Towards a pro-poor health system in Bangladesh

Towards a pro-poor health system in Bangladesh
Syed Masud Ahmed

In the words of Nobel laureate Amartya Sen, health, like education, is among the basic necessities that gives value to human life. Better health translates into greater and more equitably distributed wealth by building human and social capital and increasing productivity.

However, it has been found that the cost of healthcare itself can be a cause of poverty in low-income countries through loss of income, astronomical health expenditures, and potentially irreversible crisis coping mechanisms that involve asset and savings depletion.

Studies have shown that, of all the risks that poor households are facing, health risks probably pose the greatest threat to their lives and livelihoods. Unfortunately, health systems are frequently ineffective in reaching the poor, generate less benefit for the poor than the rich, and impose repressive cost burdens on poor households.

The consistently inequitable nature of health systems limits the access to healthcare by the poor who need it the most. Concern was raised recently about attaining the health related Millenium Development Goals (reduce child mortality, improve maternal health, combat HIV/Aids, malaria and other diseases) in low-income countries without improving the ability of health systems to reach the poor effectively.

Society in Bangladesh is characterised by substantial socio-economic differences in health status, health-care access and utilisation and health benefits gained from public and private health expenditures, all disfavouring the poor. The economic consequences of ill health for the poor households, especially the bottom 15-20% are also well documented in Bangladesh.

Cost burdens of healthcare may deter or delay healthcare utilisation or promote use of less effective healthcare sources or practices, particularly by the poor. In the absence of any risk-pooling mechanisms and pre-payments, expenditure on health is mainly met by out-of-pocket payment by the households (> 60%). This mode of payment for health-expenditure is the most repressive one and exposes people, especially the poor and disadvantaged, to great financial risk and makes the health system inequitable.

It has been found that the poor and disadvantaged households with only a few assets are likely to struggle to meet even small extra-budgetary expenses Thus, improving the ability of the health system to reach the poor/disadvantaged populations (groups with diminished capacity to take advantage of opportunities for better health and who are often denied those opportunities, whether due to internal or external factors) is essential to mitigate the income-erosion effect of ill-health and poverty alleviation in Bangladesh.

To maximise this poverty-alleviation effect, health institutions need to be designed according to the needs and priorities of the poor and the disadvantaged. Such a health system allowing access to the poor irrespective of their ability or willingness to pay, and responsive to their needs and priorities is called a "pro-poor" health system. Knowledge and understanding of the existing health-seeking behaviour including its differentials and determinants are required for this to happen.


Recent studies on health-seeking behaviour of the poor and some selected disadvantaged populations (e.g., the women, elderly, ethnic minorities, poor/ultra-poor) have found self-care to be the predominant therapeutic activity (around 30-40%) undertaken by them for managing illness. It is defined as any treatment used without a physician's prescription or direct recommendation by a healthcare professional. Self-care involves risks such as incorrect diagnosis, absence of knowledge of alternative treatments, irrational use of drugs and neglect of side effects and drug interactions.

This is especially important in a population with low literacy level like Bangladesh where self-care is largely uninformed, and there is free availability of "prescription only drugs" in the unlicensed and unregulated drug retail outlets. Enhancement of the people's scope for receiving safe and informed self-care along with the ability to assess services available locally, and evaluation of the costs, are needed. Self-care is regarded by WHO as "a primary public health resource in the health care system." To use this resource to its full potential its integration as an essential, informed and efficient component of the primary health care and as a cost-effective complement to the formal healthcare, is long overdue in Bangladesh.

Self-care is followed by treatment-seeking from unqualified providers (in around 20% of cases) in these studies. By far the single largest group among them is the "unqualified allopaths" who are the sales people in drug retail outlets or drug vendors, with little or no professional training in either the dispensing of drugs or in diagnoses and treatment. Studies from Vietnam, Laos and Nepal found that education and training efforts are necessary but not sufficient to change the practice of irrational and harmful use of drugs by these providers.. In addition, managerial and regulatory interventions are also needed.

The studies also noted a decrease in the use of traditional practitioners (faith healers, kabiraj/totka, and homeopathic) over time in Bangladesh. To avoid losing patients, many of the traditional practitioners also use allopathic medicine to supplement their treatment. Treatment-seeking from MBBS doctors varied from around 10 to 20% only in these studies of health-seeking behaviour.

What is interesting is the fact that a cadre of semi-qualified para-professionals (medical assistants, mid-wives, village doctors, community health workers or CHWs) emerged as the main provider of formal allopathic care to the disadvantaged groups in more than 25% of the cases. CHWs, trained in preventive and basic curative services by the government as well as the NGOs, working at grassroots level are the largest group among these para-professionals.

This cadre of health workers has been increasing in size since the 90s with the expansion of the primary health care infrastructure (government and NGO) in the country. They serve as a bridge between the community and the formal health providers, especially for the disadvantaged populations. Currently, the first-level health facilities at union level (Union Health and Family Welfare Centre) are staffed by the medical assistants and midwives, who are a higher-level cadre of para-professionals than the CHWs. The village doctors (palli chikitshaks) have received some semi-formal training from private institutions, including those trained through a short-lived government sponsored program that ended in 1982. Given the varying degrees of training and expertise of these para-professionals, the quality of care remains a concern.

The overall health service consumption (from any source) in Bangladesh is low compared to other developing countries. Also, the number of qualified physicians and nurses in Bangladesh is quite low, compared to other low-income countries. For example, in 1998 Bangladesh had 19 physicians and 11 nurses per 100,000 population compared to 73 and 132 respectively for low-income countries, and 286 and 750 respectively for high income countries. Around 26% of professional posts in rural areas remain vacant and there is high rate of absenteeism (about 40%), particularly among medical doctors in rural areas. Both shortage of trained manpower coupled with "brain drain," and lack of required investment in health sector are responsible for this.

A recent survey evaluating the performance of the latest Health and Population Sector Programme (1998-2003) noted that it could not fulfil the stated objective of delivering a pro-poor service catering to the needs of the poor. In this context, the importance of para-professionals for healthcare in the rural areas of Bangladesh should be recognised, and their capacity developed to ensure that the poor and the disadvantaged get an acceptable level of care. Empirical evidence shows that human resources for health is important for population health outcomes and presumed to be one of the limiting factors in achieving the MDGs.

The dominant role of a household's socio-economic level in shaping health-seeking behaviour of the disadvantaged groups supports the conviction that improving health is contingent upon reducing poverty. Reducing poverty through specific targeting of the disadvantaged groups with a pro-poor health system in a country with large out-of-pocket payments for healthcare is possible, and is urgently needed in Bangladesh. The above scenario should be kept in perspective while designing such a health care system for Bangladesh.

Syed Masud Ahmed is Research Coordinator, BRAC Research and Evaluation Division. His PhD thesis was on: "Exploring health-seeking behaviour of disadvantaged populations in rural Bangladesh."