AM Zakir Hussain
THE latest Bangladesh Bureau of Statistics data on poverty estimation, which dates back 2016, noted that 24.3 per cent of people live below the poverty line and 12.9 per cent in extreme poverty. COVID-19 has largely pauperised the whole world. Even in the United States, about 40 million people have lost their job. In Bangladesh, no estimation has been done yet, but it is perceived that a sizeable number of people will be without job and small-time sellers will be severely struggling to to feed their families.
According to the latest data of the Health Economics Unit of the health and family welfare ministry, about 68 per cent of people buy health care out of their pocket and about 80 per cent of the expenses is spent on medicine and diagnostics. Of the 3 per cent of the GDP, being expended on health care, only about 1 per cent is allocated by the government. The out-of-pocket expenditure, therefore, accounts for the remaining 2 per cent of the GDP spent on health care. It does not need much of exploration and analysis to understand that a sizeable percentage of the people who bought healthcare services in the past will be unable to do so in several years to come.
This means that the government will have to bear the cost of medicine and diagnostics for these people who have already lost the capacity to buy the services. As the exact number or percentage of these people is not known as yet, we suggest that the 24.3 per cent, living below the poverty line, should get the services free. The poor going below the poverty line usually happens because of non-communicable diseases and about 60 per cent of the death in the country is caused by these diseases. Surveys in Bangladesh estimated that about 23 per cent of the people die of heart and blood-vessel related diseases, 10 per cent from injuries, 7 per cent of cancer, 5 per cent of chronic respiratory diseases, 1 per cent of diabetes, and 5 per cent of other chronic diseases, including mental health.
Applying these estimates to the 24.3 per cent of the people who live below poverty line who might require free medical care, the estimates would be 5.6 per cent, 2.43 per cent, 1.7 per cent, 1.2 per cent, 0.24 per cent and 1.2 per cent of the people who would require support for such medical conditions. In absolute terms, the number of people who would require free medicine and diagnostic services would be: 95,20,000; 41,31,000; 28,90,000; 20,40,000; 4,08,000; 20,40,000 for heart and blood-vessel related diseases, injuries, cancer, chronic respiratory diseases, diabetes and other chronic diseases, including mental health. It may be argued that many people die from injuries instantly and some suffer from long-lasting impact. If three-fourths of the injured people suffer from the long-lasting impact, the number of the people who would require help could, in fact, be 30,98,250.
How much money will be required for such patients has to be estimated based on the market price for diagnostic services and medicines related to these diseases. It may be argued as to why the death rate was considered for estimating the budget. First, death estimates are usually much more valid than prevalence estimates and, second, those who die suffer from the diseases for an extended period before death except for injuries. It is true that more people suffer from these diseases for long periods than those who die. But we can infer that those who die are the ones who cannot take care of themselves on their own. The caveat in all this is, however, that the targeted population should get these services adequately and free. This caveat will no longer be there if those who can afford to buy health care snatch some share from these allocations. Local political system has to prevent this.
The other area of expenditure would be communicable diseases, maternal and perinatal care, including child birth and neonatal care, and nutritional deficiencies, estimated to be 46 per cent in aggregate. Expenditure on these services is mostly preventive and promotive in nature, eg, child marriage, ante- and post-natal care, child delivery and newborn care, vaccination, etc topped up by social and behavioural change communication. For communicable diseases, diagnostic and medical services would be required but these usually do not need as much as for non-communicable diseases.
If we estimate that at any time 10 per cent of the families would have members suffering from communicable diseases than the poverty-line population would be 2.43 per cent or more than four million people. They would require free medicines and some diagnostic services. But as the communicable diseases are of very different types and many of which are viral in origin, without any specific treatment other than symptomatic treatment, an average amount based on the total budget would have to be developed. As of now, there is no information on these parameters. Health care needs in this group would be mostly logistics and human resource-based. Required logistics would be micronutrients and protein supplementation, besides machines and equipment for perinatal care, vaccination and for health communication.
Health facilities at different levels suffer from the shortage of equipment and machines. The reason is not well understood always. Two clear pictures can be seen. One is indifference of the local management in installing and using the available logistics lying in the stores for long. The other is clandestine attempts to damage the available logistics or non-replenishment of used-up or stock-out materials to compel and induce service seekers to seek care in local private health facilities. Health facilities readiness surveys have time and again found that district hospitals and community clinics suffer from a shortage of the required logistics. Budget should be allocated to sensitise the local health service improvement committees or the like to monitor the use of the equipment and machines.
Budget for supervision, monitoring, mobility, repair and maintenance of equipment, machine and vehicles is always inadequate and so is it for research and survey. We suggest that 15 per cent of the allocation is spent on monitoring and 15 per cent on repairs and maintenance. Skills enhancement and capacity building activities need strong monitoring while quality care assurance needs a good supervision by trained and supportive supervisors. Skills development in planning, budgeting and managing personnel and budget is imperative. Budget should prioritise these areas and allocate adequate fund. Transparency in the health sector has become a burning issue now. It will be naive to think that lower level officials are prime movers or approvers. This will not be difficult if policymakers are keen on stopping this. We recommend the establishment of several bodies in the health sector. One is for ‘knowledge management’ and one for monitoring capacity building, focusing on training, workshop and orientation, etc. These bodies may be set up at the ministry and the directorate levels to ensure that need-based research/survey and capacity-building activities are conducted and that research findings are used in management and policy decision and an effective capacity building takes place.
On an average 42.2 per cent of the health budget is spent on human resources globally, with a 16 per cent standard deviation. In the Eastern Mediterranean, it is about 51 per cent and in the Americas, it is about 50 per cent. In Europe, 42 per cent of the health budged is expended on human resources for health while in the South Asia it is 35.5 per cent. When the remuneration of private and government health workers is estimated in percentage of the total expenditure on health, it stands at a much higher rate — in Europe, it is 73 per cent; in the Western Pacific, the amount is 60 per cent while the global average is slightly more than 49 per cent.
The health sector in Bangladesh suffers from inadequacy of human resources. The World Health Organisation says that the ratio of healthcare providers to the population should be 2.3 for 1,000 people, if 80 per cent coverage of maternal and child health care is intended. The ratio of health care providers by category, according to WHO, should be 1:2:5 for physicians, nurses and paramedics. In this light, Bangladesh needs 130,333 physicians, 260,667 nurses and 651,665 paramedics of different disciplines. Policymakers in the health sector would have difficulty to stomach this need.
What about the need for critical care? COVID-19 has bared the capacity of the health sector of Bangladesh to deal with novel coronavirus outbreak and. Oxygen, in general, and intensive care units in hospitals, in particular, are glaringly in short supply. The European Union possesses 11.5 ICU beds per 100,000 people. According to that standard, Bangladesh should need 19,550 ICUs. In the European Union, 91 per cent of death is due to non-communicable diseases and in Bangladesh, this is about 60 per cent.
A simple arithmetic would put the need for ICUs in Bangladesh to 12,890, against the availability of about 1,000, including ICUs in the private sector. We believe that the availability of ICUs could reduce the number of death taking place because of the non-availability of ICUs, which could also increase the life expectancy of people in Bangladesh by about two years, taking it to 75 years, conjecturally speaking. The professionals that are needed in ICUs are one intensivist per 10 ICU beds and one ICU-trained nurse per two beds. For 12,890 ICU beds, we, therefore, have to foot a bill for 1,289 intensivists, who should be at the level of an assistant professor. The number of ICU nurses should be 6,445 at the level of senior nurses.
For surgical care, we need one specialist for six beds on an average. The World Health Organisation suggests one physician for 1,320 people, which includes all sorts of physicians. This means 128,788 physicians for Bangladesh. The category-wise requirements of physicians, including specialists, have never been estimated in Bangladesh. Unless an analysis is done, it will be difficult to estimate the needs of physicians by type/category.
The other priority in the health sector is the physical facilities, ie hospitals and clinics. COVID-19 has exposed that almost no hospital in the country has negative pressure cabins/rooms. Designs of the health facilities are also not patient-friendly. They do not have good cafeteria or laundry facilities for patients’ attendants, club houses for them and convenient toilets for the elderly and physically debilitated. Ventilation and natural lighting systems need good fittings. Waiting rooms are nauseating. All these point to the necessity of redesigning and retrograde-refurbishing of the existing health care facilities. Besides, the number of hospital beds is too few in the country. The WHO standard is five for 1,000 people while the country has less than one.
All the above budget lines can and should absorb a huge investment in the health sector, but, unfortunately, the budget for the 2021 financial year propsoed on Thursday follows an historical trend — a 10 per cent increase from the previous year on the existing budget lines without developing the budget based on some needs assessment. There is no history in Bangladesh that budgets have been preceded with survey/research to get necessary information for developing policy, planning and budgeting.
The prioritisation of budget heads, keeping to the discussion, would absorb more than the government can allocate, provided transparency and management skills are ensured in the sector. The accusation that the health sector cannot absorb allocated budget should squarely fall on the shoulder of the policymakers and planners across all relevant sectors who have hardly showed willingness to go by the prioritised needs in the health sector. Lastly, one care provider cannot discharge the responsibility of three. It will be meaningless to blame them for failing to provide quality care.
AM Zakir Hussain is working group member of the Bangladesh Health Watch (BHW) and former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO and former staff consultant, Asian Development Bank, Bangladesh.
