and also to comply with the
commitments of the current government for ensuring improved quality and
access to healthcare facilities in the country, it is high time to get over the existing
inefficiencies and irregularities engulfing the health care sector of Bangladesh. It is
ideal for the government in leaving no stones unturned in ensuring greater access
to safe drinking water, sanitation and nutritional commodities for betterment of
public health in the country. Moreover, the disparity in the urban-rural health
services on offer should also be mitigated in order to enhance the overall health
standards. Incentives to the female population in order to embrace the profession
of medical science can also enhance the female participation in the health sector,
which at present is significantly low. The country can ideally take a leaf out of the
United Kingdom where almost 60% of the entire medical fraternity is dominated
by female representatives.

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1.2 Statement of the research problem

The statement of research problem means description of an issue which to be

described. It generates the questions such as,
*How to research will be completed?
* what are the problems in this research?
* How the problem relate with the environment, social and political trends
through the presentation if the data?
* what are the problems?
* what are the challenges and opportunities?
* what are the conditions of health sector in Bangladesh?

The statement of the problem established the Health Sector in Bangladesh to

follow in the research. How the problem will be solved? A good problem
statement is just one sentence. Such as whistle is the one problem that is
elaborate on the problem. The problem solve by a method that is used in this
term paper.

1.3 Objectives
This chapter demonstrates how health economics has had only limited success in
policy and in practice. Debates about choices of health care systems, priorities for
resource use, alternative funding mechanisms, how to pay hospitals and general
practitioners, how to price pharmaceuticals, etc., are all issues on which health
economics ought to be making a significant impact. Where there have been
contributions, they have been more limited than might have been hoped or
expected.

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The government of Bangladesh spends huge amount of money for the delivery of
health services. But resources allocated to health will not achieve their intended
results without attention to the governance issues. Research is therefore needed
to analyze the process and factors associated with access to public health
services. The present study has been undertaken to highlight governance issues in
the health sector that hinder efficiency and effectiveness of service delivery. An
attempt has also been made to identify and assess the major barriers faced by
patients in accessing services including staff absenteeism, inadequate supply of
medicine, unofficial payments, etc. The specific objectives of the study are to:
i. Assess the utilization of facilities by age (children, adults), gender (male/female)
and socio-economic variation of the users;
ii. Identify the factors affecting accessibility to services (i.e. physical and economic
accessibility);
iii. Estimate the amount of cost incurred by patients (by facility type and patient
category), the sources of financing such costs and the impact of these costs on
household consumption decisions;
iv. Assess the level of patient satisfaction and the quality of services received
(with respect to availability of doctors, their attitude/ empathy, availability of
medicine, clean premises, privacy and confidentiality, etc.);
v. Identify and prioritize a list of governance issues/risk areas within the health
sector which act as major barriers to effective utilization of public health facilities
(inadequate supply of drugs/MSR, imposition of unofficial fees, staff absenteeism.

1.4 Limitations of study

More that may be done in reaching for levels of optimal efficiency congruent with
the economic environment that surrounds nearly all medical facilities. Finally,
HMOs have had to drop many Medicaid and Medicare patients because of
reduced funding from federal and state sources. The last reduction was 4.4% in
funds for Medicare patients. These organizations simply cannot offer the legally
mandated healthcare for the per capita allocation given to them for their service.

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All of this has meant that millions of poor and senior patients have been
“dumped” into the market served by medical practitioners who have made
decisions that it is not profitable for them to serve these market niches. The
dropped patients must scramble to locate any physician willing to accept them at
the price the federal or state governments are willing to pay. Daily, the quantity
of physicians who accept these patients is diminishing - at an increasing rate.
1.5 Background of the study
Bangladesh is experiencing a rapid evolution in healthcare, witnessing a shift
towards lifestyle disease patterns.
 The public sector is increasing its focus on healthcare, particularly through
the Health Population and Nutrition Sector Development Program
(HPNSDP)
 Along with support from International Aid agencies
 However, the private sector is driving the world class health delivery in
Bangladesh
 A lack of local know-how is driving the demand for imported healthcare
products
 Business potential for international healthcare product companies exist
both in the private and public segments
 Public sector procurement is fairly centralized
 Private sector purchasing appears to be the low hanging fruit
 A local presence either directly or through a partner is required to succeed
in the market.
 The regulatory frameworks is in a developing phase
 The country has a growing market for pharmaceuticals
 Supply of raw material and equipment to local companies shows promise
 Though there is potential in local R&D and development, companies have
evident challenges such as IP protection and CSR.
The Government of Bangladesh is constitutionally committed to ensuring the
provision of basic medical requirements to all segments of the population in the
country [1]. Within the broader context of the Bangladesh National Strategy
for Economic Growth, Poverty Reduction and Social Development (Bangladesh
I-PRSP, March 2003), the Government’s vision for the health, nutrition and

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population sector is to create conditions whereby the people of Bangladesh
have the opportunity to reach and maintain the highest attainable level of
health [2]. It is a vision that recognizes health as a fundamental human
right and, therefore, stresses the need to promote health and to alleviate ill
health and suffering in the spirit of social justice Health financing in Bangladesh
is dominated by the private out-of-pocket expenditure [8, 9]. This is by far the
largest source of health financing. All public resources only make up ¼ of the total
health expenditure (THE). Social and private insurance and official user fees in
public facilities comprise a very small proportion of the total health expenditure
[10, 11]. Government health expenditures are principally undertaken by the
central government, funded mainly through general revenue and support from
international development partners [12, 13]. Government’s revenues are
mobilized through tax and non-tax revenues [14].Most of the taxes are
collected from indirect taxes on goods and services, while the non-tax revenue
includes borrowing from the domestic market and self-financing by
government-owned autonomous corporations.

CHAPTER: 2

2.1 LITERATURE REVIWE

Kenneth Arrow (1921) often credited with giving rise to health economics as
discipline, drew conceptual distinctions between health and other goods. Factors
that distinguish health economics from other areas include extensive government
intervention, intractable uncertainty in several dimensions, asymmetric
information, barriers to entry, externalities and the presence of a third party
agent. In healthcare, the third-party agent is the physician, who makes purchasing

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decisions (e.g., whether to order a lab test, prescribe a medication, perform a
surgery, etc.) while being insulated from the price of the product or service.
Krugman (1953) said that Obamacare actually works. He also thought the entire
health care system would work better if government paid all our medical bills. In
making these claims, he wrote the way a non-economist would. Wherever there
are people who thought health policy problems can be solved without any
knowledge of economics, Krugman was there to give them aid and comfort –
week after week, month after month.
Amy Finkelstein (1973) had pioneered the use of randomized controlled trials
(RCTs) in studying health care delivery systems. RCTs were the gold standard of
research in medicine and many natural sciences, but in the realm of health care
policy, RCTs had been rare. This is now changing with Finkelstein’s leadership. Her
recent research in Oregon is an example. When the budget-strapped state of
Oregon announced a lottery to assign Medicaid coverage to a fraction of a
potentially eligible population, the state created,
Unintentionally, the condition for a randomized controlled trial: two statistically
equivalent groups recognizing immediately the opportunity to apply an RCT to a
series of vital and contested Medicaid policy questions, Finkelstein led a team of
researchers on the Oregon Health Insurance Experiment. Their findings had
provided compelling evidence on how Medicaid affects health, health care use,
and financial wellbeing.
One key discovery was that Medicaid coverage effectively eliminates the prospect
that a person would experience catastrophic financial losses as a result of a health
condition. To further support the use of RCTs in health economics, and to provide
rigorous evidence that could be used to improve health care delivery, Finkelstein
and her colleagues in J-PAL North America (a research branch of the Abdul Latif
Jameel Poverty Action Lab at MIT) had also launched the US Health Care Delivery
Initiative. This effort builds partnerships between leading scholars, policy makers,
and practitioners to generate policy-relevant research and to support evidence-
informed policymaking.
Jonathan Gruber (1965) another member of MIT’s distinguished health
economics team, had studied the extent of health insurance coverage in the
United States, and the interaction between private and public insurance. Gruber
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was a key adviser in designing the Massachusetts Health Care Reform Plan, and
also consulted on the US Affordable Care Act (ACA). Gruber’s current research
explores how consumers select insurance policies under the Medicare Part D
program, which provides prescription drug insurance. In addition, he was studying
how insurance markets have responded to the enactment of the ACA.
Nikhil Agarwal who also had strong ties to health economics, studies economic
aspects of the treatment for end-stage renal disease. Agarwal was exploring the
factors that were contributing to the rising expense of dialysis, a common therapy
for this disease, while also investigating ways to improve matching in the kidney
donation market.
Jeffrey Harris (1934) explored smoking-related health issues and the links
between public policies that bear on tobacco use and population health
outcomes. In addition to his MIT research, Harris serves as an internist at federally
sponsored community health centers.
Heidi Williams (1897) had analyzed the economic forces that influence
investment in cancer drug development, and had revealed a pattern of
underinvestment by pharmaceutical firms in research for drugs to prevent cancer
and to treat early stage cancers.
Her analysis suggested that pharmaceutical companies received longer effective
patent protection on drugs that could move quickly through clinical trials than on
those with longer expected testing durations.
As a result, these firms tilt their R&D spending toward quick-to-approve products,
which often target very ill patients, rather than investing in slow-to-approve
products that could help to prevent particular cancers. Williams, who was an
expert on innovation and intellectual property issues, had proposed several policy
reforms—such as using the effective date of new patents as the date of drug
approval rather than discovery—that could reverse these incentives and help
catalyze research on drugs for early-stage cancers, when the disease is easiest to
treat, and for cancer prevention.
Kessel’s (1958) article on price discrimination in the medical market place and the
most recent year for which articles were cited was 2003. While there was a strong
indication (see Figure 2) that the passage of time has a considerable winnowing

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effect, with half the articles being dated between 1995 and 2003, others have had
considerable staying power (including two by well-known health economists
(Newhouse 1970 and Zechauser 1970).
Gary Becker’s (1930-2014) contributed to the field of health economics started
somewhat indirectly. The early developments in human capital theory, to which
Becker was one of the main contributors, had obvious implications to the
economic analysis of expenditures on health, but were almost exclusively focused
on schooling and training (Schultz, 1960; Becker, 1962 and 1964). Human capital
theory advanced the idea that actions that imply present costs but enhanced
individual productivity in the future could be seen as investments in a form of
capital. Expenditures in health had many dimensions where such trade-offs were
present. A good diet or exercising might not be very much fun, but potentially
delivered long term benefits in the form of a longer and healthier life. Preventive
medical care demanded time and money, but might also improve future health
prospects. This was recognized early on, and a paper on health was even included
in the 1961 conference organized by Theodore Schultz and Gary Becker that laid
much of the groundwork for later developments in human capital theory
(Mushkin, 1962).
But the early explorations of health as human capital were somewhat timid
conceptually and did not give the field a push that remotely resembled that
received by the economic research on education. For the years that followed,
health economics persisted mostly as a field dealing with the analysis of health
systems and delivery of health technologies.
Becker, who won the Nobel Prize in 1992, pioneered the study of the family as an
economic unit. The paper, titled “A Theory of Intergenerational Mobility,” which
will be published in the Journal of Political Economy, is an important contribution
to his body of work. Gary Becker transformed economics by broadening the range
of problems considered by economists and by creating new analytical
frameworks. He founded flourishing fields of economics and public policy. It is
said that Helen of Troy was “The Face that Launched a Thousand Ships.” It can be
said of Gary Becker that his ideas launched the production of hundreds of data
sets and thousands of empirical and theoretical studies.

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Tyler Cowen (1962) said public health is very important, even more important
than medical care. He says the best way to improve health care in America is to
boost innovation, and that spending more on innovation is actually an "egalitarian
approach."
Amitabh Chandra (said there are three challenges in health care: coverage, quality
and innovation. He calls this a "trireme."
1) How do we cover people?
2) How do we make sure everybody gets quality health care?
3) How do we continue to do 1 and 2 as new medical innovations arrive?
Chandra says we should not pursue only two of these three challenges.

Gluckman and Hanson (2006) demonstrated that in utero environments affect

adult health. The essays in Gluckman and Hanson discuss the importance of a
variety of early environments on adult health.

Fogel (1997,2004) showed that early nutrition affects adult health. Barker (1998)
demonstrates that environmental insults in utero and in infancy predict the onset
of adult coronary disease, stroke, diabetes and hypertension. Fetal and maternal
nutrition are important predictors of adult health. Currie (2009, 2011) and
Almond and Currie (2011) survey empirical relationships between early-life
conditions and adult health reported in the recent literature in economics.

While epidemiologists typically adopt a life cycle, developmental, perspective

(see, e.g., Davey-Smith, 2007), most health economists do not. For example, the
influential analysis of Grossman (1972, 2000) focuses exclusively on adult health
investment decisions, taking the childhood health endowment and adult
preferences as given. Galama and van Kippersluis (2010) and Galama (2011)
substantially extend the Grossman framework. However, they do not model how
preferences or childhood endowments are determined.

20
Parallel to the epidemiological literature, an emerging developmental literature in
economics demonstrates the importance of early environmental conditions on
the evolution of adolescent and adult cognitive and non-cognitive capabilities
(see, e.g., Knudsen et al., 2006; Cunha and Heckman, 2007). These capabilities
strongly influence educational attainment; criminal behavior, earnings, and
participation in risky behaviors (see Almlund et al., 2011). Like the fetal
programming literature, this literature documents critical and sensitive periods in
the development of capabilities. Unlike the fetal programming literature, it also
considers environmental influences on development over the entire life cycle
from childhood through adulthood.

Remediation of early disadvantage and resilience in response to adversity receive

much more attention in this literature than in the current literature in health
economics. For policy purposes, it is not enough to know that early-life conditions
matter. It is important to know the costs and benefits of remediating early life
deficits.

Each literature has much to learn from the other. Evidence on the importance of
early environments on a spectrum of health, labor market, and behavioral
outcomes, suggests that common developmental processes are at work.
Cognitive and non-cognitive capabilities — self-regulation, motivation, time
preference, far-sightedness, adventurousness and the like — affect the evolution
of health capital by influencing choices made by parents and children including
educational choices. In turn, education shapes personality and cognitive traits
(Almlund et al., 2011; Heckman et al., 2006, 2011). Grossman (2000), Cutler and
Lleras-Muney (2010), Conti et al. (2010a,b), and Heckman et al. (2011) show that
education also causally affects health. Personality and cognition determine health
and healthy behaviors beyond their direct e ects on education and through the
education on health (Conti et al., 2010a, b, 2011).

2.2 Methodology of study

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The health system is the societal response to the determinants of health.
Every society believes in a set of determinants of health, not always following
science or logic. The fundamental premise of a health system is the value of
human life. The value that a society puts on human life largely determines the
resources - human, material and financial - that it allocates for the health
system. The effectiveness of a health system depends on the availability and
accessibility of services in a form which the people are able to understand,
accept and utilize. The Government of Bangladesh is constitutionally
committed to “supply the basic medical requirements to all segments of the
people in the society” and the “improvement of the nutritional and the public
health status of the people” [1]. In its early phase, the providing curative services
targeting maternal, child and newborn health. Since the 1990s, with the
development of modern science and technology and with the greater role of
United Nations agencies and non-government organizations, the health systems
gradually shifted its emphasis equally on services also expanded its reach. Yet
a large number of the people of Bangladesh, particularly in rural areas, remain
with little access to health care facilities.
Nevertheless, it must be recognized that Bangladesh has a well-structured
health system with three tiers of primary health care – Upazila Health
Complexes (UHC) at the sub-district level, Union Health and Family Welfare
Canters (UHFWC) at the Union (CC) at the village level. These are backed by
the District Hospitals providing secondary level care and the tertiary hospitals
of various kind in large urban centers. From a purely structural point of view,
the health system is based on sound principles covering the entire spectrum of
services and care – from health education and promotion to treatment, care
and rehabilitation. Moreover, the system is decentralized covering all districts,
sub-districts and rural towns and villages in the country. The Government,
thereby, seeks to create conditions whereby the people of Bangladesh have the
opportunity to reach and maintain the highest attainable level of health. In
short, Bangladesh has a good infrastructure for delivering primary health care
services. However, due to inadequate logistics the full potential of this
infrastructure has never been realized. Clearly
the health system in Bangladesh needs further strengthening in order to
fully realize its potential. A good health system improves and sustains

22
people’s lives tangibly every day. Health systems strengthening (HSS) is crucial
for the successful scale up of disease control interventions as well as
promoting health education [2-4]. Additional evidence also suggests that weak
health systems are one of the main barriers in reaching the healthrelated
Millennium Development Goals (MDGs)[4-5]. After independence Bangladesh
has made tremendous progress in health and development. In some cases,
it has made more impressive gains compared to most of its neighbors in
reducing poverty, malnutrition, illiteracy and disease and deprivation. Despite
these successes, the Bangladesh health system continues to suffer from
innumerable challenges [6]. It is difficult to list and comment on all these
challenges. This paper is concentrated on an analysis of a number of major
challenges faced by the health system in Bangladesh.

The definition of economics above includes the term to produce,

emphasizing that economics deals with both health and health care as a good or
service that is manufactured, or produced. All production requires the use of
resources such as raw materials and labor, and we can regard production as a
process by which these resources are transformed into goods.

Mediating
factors

Input
(Research) Production
(process ) Outputs
(Goods &
services) 23
2.3 Research on health system
Health Systems Research Considerable challenges remain in the forefronts in the
efforts to improve the health status of the population, reduce health inequalities,
improve the quality of care and public satisfaction with healthcare, and to
increase the efficiency and sustainability of service-delivery agencies. These
challenges point to the growing need for appropriate and applied research to
enhance the knowledge about factors affecting the governance, provision,
organization, financing and use of healthcare and health services as well as at the
role of key multi-sectoral players within the healthcare system. Where resources
are scare, it is vital that health system be strengthened so that every decision is
the best decision. Health systems research can support that decision-making.

2.4 Sample design

This paper describes existing guides and analytic frameworks that have been
suggested for the economic evaluation of healthcare interventions. Using selected
examples of digital health interventions, it assesses how well existing guides and
frameworks align to digital health interventions. It shows that digital health
interventions may be best characterized as complex interventions in complex
systems. Key features of complexity relate to intervention complexity, outcome
complexity, and causal pathway complexity, with much of this driven by iterative
intervention development over time and uncertainty regarding likely reach of the
interventions among the relevant population. These characteristics imply that
more-complex methods of economic evaluation are likely to be better able to
capture fully the impact of the intervention on costs and benefits over the
appropriate time horizon. This complexity includes wider measurement of costs
and benefits, and a modeling framework that is able to capture dynamic
interactions among the intervention, the population of interest, and the

24
environment. The authors recommend that future research should develop and
apply more-flexible modeling techniques to allow better prediction of the
interdependency between interventions and important environmental influences.

2.5Sample size
Sample size is a count the of individual samples or observations in any statistical
setting, such as a scientific experiment or a public opinion survey. Though a
relatively straightforward concept, choice of sample size is a critical determination
for a project. Too small a sample yields unreliable results, while an overly large
sample demands a good deal of time and resource .To determine the sample size
needed for an experiment or survey, researchers take a number of desired factors
into account. First, the total size of the population being studied must be
considered -- a survey that is looking to draw conclusions about all of New York
state, for example, will need a much larger sample size than one specifically
focused on Rochester. Researchers will also need to consider the margin of error,
the reliability that the data collected is generally accurate; and the confidence
level, the probability that your margin of error is accurate.
Finally, researchers must take into account the standard deviation they expect to
see in the data. Standard deviation measures how much individual pieces of data
vary from the average data measured. For instance, soil samples from one park
will likely have a much smaller standard deviation in their nitrogen content than
soils collected from across whole county sources.

CHAPTER: 3

3.1 Present condition of health sector in Bangladesh

The health care designated to meet the health needs of the community through
the use of available knowledge and resources. The services provided should be
comprehensive and community based. The resources must be distributed
according to the needs of the community. The final outcome of good health care
system is the changed health status or improve health status of the community

25
which is expressed in terms of lives saved, death averted, disease prevented,
disease treated, prolongation of life etc.
Health care delivery system in Bangladesh based on PHC concept has got various
Level of service delivery:
• Home and community level.
• Union level,
• Union sub center (USC) or Health and family welfare center; this is the first
health facility level.
• Thana level, Thana Health Complex (THC): This is the first referral level.
• District Hospital: This is the secondary referral level.
• National Level: This is the tertiary referral level.
Primary level health care is delivered though USC or HFWC with one in each union
domiciliary level, integrated health and family planning services through field
workers for every 3000–4000 population and 31 bed capacities in hospitals.
The secondary level health care is provided through 500 bed capacities in district
hospital. Facilities provide specialist services in internal medicine, general surgery,
gynecology, pediatrics and obstetrics, eye clinical, pathology, blood transfusion
and public health laboratories. Tertiary Level health care is available at the
medical college hospital, public health and medical institutes and other specialist
hospitals at the national level where a mass wide range of specialized as well as
better laboratory facilities are available.

3.2 Health policy in Bangladesh

The Bangladesh health policy document was published in 2011 and adheres to the
following principles:
Health is defined as "A state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity."[1]
1. Every citizen has the basic right to adequate health care. The State and the
government are constitutionally obliged to ensure health care for its citizens.
26
2. To ensure an effective health care system that responds to the need of a
healthy nation, health policy provides the vision and mission for development.
3. Pursuit of such policy will fulfill the demands of the people of the country,
while health service providers will be encouraged and inspired. People's physical
well-being and free thought process have proved to be a precondition for the
growth and intellectual enrichment in today's human society
4. Bangladesh expressed agreement on the following declarations:
• The Alma Ata Declaration (1978)
• The World Summit for Children (1990)
• International Conference on Population and Development (1994)
• Beijing Women's Conference (1995)[2]
In the absence of a written and approved Health Policy, the national Annual
Development Program and Five Year Plans substituted for policy principles.
The problems in the health services multiplied in the absence of a clear policy.
Bangladesh is a developing country with the world's highest population density.
History of the development of the policy[edit]
The Ministry of Health and Family Welfare [3] assembled a Committee in 1996 for
the purpose of preparing a health policy, with members drawn from civil society
and professional bodies, including technocrats and bureaucrats.
A further five sub-committees were formed to:
• Evaluate the existing health services and determining the goals
• Formulate policies to ensure essential services
• Formulate policies to ensure hospital-based services
• Design Strategies for HRD
• Integrate NGOs and the Private Sector and plan for resources and
utilization of funds.

27
The sub-committees worked for more than a year and submitted their
efforts/recommendations. A working group was formed and entrusted with the
responsibilities for compiling the recommendations contained in the reports. The
working group also organized workshops in all six Divisions to elicit opinions of
cross-section of the society on these reports. Finally the working group presented
the proposals and recommendations to the National Health Policy Formulation
Committee. A report on the health policy was thus formulated on the basis of
consensus. The Cabinet on 14 Aug 2000 approved the National Health Policy.

3.3 Institute of health economics

Health economics has emerged over the past three decades as a major branch of
economics that has enabled academicians of both developed and developing
countries to influence the way we think about the determinants of health, and
how we approach the organization and delivery of health care.
The Institute of Health Economics (IHE), University of Dhaka, pioneered the
development of health economics in Bangladesh in 1998, which is the only health
economics teaching and research institute in South-Asia.
IHE operates across all areas of the discipline, with a particular emphasis on
methodological thinking and high policy impact through offering short courses/
trainings and different academic degree programs. It is known for its quality
education and also for its work in health status measurement, performance
measurement and productivity, health care financing, economic evaluation of
alternative healthcare programs and treatment methods, measurement of
burden of diseases, and econometric methodology. IHE offers the following
academic programs.

3.4 Healthcare Industry in Bangladesh

a. Industry in Numbers

28
b. Healthcare Expenditures
Currently the 57th largest economy in the world, Bangladesh has been making
significant socio-economic developments in recent years. GDP has been growing
at an average rate of 6-7% over the past decade. However, despite improving
healthcare indicators such as decline in mortality rates and increase in average
life expectancy, the health sector of the country is yet to reach its full potential.
Total healthcare expenditure stands at only 3.7% of total GDP of the economy.
The major share of total health expenditure in 2007 was spent on drug retail
services (46.1%) and curative care services (28.6%) followed by prevention and
public health services (11.2%) (MOHFW, 2003).
• Public vis-à-vis Out-of-Pocket Expenditure
Bangladesh ranks 3rd from the bottom in Total Healthcare Expenditure as % of
GDP Index for the South East Asia region. However, when public expenditure as %
of total healthcare expenditure is compared Bangladesh ranks among the top 5
nations.
Bangladesh govt.’s share of spend on healthcare is 37% of the total healthcare
expenditure. Public spending on health is financed from the non-development or
revenue budget and the development budget or Annual Development Program
(ADP) in the form of national tax, foreign development funds, and corporations
and autonomous bodies. Tax and non-tax revenue and foreign loans and grants
are channeled by the Ministry of Finance to the Ministry of Health and Family
Welfare and other ministries.

CHAPTER: 4

29
4.1 Health Financing in Bangladesh
Bangladesh has achieved remarkable improvement in health indicators since its
independence in 1971, despite poor economic conditions. It achieved Millennium
Development Goal 4 on child mortality and progressed substantially toward Goal
on maternal mortality, even with health system bottlenecks such as weak
governance, insufficient health financing, and limited capacity to address local
need.1Bangladesh Planning Commission, General Economics Division. Millennium
Development Goals: Bangladesh progress report 2015. Dhaka: Bangladesh
Planning Commission, Government of the People's Republic of Bangladesh; 2015.
Bangladesh Planning Commission, General Economics Division background paper
on health strategy for preparation of 7th five year plan. Dhaka: Government of
the People's Republic of Bangladesh; 2014. of the government of Bangladesh
(which is the overarching development plan for Bangladesh covering 13 sectors)
and the fourth Health, Population and Nutrition Sector Program Ministry of
Health and Family Welfare (Bangladesh), Planning Wing. 4th Health, Population
and Nutrition Sector Program (4th HPNSP) (January 2017 – June 2022).
Program implementation plan (PIP), better health for a prosperous society. vol. I.
Dhaka, (Bangladesh): Ministry of Health and Family Welfare, Government of the
People's Republic of Bangladesh; 2017 of MOHFW (which is the sector-wide
approach for the health sector) highlight the importance of and commitment to
implementing the health care financing strategy.

4.2 Who pays for health care in Bangladesh?

Background
The relationship between payments towards healthcare and ability to pay is a
measure of financial fairness. Analysis of progressivity is important from an equity
perspective as well as for macroeconomic and political analysis of healthcare
systems. Bangladesh health systems financing is characterized by high out-of-
pocket payments (63.3%), which is increasing. Hence, we aimed to see who pays

30
what part of this high out-of-pocket expenditure. To our knowledge, this was the
first progressivity analysis of health systems financing in Bangladesh.
Methods
We used data from Bangladesh Household Income and Expenditure Survey, 2010.
This was a cross sectional and nationally representative sample of 12,240
households consisting of 55,580 individuals. For quantification of progressivity,
we adopted the ‘ability-to-pay’ principle developed by O’Donnell, van Doorslaer,
Wagstaff, and Lindelow (2008). We used the Kakwani index to measure the
magnitude of progressivity.
Results
Health systems financing in Bangladesh is regressive. Inequality increases due to
healthcare payments. The differences between the Gini coefficient and the
Kakwani index for all sources of finance are negative, which indicates regressivity,
and that financing is more concentrated among the poor. Income inequality
increases due to high out-of-pocket payments. The increase in income inequality
caused by out-of-pocket payments is 89% due to negative vertical effect and 11%
due to horizontal inequity.
Data and methods
Sampling technique
We use the Bangladesh Household Income and Expenditure Survey [20] dataset
conducted by Bangladesh Bureau of Statistics (BBS). This is the source of data for
estimating household income, expenditure, consumption, income inequality and
incidence of poverty. For this round, data collection was started on 1st February
2010 and continued up to 31st January 2011.

A two-stage stratified random sampling technique was followed in drawing the

sample for this survey under the framework of Integrated Multipurpose Sampling
(IMPS) design developed on the basis of the 2001 Bangladesh population and
housing census. In IMPS design, the whole country was divided into 16 strata,
which included six from rural, six from urban, and four from sub-municipal areas
(SMAs). The design consists of 1000 primary sampling units (PSUs) throughout the

31
country systematically drawn from the 16 strata. Out of 1000 PSUs, 640 were
from rural and 360 from urban areas. Each PSU is comprised of approximately 200
households. In the first stage, 612 PSUs were drawn from 1000 PSUs. In the
second stage, 20 households were randomly selected from each PSU. Thus, PSUs
selected for HIES 2010 are actually a subset of PSUs of the IMPS design. The total
sample size stands at 12,240 households comprising of a population of 55,580.
Methods
We used two methods to measure the progressivity of health payments:
comparing the share of health payments to their share of ATP, and assessing
departure from proportionality or Lorenz dominance analysis. Under the
progressive system, the share of health payments are less than their ATP and the
Lorenz curve dominates (lies above) the concentration curve. The opposite is true
for a regressive system. Kakwani index is being used to measure the magnitude of
progressivity.
We have used STATA 14.0 [21] and the Automated Development Economics and
Poverty Tables (ADePT) software, version 5.0 developed by World Bank’s experts
[22]. Progressivity is assessed using a direct and a less direct method.
A direct method is a percentage of OOP payments for healthcare as a percentage
of total household expenditure by quintile/decile groups of equivalent household
expenditure. A less direct method of assessing progressivity is defined in relation
to departure from proportionality. This method compares the share of health
payments contributed by proportions of the populations ranked by ATP with their
share of ATP. It compares the concentration curve of health payments (LH(p))
with the Lorenz curve for ATP, (L(P)). The merit of this curve is that it provides a
visual representation of the distribution information. However, it does not show
the distribution exactly, and it is difficult to compare this curve between the
countries.

Because the Lorenz dominance analysis alone does not provide a measure of
magnitude of proportionality, Kakwani index [23] is used to measure the
magnitudes of progressivity/regressivity. Kakwani index is twice the area between
a payment concentration curve and a Lorenz curve. It is calculated as

32
πk = C − G 1
Where, C is the concentration curve and G is the Gini coefficient of the ATP
variable. The Gini coefficient (G) is used to measure of inequality of a distribution.
The value of G varies from 0 to 1. The Gini coefficient is regarded as the gold
standard in economic analysis in assessing inequality.

Key variables
The variables for this part of analysis are ability to pay (ATP) (Table (Table1),1),
food consumption, non-food consumption, and amount of healthcare payments.
Ability to pay for each household was calculated by adding all forms of
consumption such as food consumption and non-food consumption. The amount
of healthcare payments was calculated by adding all the related costs of
healthcare including direct and indirect costs.

4.3 Economic problems in health issue in Bangladesh

In South-East Asia the main public health issues are infectious diseases and
communicable diseases. Public health has improved markedly in Bangladesh over
the past three decades. Nevertheless, Bangladesh faces major health challenges.
A scoping study was performed according to York methodology. The study was
aimed to find out the major public health issues and challenges in Bangladesh.
Bangladesh has one of the worst burdens of childhood malnutrition in the world.
Communicable diseases are a major cause of death and disability in Bangladesh.
Unsafe food remains a major threat to public health each year, citizens suffer
from the acute effects of food contaminated by microbial pathogens, chemical
substances and toxins. Bangladesh still ranks among the top ten countries in the
world with the highest TB burden. Pneumonia and other infections are major
causes of death among young children. In Bangladesh only 1% of the population is
reported to be HIV-positive, but rates are much higher among high-risk
populations: injecting drug users, sex workers, and men who have sex with men.
The toll of non-communicable diseases chronic diseases, cancer, diabetes,

33
cardiovascular diseases, and chronic respiratory diseases is increasing in
Bangladesh as the population becomes more urbanized.
The converging pressures of global climate change and urbanization have a
devastating effect on Bangladesh’s most vulnerable populations. The disease
burden Bangladesh is further exacerbated by unsanitary living conditions that
underscore the poor economic conditions of both urban and rural home dwellers.
There are still several issues that Bangladesh health care system is yet to tackle,
governance, accessibility, and affordability are key issues that are preventing the
implementation of solutions to the public health issues in Bangladesh.
Results and Discussion
Bangladesh faces a number of health challenges which can be grouped as follows:
 Population problems
 Communicable diseases problems
 Nutritional problems
 Environmental sanitation problems
 Health problems
Population problems
Bangladesh has a population of more than 1.55 million people in 2012, is one of
the most densely populated countries in the world, having a population density of
1050 per km21,12 The male/female ratio is 104.9/100.0 and the annual
population growth rate is 1.37%.2 The population of Bangladesh is very young as
depicted by its wide-based population pyramid. A large cohort of the young
population will enter reproductive age in the coming decades, a phenomenon
partly explaining why the adolescent (15-19) fertility rate in Bangladesh of 118 per
1000 women is not expected to decrease significantly for decades.3 As in other
countries, the population is ageing over time due to decreasing fertility rates (6.3
births per woman in 1975 to 2.3 in 2011) and increasing life expectancy at birth of
69 years in 2011.3 The national population is projected to grow to between 200
to 225 million over the next four decades.3 While fertility has declined, women
have on average 2.3 children, and only about half use modern and effective

34
contraceptive methods.3 Despite improvements in maternal health, Bangladesh
still ranks in the bottom fourth of countries worldwide with approximately 240
deaths per 100,000 live births.11 Only one-in-four births takes place in a health
care facility, putting both mothers and babies at risk.11
Communicable diseases
Communicable diseases are a major cause of death and disability in Bangladesh.
While the prevalence of tuberculosis (TB) has declined substantially, Bangladesh
still ranks among the top ten countries in the world with the highest TB burden.13
Bangladesh is one of the 22 high tuberculosis-burden countries. The incidence,
prevalence and mortality estimates for tuberculosis (TB) are 225/100 000, 434 per
100 000 and 45/100 000 respectively and 1.4% statistics of multidrug resistant
cases.14 TB services are integrated in the primary health care system. The
treatment success rate is 92% for the cohort of patients registered in 2011.13
Pneumonia and water-borne diseases also are widely prevalent. Pneumonia and
other infections are major causes of death among young children.11 Pneumonia
is the leading cause of death worldwide in children under five years of age.
According to the World Health Organization, nearly 400 children die each day
from ARIs in Bangladesh. Pneumonia, infection, and birth asphyxia are major
causes of under-five deaths in the country. Early detection and treatment of
infection is key to saving lives.

Nutritional problems

Poor nutrition, often called under-nutrition can damage physical, intellectual, and
mental health, leading to reduced immunity, increased susceptibility to disease,
impaired physical and mental development and reduced educational and
economic productivity. It is well recognized that the period from birth to two
years of age is the critical window of behavioral and cognitive development
promotion. In Bangladesh, close to 50% of children-under-five are stunted due to
poor nutrition, with urban poor most affected.3 Twenty-two percent of infants

35
are low birth weight, only 43% of infants are exclusively breastfed, and 41% of
children-under-five are moderately to severely underweight. Improving nutrition
should be a major public health priority in Bangladesh.3 Although infant and child
mortality is decreasing, poor nutrition is a critical health problem in
Bangladesh.11 About half of children age 6-59 months suffers from anemia; four-
in-ten are stunted; and one in three is underweight.11 Bangladesh has one of the
worst burdens of childhood malnutrition in the world.

4.4 Health system in Bangladesh: Challenges and opportunities

The health system of Bangladesh relies heavily on the government or the public
sector for financing and setting overall policies and service delivery
mechanisms. Although the health system is faced with many intractable
challenges, it seems to receive little priority in terms of national resource
allocation. According to the World Health Organization (WHO 2010) only about
3% of the Gross Domestic Product (GDP) is spent on health services. However,
government expenditure on health is only about 34% of the total health
expenditure (THE), the rest (66%) being out-of-pocket (OOP) expenses.
Inequity, therefore, is a serious problem affecting the health care system was
based on a review of secondary data, the paper assesses the current challenges
and opportunities of the health system in Bangladesh. The findings suggest that
although the health system faces multifaceted challenges such as lack of
public health facilities, scarcity of skilled workforce, inadequate financial
resource allocation and political instability; Bangladesh has demonstrated
much progress in achieving the health-related Millennium Development Goals
(MDGs) especially MDG 4 and MDG 5.
Although the country has a growing private sector primarily providing tertiary
level health care services, Bangladesh still does not have a comprehensive
health policy to strengthen the entire health system. Clearly, the most crucial
challenge is the absence of a dynamic and proactive stewardship able to design
and enforce policies to further strengthen and enhance the overall health system.
Such strong leadership could bring about meaningful and effective health system
reform, which will work more efficiently for the betterment of the health of the

36
people of Bangladesh, and would be built upon the values of equity and
accountability.

Health effects
Undernourished mothers often give birth to infants who will have difficulty with
development, pertaining to health problems such as wasting, stunting,
underweight, anemia, night blindness and iodine deficiency. As a result,
Bangladesh has a high child mortality rate and is ranked 57 in the under-5
mortality rank.
Economic effects
As 40% of the population of Bangladesh is children, malnutrition and its health
effects among children can potentially lead to a lower educational attainment
rate. Only 50% of an age group of children in Bangladesh managed to enroll into
secondary school education. This would result in a low-skilled and low
productivity workforce which would affect the economic growth rate of
Bangladesh with only 3% GDP growth in 2009.
Efforts to combat malnutrition
Many programs and efforts have been implemented to solve the problem of
malnutrition in Bangladesh. UNICEF together with the government of Bangladesh
and many other NGOs such as Helen Keller International, focus on improving the
nutritional access of the population throughout their life-cycle from infants to the
child-bearing mother. The impacts of the intervention are significant. Night
blindness has reduced from 3.76% to 0.04% and iodine deficiency among school-
aged children has decreased from 42.5% to 33.8%.
Maternal and child health
One in eight women receives delivery care from medically trained providers and
fewer than half of all pregnant women in Bangladesh seek ante-natal care.
Inequity in maternity care is significantly reduced by ensuring the accessibility of
health services. The 2010 maternal mortality rate per 100,000 births for
Bangladesh is 340. This is compared with 338.3 in 2008 and 724.4 in 1990. In

37
Bangladesh the number of midwives per 1,000 live births is 8 and the lifetime risk
of death for pregnant women 1 in 110.
4.5DATA ANALYSIS
Bangladesh stands out as a country that has taken giant steps in healthcare and
has made significant improvement in health sector, which make it an example for
other developing countries even though being a resource poor country. Over the
last decades, key health indicators such as life expectancy and coverage of
immunization have improved notably, whilst infant mortality, maternal mortality
and fertility rates have dropped significantly. Long before the emergence of
contemporary global health initiatives, the government placed strong emphasis
on the importance of childhood immunization as a key mechanism for reducing
childhood mortality. Expanded Program on Immunization (EPI) in Bangladesh is
considered to be a health system success because of its remarkable progress over
the last two decades. It provides almost universal access to vaccination services,
as measured by the percentage of children less than 1 year of age who receives
BCG (a vaccine against tuberculosis) is increased from 2% in 1985 to 99% in 2009.
Coverage of other vaccines has also improved substantially.

Table-I: Development indicators and health outcomes for Bangladesh and

neighboring countries and regions.

Development indicators Health outcomes

38
 Population Per head Poverty Girls enrolled in Life Infant Under 5 Material
GDP primary expectancy mortality mortality mortality (per
education at birth (per 1000 (per 100000 100000 live
(years) live births) live births) births)

South Asia

Bangladesh 152.9 673 30.0% 92.3% 68.3 42 51 194

Pakistan 173.6 1007 22.3% 69.8% 65.0 66 86 260

Nepal 30.0 524 30.9% NA 68.0 46 54 380

India 1224.6 1476 27.6% 89.3% 64.8 48 65 230

West Bengal 91.3 612 NA NA 64.8 33 40 145

Southeast Asia

Cambodia 14.1 802 30.1% 95.7% 63.1 53 69 85

Laos 6.2 1208 27.6% 87.8% 66.7 37 46 580

Burma 48.0 NA NA 32.0% 64.2 45 57 240

SOURCE: Data from references 1, 30, 31 and 40.GDp-gross domestic product. NA-
not available. *Primary education denotes girls aged 6-10 years.

CHAPTER: 5

5.1 Recommendation:

The above noted health economic issues point out that if nothing is done, rising
healthcare premiums will force individuals and families to be unable to purchase

39
health insurance and prescription drugs. Physicians and HMOs will leave the rural
markets and concentrate on the more profitable large metropolitan areas. The
medical industry may have reached a dilemma that only economists and
professional managers may help resolve if the general public is to continue to
have access to reasonably affordable healthcare.
In the light of the findings of this paper, it can be fairly argued that
Bangladesh faces a lot of challenges in its health system. These challenges must
be resolved in order to improve the existing health system, so that the
disadvantaged and vulnerable people can get better access to basic health
care services. Health is a fundamental human right, and regardless of their
socio-economic status everybody has the right to enjoy optimal health status.
The paper emphasizes once again the issue of equity in health systems, and
the importance of a multi sectorial comprehensive approaches to improve the
health system. The health system in Bangladesh desperately needs a dynamic
leadership that is prepared to design and enforce evidence-based policies
and programs. The steward of the health system must have a strategic vision and
determination to improve and strengthen both the public and private health
sectors of the country. Equity must be the overarching guiding principle
underpinning the health system.
Health service is most important factor for human wellbeing. So people’s
participation in health service is very significant in ensuring health policy of
Bangladesh. Health services based on primary health services have been
expanding gradually in Bangladesh to improve the health status of the people,
especially in rural areas where more than 85 percent of the people are living and
are underserved and underprivileged groups.
The study focused on the degree of people’s participation in public health services
of it suggests that the people’ participation in health services is not satisfactory.
The Government of Bangladesh has taken some initiatives according to the Alma-
Ata Declaration of 1978 to increase the people’s participation in health service.
However, these initiatives have not been achieved in Bangladesh till now. Now-a-
days, the Government tries to create awareness among the village people as
stipulated in the constitution. It also tries to encourage the disadvantaged group
to become self-reliant and self-dependent and conscious. However, these

40
initiatives have been limited and their goal has not been achieved yet. The
Government also tries to motive the people to use the existing health facilities,
but most of the people are not willing to use modern health care facilities due to
the ignorance and traditional mentality of rural people. The present study
revealed that most of the respondent expresses that health education and
information is critical for ensuring people’s participation in rural health service.
But the health education and information is not possible due to the apathy of the
Government, and thus, the people’s participation and integration of health care
services remain poor.
On the basis of our findings we present the following recommendations:
1. Though the National Health Policy is essentially people-oriented, our analysis
shows that the problem lies in the implementation of these policies. So the
Government needs to modify its traditional process and be more people-oriented.
2. Accountability and transparency is an important factor for all sectors. But the
health sector is absence of accountability and transparency. So the accountability
of the concerned staff should be ensured in rural health complex.
3. Bureaucratic response is also very important in the health sector. So the
bureaucratic response should be a positive view to the mass people for ensuring
participation in health.
4. The Government should be given accessibility of community based health
service providers in the rural health complex and other organizations.
5. The Government needs to make sure that the donors’ view does not negatively
influence its policy making and implementation in the health sector.
6. Campaigns of government health programs, such as-family planning, safe
motherhood, expanded program of immunization, should be increased.
7. The qualities and the behavior of health personnel working should be helpful to
the people in order to improve the participation in rural health service.
8. Most of the doctors said that the public salary is not enough and that they are
therefore forced to go to the private sector. The Government should revise the
current pay structure and improve the working conditions of rural doctors.

41
9. Education, awareness and motivational strategies are important factors for
ensuring the people’s participation in health services and the success of different
health programs. Hence, these strategies should be strictly followed on the
development programs.
10. Financial and technical support is also important for ensuring a high quality of
health care but the government’s allocation does not match the demand. The
Government should provide the necessary financial and technical support to the
rural health complex.
11. Given that the Government receives foreign funds, they are accountable to
the foreign donors. But the Government should also keep in mind national
interests. Donor’s performance may go against national interests. So the
Government should try to become independent from the donors.
12. Apart from insufficient infrastructure and logistics, the corrupt practices and
unwillingness of some government doctors to stay at their posted place makes
the government health services inaccessible to the people. These doctors should
be identified and punished in order to improve the efficiency of health services.
13. Regular monitoring and supervision should be adopted in government health
sector for ensuring participation of people in rural health complex.
14. Seminars and focus group discussions can be arranged to attract the people’s
information about health services. Television programs, radio programs, and
newspaper advertisements can be helpful in this regard.
The goal of health services is to protect and improve the health of individuals and
populations. In a landmark 2001 report, Crossing the Quality Chasm: A New
Health System for the 21st Century,25 the Institute of Medicine (IOM) of the
National Academy of Sciences proposed that the goals for health services should
include six critical elements: Patient Safety: Patients should not be harmed by
health care services that are intended to help them. The IOM report, To Err Is
Human, 26 found that between 46,000 and 98,000 Americans were dying in
hospitals each year due to medical errors. Subsequent research has found
medical errors common across all health care settings. The problem is not due to
the lack of dedication to quality care by health professionals, but due to the lack

42
of systems that prevent errors from occurring and/or prevent medical errors from
reaching the patient.
Effectiveness: Effective care is based on scientific evidence that treatment will
increase the likelihood of desired health outcomes. Evidence comes from
laboratory experiments, clinical research (usually randomized controlled trials),
epidemiological studies, and outcomes research. The availability and strength of
evidence varies by disorder and treatment.
Timeliness: Seeking and receiving health care is frequently associated with delays
in obtaining an appointment and waiting in emergency rooms and doctors’
offices. Failure to provide timely care can deny people critically needed services or
allow health conditions to progress and outcomes to worsen. Health care needs
to be organized to meet the needs of patients in a timely manner.
Patient Centered: Patient-centered care recognizes that listening to the patient’s
needs, values, and preferences is essential to providing high-quality care. Health
care services should be personalized for each patient, care should be coordinated,
family and friends on whom the patient relies should be involved, and care should
provide physical comfort and emotional support.
Efficiency: The U.S. health care system is the most expensive in the world, yet
there is consistent evidence that the United States does not produce the best
health outcomes27–30 or the highest levels of satisfaction.31 The goal is to
continually identify waste and inefficiency in the provision of health care services
and eliminate them.
Equity: The health care system should benefit all people. The evidence is strong
and convincing that the current system fails to accomplish this goal.
The IOM report, Unequal Treatment,32 documented pervasive differences in the
care received by racial and ethnic minorities. The findings were that racial and
ethnic minorities are receiving poorer quality of care than the majority
population, even after accounting for differences in access to health services.
Crossing the Quality Chasm concludes that for the American health care system to
attain these goals, transformational changes are needed.25 The field of HSR
provides the measurement tools by which progress toward these goals is
assessed, as seen in the National Healthcare Quality Report.11 Equally important,
43
health services researchers are developing and evaluating innovative approaches
to improve quality of care, involving innovations in organization, financing, use of
technology, and roles of health professionals.

5.2 Conclusion

The goal of health services is to protect and improve the health of individuals and
populations. In a landmark 2001 report, Crossing the Quality Chasm: A New
Health System for the 21st Century,25 the Institute of Medicine (IOM) of the
National Academy of Sciences proposed that the goals for health services should
include six critical elements:
Patient Safety: Patients should not be harmed by health care services that are
intended to help them. The IOM report, To Err Is Human, 26 found that between
46,000 and 98,000 Americans were dying in hospitals each year due to medical
errors. Subsequent research has found medical errors common across all health
care settings. The problem is not due to the lack of dedication to quality care by
health professionals, but due to the lack of systems that prevent errors from
occurring and/or prevent medical errors from reaching the patient.
Effectiveness: Effective care is based on scientific evidence that treatment will
increase the likelihood of desired health outcomes. Evidence comes from
laboratory experiments, clinical research (usually randomized controlled trials),
epidemiological studies, and outcomes research. The availability and strength of
evidence varies by disorder and treatment.
Timeliness: Seeking and receiving health care is frequently associated with delays
in obtaining an appointment and waiting in emergency rooms and doctors’
offices. Failure to provide timely care can deny people critically needed services or
allow health conditions to progress and outcomes to worsen. Health care needs
to be organized to meet the needs of patients in a timely manner.
Patient Centered: Patient-centered care recognizes that listening to the patient’s
needs, values, and preferences is essential to providing high-quality care. Health
care services should be personalized for each patient, care should be coordinated,

44
family and friends on whom the patient relies should be involved, and care should
provide physical comfort and emotional support.
Efficiency: The U.S. health care system is the most expensive in the world, yet
there is consistent evidence that the United States does not produce the best
health outcomes27–30 or the highest levels of satisfaction.31 The goal is to
continually identify waste and inefficiency in the provision of health care services
and eliminate them.
Equity: The health care system should benefit all people. The evidence is strong
and convincing that the current system fails to accomplish this goal. The IOM
report, Unequal Treatment,32 documented pervasive differences in the care
received by racial and ethnic minorities. The findings were that racial and ethnic
minorities are receiving poorer quality of care than the majority population, even
after accounting for differences in access to health services.
Crossing the Quality Chasm concludes that for the American health care system to
attain these goals, transformational changes are needed.25 The field of HSR
provides the measurement tools by which progress toward these goals is
assessed, as seen in the National Healthcare Quality Report.11 Equally important,
health services researchers are developing and evaluating innovative approaches
to improve quality of care, involving innovations in organization, financing, use of
technology, and roles of health professionals.

5.3 References

International Relations and Security Network, Primary Resources in International Affairs

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Okamoto. 2011. Capitalizing on the demographic transition: tackling no
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Bleich, S.N., T.L.P. Koehlmoos, M. Rashid, D.H. Peters and G. Anderson. 2011. No
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Bangladesh Bureau of Statistics (BBS). 2011. Statistical pocketbook of Bangladesh
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http://www.tradingeconomics.com/bangladesh/gdp-growth-annual (accessed 18 April
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World Bank. 2012d. World development report 2012: Gender equality and
development. Washington, DC.
World Bank. 2011. Bangladesh—Health Sector Development Program. Dhaka.
Bangladesh Health Watch (BHW). 2011. Moving Towards Universal Health Coverage.
Directorate General of Health Services (DGHS). 2010. Secondary and Tertiary Health
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World Bank. 2012b. Death rate, crude (per 1,000 people), Bangladesh 2012. :
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2012)
Bangladesh Health Watch (BHW). 2007. Bangladesh State of Health Report: Health
Workforce in Bangladesh, Who Constitutes the Healthcare System? James P grant
School of Public health, BRAC University, Bangladesh.

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