Policy paper on Universal Health Coverage in Bangladesh

Analysis through the framework of Alford's theory of structural interests in health care

Presented by
Syed Rashedul Hossen, ID: 6320131003
September 28, 2021
 Universal Health Coverage
For a community or country to achieve universal health coverage, several factors must be in
place, including:
A strong, efficient, well-run health system that meets priority health needs through people-
centered integrated care (including services for HIV, tuberculosis, malaria, no communicable
diseases, maternal and child health) by:
 informing and encouraging people to stay healthy and prevent illness;
 detecting health conditions early;
 having the capacity to treat disease; and
 helping patients with rehabilitation.
Affordability – a system for financing health services so people do not suffer financial
hardship when using them. This can be achieved in a variety of ways.
Access to essential medicines and technologies to diagnose and treat medical problems.
A sufficient capacity of well-trained, motivated health workers to provide the services to
meet patients’ needs based on the best available evidence.
What is Universal Coverage?

Universal coverage (UC), or universal health coverage (UHC), is defined as ensuring that all
people can use the promotive, preventive, curative, rehabilitative and palliative health services they
need, of sufficient quality to be effective, while also ensuring that the use of these services does not
expose the user to financial hardship.
This definition of UC embodies three related objectives:
 equity in access to health services - those who need the services should get them, not only those
who can pay for them;
 that the quality of health services is good enough to improve the health of those receiving
services; and
 financial-risk protection - ensuring that the cost of using care does not put people at risk of
financial hardship.
Universal coverage brings the hope of better health and protection from poverty for hundreds of
millions of people - especially those in the most vulnerable situations.
Universal coverage is firmly based on the WHO constitution of 1948 declaring health a
fundamental human right and on the Health for All agenda set by the Alma ‑Ata declaration in
1978.
Recent History of implementing UHC

From the 1970s to the 2000s, Southern and Western European countries began
introducing universal coverage, most of them building upon previous health insurance
programs to cover the whole population. For example, France built upon its 1928 national
health insurance system with subsequent legislation covering a larger and larger
percentage of the population, until the remaining 1% of the population that was uninsured
received coverage in 2000. In addition, universal health coverage was introduced in
some Asian countries, including South Korea (1989), Taiwan (1995), Israel (1995), and 
Thailand (2001).
Following the collapse of the Soviet Union, Russia retained and reformed its universal
health care system, as did other former Soviet nations and Eastern bloc countries.
Beyond the 1990s, many countries in Latin America, the Caribbean, Africa, and the 
Asia-Pacific region, including developing countries, took steps to bring their populations
under universal health coverage. A 2012 study examined progress being made by these
countries, focusing on nine in particular: Ghana, Rwanda, Nigeria, Mali, Kenya, India,
Indonesia, the Philippines, and Vietnam.
The policy Goal of Universal Health
Coverage
First, securing access to health services is motivated by the individual benefits
from service utilization.
These improvements in health can be seen as an end in themselves as well as
crucial to overall well-being and the related concepts of capabilities and
opportunities.

Health can affect overall well-being directly and indirectly, for example,
through income and wealth.

Health can also be seen as of great importance due to its impact on people’s
range of opportunities—such as their ability to work or pursue an education—
or the range of life plans open to them.
The Scope of Universal Health
Coverage policy

UHC must be understood in a comprehensive way.

More specifically, the goal of UHC calls for quality
services of many kinds, for strengthening the entire health
system, and for intersectoral action.
Inequalities in health and inequalities in service coverage
are often correlated, so that coverage is the least where
needs are the greatest. These inequalities and the variation
in country capacity to address health needs raise number
of important other policy issues.
Figure 1.1: Three dimensions to consider when
moving towards Universal Health Coverage
Figure adapted from the World Health Report 2010
 Dimensions of Progress and Critical Choices
(contd.)

Dimensions of progress Critical Choice

Expanding priority Which services to expand
services first?
Including more people Whom to include first?
How to shift from out-of-
Reducing out-of-pocket
pocket payment toward
payments
prepayment?
Box 1.1: Critical dimensions and choices on the path
to universal health coverage
Including more people
Progress toward UHC can be sought by including more
people. To do so, Bangladesh must seek to reduce all
barriers to effective coverage.
Among these barriers are prohibitive payments for services
and other financial barriers and many nonfinancial barriers.
The latter include legal, organizational, technological,
informational, geographic, and cultural barriers.
Since these barriers cannot be eliminated for everyone
immediately, countries are faced with the following choice:
Whom to include first?
Reducing out-of-pocket payments
Progress toward UHC can be sought by
reducing out-of-pocket payments while
increasing mandatory prepayment, for
example, in the form of taxes or premiums.
When doing so, Bangladesh may face with the
following choice: How to shift from out-of-
pocket payment toward prepayment?
The Context of Choice
Numerous actors influence the progress toward UHC. These actors are institutions,
groups, and individuals, within and outside government, locally, nationally, and
internationally.
Their choices are shaped by multiple considerations, which include economic and
political circumstances and the actors’ economic and political interests as well as their
ideals.
Central among these ideals are those related to fair and equitable distribution of
benefits and burdens in society. This policy paper addresses issues of fairness and
equity arising on the path to UHC.
For all actors affecting that path, it is crucial to be keenly aware of these issues and to
make the accompanying decisions with care.
Central among these actors are obviously health workers. This paper, however,
mainly addresses the choice situations relevant for governments in charge of
overseeing and guiding the progress toward UHC.
Strong Health Systems for UHC
 UHC emphasizes not only what services are covered, but also how
they are covered through focusing on people-centered health care and
integration of care. A shift in health service delivery is necessary to
better tailor services to the individuals of the population they serve.
Health systems should be organized around the needs and expectations
of people in terms of holistic long-term health to help them better
understand their own health-care needs.
 Integrated health services mean a delivery that enables people to
receive a continuum of health promotion, disease prevention,
diagnosis, treatment, disease-management, rehabilitation and palliative
care services, through the different levels and sites of care within the
health system over the course of a lifetime. Members of a community
are then better equipped to take preventative measures on their own
creating cost-saving efficiency in the long term.
Benefits of Implementing UHC
 UHC maintains and improves health. Good health
allows children to learn and adults to earn. This helps
people escape from poverty and provides the basis for
long-term economic development.
 At the same time, financial risk protection in health
prevents people from being pushed into poverty
because unexpected illness requires them to use up
their life savings, sell assets, or borrow – destroying
their futures and often those of their children.
Can progress be monitored?
 Monitoring progress towards UHC should focus on both coverage of the
population with essential quality health services and on financial
protection against catastrophic out-of-pocket health payments. Special
attention should be given to the most disadvantaged population groups,
such as the poorest individuals or those living in remote rural areas.
 Monitoring should be placed within a broader health systems performance
framework which allows health workers, medicines, technologies to be
tracked, and impacts on health and financial security to be measured.
 It is important for countries to measure their progress towards UHC. Given
each unique country-specific context the measuring indicators may be
focused on different areas. There is also value in a global framework for
monitoring UHC that uses standardized measures that are internationally
recognized so that they are comparable across borders and over time.
Inequality in Bangladesh

 Equity in health is one of the central pillars in promoting social justice

and improved health of the population.
According to the International Society for Equity in Health, “Equity is
the absence of systematic and potentially remediable differences in one or
more aspects of health across populations or population groups defined
socially, economically, demographically, or geographically” (Starfield,
2002).
Equality in health services is based on the principle that everyone has an
equal right to access health services.
 Equity takes it one step further and addresses the fact that some groups
within each society have less access to health services than others, and
that steps should be taken to address this differential. Achieving equity in
a health program means successfully reaching those people that are
Inequality in Bangladesh
Out of pocket (OOP) payments are one of the most
inequitable sources of healthcare financing. Only 23%
of the total health expenditure comes from the
Government.
Total per capita expenditure on health is only $37 and
this figure includes government, donor and household
contributions.
OOP contributions to health expenditure in Bangladesh
are among the highest in the world with 67% of health
expenditure coming from households (Government of
Bangladesh, 2017).
Policy scan
 In order to address inequities and foster UHC, the GoB has
taken these policy initiatives. Besides, various multilateral
organizations, civil society consortia, and academic and research
organizations based in Bangladesh are aligned with policy
directives for UHC in Bangladesh.
 This UHC policy acknowledged the importance of bringing more
funds to the health sector and pooling the resources effectively.
 It summarized challenges of health financing in Bangladesh as:
1. Inadequate health financing; 2. Inequity in health financing
and utilization; and 3. Inefficient use of existing resources and
designed to address the health financing issues for the next 20
years.
Policy scan
 This policy also proposed ways to combine funds from tax-based budgets with
proposed social health protection schemes (including for the poor and the formal
sector), existing community based and other pre-payment schemes and donor funding to
ensure financial protection against health expenditures for all segments of the population,
starting with the poorest.
 It recognized the importance of and proposed collaboration with the for-profit and not-
for-profit private sector, development partners, and the community people; to resolve
the health financing challenges.
 It proposed a gradual process to achieve universal coverage, starting from the poor and
the formal sector (public, for-profit private, and not-for-profit private), progressively to
remaining segments of the population by 2032.
 It proposed three strategic objectives: 1. Generate more resources for effective health
services; 2. Improve equity and increase healthcare access, especially for the poor and the
vulnerable; and 3. Enhance efficiency in resource allocation and utilization.
 It proposed three strategic interventions and supportive actions: 1. Design and
implement a Social Health Protection Scheme; 2. Strengthen financing and provision of
public healthcare services; and 3. Strengthen national capacity
Stakeholders of the UHC Policy in
Bangladesh

Public Sector
Private Sector
NGO Sector
Academia and Research
Media
International development partners
Barriers to implementing UHC policy
The barriers to progress towards UHC can be felt at different levels. I
categorized the barriers in three levels, which are again crosscut by one
important barrier, the lack of a shared understanding on UHC. The three
levels are:

 1. Larger policy-level barriers, often beyond the jurisdiction of health

sector alone;

 2. Implementation barriers in health sector; and

 3. Demand-side barriers
Large policy-level barriers
 Public finance management has been designed such that, only health sector finance is very
difficult to alter separately. Ministry of Finance needs to change all its mechanisms and
rules of procedures for all other ministries, if it wants to do something for one
particular ministry. Bangladesh has traditionally been practicing supply-side budgeting;
changing which is complicated, has crosscutting ramifications, and therefore, demands
much broader or revolutionary commitment for whole system change.
 In tandem with the increase in economic activities in people’s lives, the size of the
economy is increasing. Since the purchasing power of people are increasing, their health
seeking behaviour is changing consequently, culminating in higher healthcare cost.
 Apart from the financial issues, there is deficiency in health systems governance and
stewardship. Accountability and transparency is difficult to ensure in public sector,
especially in the presence of a highly centralized system.
 Even in the private sector, a proper regulatory mechanism is missing. There is currently
no such structure for functional mediatory mechanism, to resolve or mediate the
complaints of the service seekers. Unqualified providers often continue harmful medical
practices, capitalizing loopholes in the regulatory framework and its implementation.
Implementation barriers in health sector
 Poor human resource management, including shortages, deficient
training, low motivation, failure in retention, skill-mix imbalance,
quality service provision, etc. are staggering. Recruitment mechanisms
by Bangladesh Civil Service (BCS) are also criticized for taking too
long to deploy physicians to the vacant posts in time. Political
interference is often adding insult to injury, as recruitment, retention,
and disciplinary measures become difficult for the managers to exercise.
 Deficient monitoring mechanisms often exacerbate the shortage of
human resources, as the existing service providers cannot be ensured to
stay in their posted positions. There is no agreed-upon protocol for
treatment, referral, follow-up, and even general service management. As
a result, uniform care with sufficient quality is difficult to provide.
 Identifying and reaching the hard-to-reach areas and population is
another challenge to achieve.
Demand side barriers

 Due to the pervasive lack of societal trust, coupled with

lack of historical precedence to insurance mechanisms,
it is difficult to convince people to give their money to a
pooled fund.
 Another historically established perception among the
people is that, the government is solely responsible for
health, and that must be free of cost.
 People are not receptive to the idea of paying for
government healthcare, be it in the form of prepayment or
otherwise.
 Lack of information on the available services is another
demand side barrier to UHC. Communities also lack
awareness regarding their own entitlements. They are not
empowered enough to hold the decision makers and
Policy interventions to achieve UHC in
Bangladesh
 Redesigned the public finance
 Improve governance and regulatory mechanism
 Code of conduct for service provider
 Health insurance and health financing reform
 Inter-sectoral collaboration
 Decentralization
 Special attention to hard-to-reach areas and marginalized
populations.
 Political commitment
 Health systems strengthening
 Research and advocacy
Policy interventions to achieve UHC in Bangladesh: Centralization vs Decentralization
Analysis through the framework of Alford's theory
of structural interests in health care
 Alford’s Theory of Structural Interests in Health Care Alford (1975) views the total health
care system as a network involving different structural interests. His theory of structural
interests determines which group within the structure is powerful and to what extent and
what is the interest of particular groups within the health service structure and how they
are interdependent with each other.
 By using the term ‘structural interests’ he means the interests that gain or lose from the
form of organisation of health services. In this regard, he identifies three different types
of structural interests termed as dominant interests, challenging interests and repressed
interests.
 A. Dominant Interests Alford (1975) has portrayed the interests of the
medical profession as the ‘dominant structural interest’ in health care policy.
Alford argues that the medical profession is in a dominant, exclusive and
monopolistic position within the health sector.
 He states that professional autonomy is represented by a diverse nature of
professionals involving physicians in private or group practice, salaried
physicians, and those in other health occupations holding or seeking
professional privileges and status. Amongst all these groups ‘physicians are the
most important interest group representing professional monopoly’ . All of
these groups have different interests and are related to the health system in
Analysis through the framework of Alford's theory
of structural interests in health care
 Existing socio-political institutions provide the source of power to the
professionals. Thus the professional monopoly derives from the society
and state policy rather than their interest group organisation. All these
reasons explain why, as long ago as 1975, Alford identified doctors as
the dominant interests.
 B. Challenging Interests: Professionals exercise autonomy and
dominance within an institutional set-up which in turn challenges their
power. Alford argues, ‘the changing technology and division of labour
in health care production and distribution and the shifting rewards to
social groups and classes are creating new structural interests which I
label corporate rationalization’. The structure within which
professionals function is termed by Alford as ‘corporations’. By its
definition, ‘corporation’ refers to ‘a group of people producing goods
and services under clearly defined legal structures’ (Wohl, 1984.
According to Alford, health service is produced and managed by large
scale organizations or corporations like hospitals, medical schools
and public health agencies at all governmental levels and health
Analysis through the framework of Alford's theory
of structural interests in health care
 C. Repressed Interests Alford has termed the ‘repressed interests’ as ‘negative
structural interests’, ‘because no social institutions or political mechanisms in
the society insure that these interests are served’. Repressed interests are
heterogeneous with respect to their health needs, ability to pay, and ability to
organise their needs into effective demands. Interests of the community
population are portrayed as ‘repressed interests’ as they are not organised as are
the other interest groups. Although they are not organized, they share a
common interest ‘in maximising the responsiveness of health professionals and
organisations to their concerns for accessible high quality health care’. Access
of this group to the health services is also restricted.
 This is the central thesis of Alford. Alford’s theory encompasses almost all the
key interest groups influencing the health care system. This theory provides an
understanding of the changing balance of influence within the policy network
through examining to what extent are the professional monopolizers under
challenge, by whom and to what effect, whether the corporate rationalizers
challenge them on particular issues or at particular periods; and how far the
community interests remain repressed. Thus Alford identified three distinct
structural interests in health care but he cautioned against overemphasizing the
difference between the dominant and challenging interests as both of them are
Relevance of Alford’s framework of structural
interests in achieving UHC
Alford’s theory has three major limitations when
apply in the context of Bangladesh.
Firstly Bangladesh has centralized political
structure so decision making is highly
centralized.
Secondly professionals are mostly in
government sector and accountable to the higher
government authority, instead of local level
managers.
Thirdly resource scarcity and incapacity of
government induced the two other policy actors,
one is mushrooming NGOs and ungoverned
Relevance of Alford’s framework of structural
interests in achieving UHC
 Given these differences of policy contexts of Bangladesh, it is seen
that theories derived from the studies of industrially developed
countries can not be instantly applied for studying the health policies
of developing countries like Bangladesh due to different contextual
environment.
 But it can be argued that it would not be useful to apply this theory
to the case of Bangladesh without a factual study of the Bangladeshi
system.
 Varieties of socio-political and economic forces peculiar to every
single country shape a specific nature of policy context which in
turn, produces a different kind of health policy.
 As a result, although Alford’s theory as well as other theories of
policy making derived from the studies of developed countries can
provide the basis of a systematic analysis of the health policy of a
developing country like Bangladesh, they can not be utilised directly
without an empirical study of the Bangladeshi system.
 So in case of UHC policy also needs to consider those unique