EHC-II

Health Care Financing

OVERVIEW
▪ Health Care Financing and UHC
▪ Limitations of the existing health financing mechanisms
▪ Identifying the new health financing options
▪ Essential reforms
▪ Questions to discuss and think about
THREE DIMENSIONS OF UHC
WHAT IS HEALTH FINANCING?
▪ Collection: To collect sufficient revenue in an efficient and
equitable way

▪ Pooling: To pool and channels funds appropriately

▪ Purchasing: To make the best use of resources to maximize

the health benefits
FINANCING OPTIONS
▪ General revenue taxation ✔
▪ Out-of-pocket payment ✔
▪ Insurance
-Private health insurance (individual) ✔
-Private health insurance (group) ✔
-Community based health insurance (CBHI) ✔
-Social health insurance? ×
▪ Medical Savings accounts? ×
▪ DPs contribution✔
HEALTH INSURANCE
HOW DOES INSURANCE WORK
HOW DOES INSURANCE WORK
CONTRIBUTION OF DIFFERENT OPTIONS
AVAILABLE IN BANGLADESH
Source Contribution

General tax revenue 23%

Out-of-pocket payment 67%/73% (World Bank 2019)

Donor 7%

Insurance and others 3%

Total 100%
HOW FAR WE ARE FROM UHC?
▪ UHC requirement of OOP: 30% or less
▪ OOP needs to bring down to BDT 30,500 crore in the
current context
▪ OOP needs to reduce by BDT40,666 crore in the current
context
▪ Optimum per capita THE : $54 (7th five year plan)
▪ Currently optimum per capita THE may be about $65
▪ How much will be optimum per capita THE in 2030: 100?
MORE STATISTICS
Year Health budget as %
of total budget
2010-11 5.86
2011-12 5.03
2012-13 4.86
2013-14 4.97
2014-15 4.81
2015-16 4.30
2016-17 5.2
2017-18 5.0
2019-20 4.72
2020-21 5.15
2021-22 5.42
2022-23 5.43
COMPARATIVE STATISTICS (REGIONAL
VARIATIONS)
SHARE OF MEDICINE COSTS OF OOP
SHARE OF MEDICINE COSTS OF OOP BY
INCOME QUINTILES
CAN YOU NOW FIND THE LIMITATIONS OF HEALTH
FINANCING IN BANGLADESH?
▪ Adequacy of THE ?
▪ Govt. share of THE ?
▪ Budget share of health sector?
▪ OOP share of THE ?
▪ Medicine costs?
▪ Gap between Govt. share and OOP ?
▪ Regulation of private sector?
▪ Role of voluntary health insurance (traditional and CBHI)?
▪ Donors’ contribution?
▪ Contribution of NGOs?
POSSIBLE RESPONSES
▪ Inadequate expenditure on health
▪ Declining of Govt. share of Health Expenditure
▪ Declining of budget share of health sector
▪ Rising of OOP share of THE
▪ Medicine accounts for two-thirds of OOP
▪ Widening of gap between Govt. share and OOP
▪ Unregulated private sector
▪ Negligible role of voluntary health insurance
▪ Reduction of donors’ contribution
▪ Poor contribution of NGOs
BURDEN OF THE HEALTH FINANCING
PROBLEMS?
▪ Majority of the patients sought care from informal providers: about 60%
▪ Low use of Govt. facilities: about 13%
▪ High catastrophic health expenditure: about 13%
▪ High impoverishment impact of OOP:
▪ overall: about 3.4%
▪ NCDs: about 6%
▪ Catastrophic: about 17%
IDENTIFYING THE CAUSES OF THE
PROBLEMS
▪ Underutilization and inefficiency of lower tier govt. facilities
(especially upazila and below)
▪ Lack of adequate fund for risk pooling
▪ Lack of regulation/accreditation of private hospitals
▪ Compromising the spirit of National Drug Policy 1982
▪ Lack of capability of implementing the drug policy by
DGDA
UNDER UTILIZATION AND INEFFICIENCY OF
GOVT. FACILITIES
▪ Huge number of vacant posts of medical and non-medical staff
▪ Inability to retain health staff in rural and hard to reach areas
▪ Lack of fund for smoothening the services (which leads to poor quality of care)
▪ Lack of appropriate input mix (e.g., operation theater without a surgeon)
▪ Lack of appropriate skill mix (e.g., surgeon without a anesthesiologist)
▪ Highly centralized administration
▪ Lack of motivation, sincerity and accountability
▪ Poor responsiveness : prompt attention, dignity, clear communication, autonomy,
confidentiality, quality of basic amenities, and choice of health providers
COMPROMISING THE IMPLEMENTATION
NATIONAL DRUG POLICY
▪ Escalation of drug price
▪ Aggressive marketing by the pharmaceutical companies for promoting non-listed
drugs
▪ Poor quality of drugs leads to prolonging the treatment process
▪ Self- medication and purchase of all types of drugs without any prescription
▪ Continuous proliferation of unlicensed and unregulated drug stores
▪ Irrational prescription of drugs
▪ Self-medication
WHAT’S GOING ON AROUND
UNIVERSITY STUDENTS’ SCHEME BY IHE
DHAKA UNIVERSITY STUDENTS’ SCHEME
▪ Financial protection of the students from treatment expenses
▪ Practical experience of the benefits of the health insurance
▪ Rising positive perception about insurance
▪ Making the students as insurance advocate
Expectations
▪ All the students of other public and private universities will come under health
insurance coverage by 2030
Key features
❑Compulsory for all students of the university
❑Premium BDT 270 annually per student (solely shared by the student)
❑ Hospitalization coverage: BDT 50,000
❑OPD coverage: BDT 10,000
❑Life coverage: BDT 1,00,000

Details: https://ssl.du.ac.bd/fontView/images/file/1636972046Circular.pdf
SSK
SOME SCHEMES IN THE PIPELINE
▪ Compulsory contributory civil service scheme
▪ Health protection scheme for Tea Garden workers
▪ Financing kidney and cancer treatment through imposing levy on mobile phone
subscribers
▪ Some potential schemes
▪ Pension and social security beneficiaries
▪ Transport workers
▪ Other large organized groups/associations
WHAT REFORMS ARE ESSENTIAL?
▪ Need based budgeting
▪ Fiscal autonomy of public hospitals to retain reimbursement from insurer
▪ Enactment of National Health Security Office
▪ Amending Private Clinics and Diagnostic Centers Ordinance 1984
▪ Accreditation of private hospitals
▪ Strategic purchasing
▪ Purchaser-provider split
▪ Establishing functional referral system
WHAT ELSE COULD BE THOUGHT?
▪ Making functional of public facilities through
▪ increasing efficiency of budget use
▪ filling up the vacant posts
▪ reducing skill-mix and input-mix problems
▪ enhancing the managerial skills of the hospital managers through regular training
▪ give responsibility of MOHFW to the trained medical professional like Sri Lanka
▪ keeping medical profession outside BCS
▪ Institutional private practice in Medical College Hospitals and District Hospitals
using safety net for the poor using equity fund
QUESTIONS
▪ What are the key health financing problems for UHC in Bangladesh?
▪ Why is budgetary allocation for health not increased and how can it be increased?
▪ What are the ways for improving efficiency in use resource use?
▪ Should we re-think about user fees option with adequate safety net to the poor?
▪ Should we introduce health insurance for selected chronic illness?
▪ What about introducing private practice in public facilities?