Path to Transform Bangladesh's Health System for Better Results 1 © 2024 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Examples of components can include, but are not limited to, Tables, Figures, or images. 3 CONTENTS Acknowledgements................................................................................................. 5 Abbreviations ................................................................................................................................... 6 Boxes .............................................................................................................................................. 11 Figures ............................................................................................................................................ 12 Tables ............................................................................................................................................. 13 Executive Summary........................................................................................................................ 14 Chapter 1: Introduction and setting the scene .............................................................................. 18 Chapter 2: Strengthening equity in the health sector ................................................................... 24 Chapter 3: Making health expenditures more efficient ................................................................ 38 Chapter 4: Strengthening primary health care to address a growing non-communicable disease burden ............................................................................................................................................ 51 Chapter 5: Ensuring health services in urban areas....................................................................... 59 Chapter 6: Building on key gains in nutrition outcomes................................................................ 68 Chapter 7: Catalyzing development of the private health sector ................................................. 76 Chapter 8: Improving quality, availability, and affordability in the pharmaceutical sector .......... 85 Chapter 9: Transforming and integrating digital health to improve service delivery.................... 92 Chapter 10: Equipping the health sector to address climate change impacts on health ............ 100 Chapter 11: Breaking the cycle of panic and neglect for pandemic prevention, preparedness, and response....................................................................................................................................... 110 Chapter 12: High-level changes to transform the health sector ................................................. 118 Appendix I: Scenario Planning for Bangladesh ............................................................................ 123 Appendix II: Health Sector at a Glance ........................................................................................ 133 4 Acknowledgements This report was prepared under the Advisory Service and Analytics, “Health, Nutrition and Population (HNP) Service Delivery (P169452).” This activity was coordinated by Atia Hossain, Senior Economist (Health), and supervised by Feng Zhao, Practice Manager of the HNP Global Practice, South Asia Region, and Mickey Chopra, Lead Health Specialist, Global Engagement, HNP Global Practice. Zhao provided intellectual leadership in the conceptualization of the report. World Bank authors and contributors included Bushra Binte Alam, Tahmina Begum, Deepika Chaudhery, Mickey Chopra, Alethea Cook, Aissatou Diack, Syed Abdul Hamid, Sabrina Sharmin Haque, Atia Hossain, Matthew Hulse, Sneha Kanneganti, Aneire Khan, Nondini Lopa, Iffat Mahmud, Rianna Mohammed- Roberts, Asib Nasim, Munirat Ogunlayi, Mohammad Rafi, Sayedur Rahman, Wameq Azfar Raza, Abdus Sabur, Zara Shubber, Mengxiao Wang, and Shiyong Wang. In addition, Professor Igor Rudan and Dr. Davies Adeloye, on behalf of the International Society of Global Health, provided important analysis of the health sector and projections about national and global trends that could impact Bangladesh to inform this report. The team is also grateful for contributions from external experts including Dr. Khairul Islam South Asia Regional Director, WaterAid; Md Sayedur Rahman, Chairman, Department of Pharmacology, Bangabandhu Sheikh Mujib Medical University; Dr. Shafiqul Islam, Health Advisor, UKAid; Syed A. Hamid, Professor at the Institute of Health Economics, University of Dhaka, and Dr. Tim Grants Evans, Inaugural Director and Associate Dean of the School of Population and Global Health (SPGH) in the Faculty of Medicine and Associate Vice-Principal (Global Policy and Innovation), McGill University. We acknowledge the helpful feedback received on report drafts from the HNP leadership team and colleagues. The team also thanks Ann Jaime Banks and Karen Schneider for their skillful editing of the report and Team Associate Tasfia Kamal for her coordination and logistics support. 5 Abbreviations AAR After-action Review ADB Asian Development Bank ADR Adverse drug reaction AI Artificial intelligence AMR Antimicrobial resistance ANC Antenatal care API Active pharmaceutical ingredients ARI Acute respiratory infections BDHS Bangladesh Demographic and Health Survey BMD Bangladesh Meteorological Department BMI Body Mass Index BNHA Bangladesh National Health Accounts BRAC Bangladesh Rural Advancement Committee CC Community clinic CHE Catastrophic health expenditure CHCP Community health care provider CHW Community health worker CMSD Central Medical Stores Depot CSO Civil society organization CSR Corporate social responsibility DALY Disability-adjusted life year DGDA Directorate General of Drug Administration DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DHIS-2 District Health Information System 2 eAMS Electronic Asset Management System 6 EDCL Essential Drug Company Limited EID Emerging infectious disease eMIS Electronic Management Information System EML Essential Medicines List EMR Electronic medical records EPI Expanded Program on Immunization ESP Essential Services Package FP Family planning FYP Five-Year Plan GAIN Global Alliance for Improved Nutrition GAVI Global Alliance for Vaccines and Immunization GDP Gross domestic product GHSI Global Health Security Index GMP Good Manufacturing Practice GoB Government of Bangladesh GoD Government Outdoor Dispensary GRB Gender-responsive budgeting HDS Health Development Surcharge HEU Health Economic Unit HIES Household Income and Expenditure Survey HIS Health information system HMIS Health management information system HNP Health, nutrition, and population HNPSP Health, Nutrition, and Population Sector Program HPNSDP Health, Population and Nutrition Sector Development Program HPSP Health Population Sector Program HRH Human resources for health 7 HSSP Health Sector Support Project ICT Information and communication technology ICU Intensive care unit IEDCR Institute of Epidemiology, Disease Control, and Research IFYC Infant and young child iHRIS Integrated Human Resource Information System IHR International Health Regulations IPC Infection, prevention, and control IRP International Reference Prices JEE Joint External Evaluation LDS Least Developed Countries LGD Local government division LGI Local government institution LMIC Lower-middle-income country MICS Multiple Indicator Cluster Survey MNCH Maternal, neonatal, and child health MoHFW Ministry of Health and Family Welfare MoLGRD&C Ministry of Local Government, Rural Development, and Co-operatives MPR Median price ratio NCD Non-communicable disease NGO Non-governmental organization NIPORT National Institute of Population Research and Training OH One Health OHZDP One Health Zoonotic Disease Prioritization OOP Out-of-pocket OP Operational plan PFM Public financial management 8 PFP Private for-profit PHC Primary health care PHEOC Public Health Emergency Operation Center PMTI Private medical training institution PNC Post-natal care PNFP Private not-for-profit PPD Public-private dialogue PPE Personal protective equipment PPP Public-private partnership PPPA Public Private Partnership Authority PPR Prevention, preparedness, and response RRT Rapid response team SAR South Asia Region SBCC Social and behavior change communication SDG Sustainable Development Goal SHN Shurjer Hashi Network SHR Shared Health Record SIP Strategic Investment Plan SPAR States Parties Self-Assessment Annual Report STAR Strategic Tool for Assessing Risks SWAp Sector-wide approach THE Total health expenditure TFR Total fertility rate TRIPS Trade-related Intellectual Property Rights TWG Technical Working Group UHC Universal health coverage UMIC Upper-middle-income country 9 UPHPC Urban Primary Health Care Project USAID United States Agency for International Development WASH Water, sanitation, and hygiene WHO World Health Organization WTO World Trade Organization 10 Boxes Box 3.1: Wastage from unused medical equipment Box 6.1: Urban context 11 Figures Figure 2.1 Factors affecting quality of care, by facility type (in percentage) Figure 2.2 Facility-level maternal deliveries Figure 2.3 Population per community clinic by division Figure 3.1 Spending as percentage of GDP Figure 3.2 MoHFW budget as percentage of Bangladesh’s national budget, FY2011-FY2024 Figure 3.3 Share of development partner financing Figure 4.1 Hypertension care cascade for adults age 18 and older in Bangladesh, 2017-2018 Figure 4.2 Diabetes care cascade for adults age 18 and older in Bangladesh, 2017-2018 Figure 5.1 Dengue cases and related deaths in Bangladesh: January 2000 to October 2023 Figure 5.2 Dengue cases and related deaths in 2019, % of total Figure 6.1 Trends in nutritional status of children under age 5 Figure B6.1.1 Spatial heterogeneity of malnutrition Figure B6.1.2 Spatial heterogeneity in service utilization Figure 6.2 Trends in breastfeeding practices Figure 6.3 Trends in key complementary feeding practices Figure 6.4 Trends in underlying determinants of malnutrition Figure 7.1 Distribution of public and private facilities by region and facility level Figure 10.1 Pathways by which climate change affects human health Figure 11.1 Impact of COVID-19 on outpatient consultation in Bangladesh, 2020 to 2021 12 Tables Table 1.1 Framework for determinants of transformation in the health sector Table 3.1 Health spending by source, 1997 and 2020 Table 11.1: Priority infectious diseases in Bangladesh Table 11.2: Key Lessons Learned from the COVID-19 Response in the WHO South-East Asia Region, 2022 13 Executive summary Over the past decade, under the astute leadership of the Government of Bangladesh (GoB), the country has made impressive strides in enhancing the health and well-being of its people. The remarkable gains include a notable surge in life expectancy and a significant reduction in maternal mortality rates—a testament to Bangladesh's commitment to fostering a healthier future for all. The GoB’s maternal and child health programs showcase a comprehensive approach to public health, with immunization drives and family planning initiatives serving as models for other health challenges. Disease control efforts, such as those targeting tuberculosis and malaria, and the eradication of polio, leprosy, and Kala-azar highlight the effectiveness of targeted interventions and strategic planning. Central to this progress is the commitment of the Bangladeshi people, particularly women, to healthy and prosperous families, supported by the GoB's clear vision, incremental budget increases, and strategic policy initiatives, recognizing health as fundamental to national development. As Bangladesh works to achieve its ambition of becoming an upper-middle-class country, improving the health of its people will be key to success. To do so, it must anticipate and address numerous challenges, including those that originate from outside its borders, such as climate change and pandemics. The world's eighth-largest country, Bangladesh faces increased risks of infectious and climate-induced diseases because of its large, dense population—170 million people live together on only 150,000 square kilometers. The population is aging and non-communicable diseases (NCDs) are rising, which exacerbate challenges for the unprepared health sector, necessitating a shift toward an integrated, person-centered primary health care (PHC) system. The World Bank's review of the Bangladesh health sector for this report identifies five systems-level changes the country needs to make to strengthen health service delivery. First, the country should finance a resilient health system through measures such as increasing public funding and exploring earmarked taxes. Second, the country needs to improve governance and political commitment including by prioritizing political support for health financing and strengthening regulatory capacity. Third, the country should advance digital health including by strengthening investment in digital technology and improving regulatory oversight of digital health initiatives. Fourth, the country needs to address market failures that result in poor quality of many private-sector providers including by adopting measures to remove the lowest-quality practitioners and benchmarking the performance of licensing and accreditation bodies. Finally, the country should purchase support services at scale including by developing more coherent policy, legal, and administrative frameworks for this purchasing and grounding strategic health purchasing in performance data. The report also identifies 10 specific areas to accelerate progress and presents a roadmap of recommendations for a transformation agenda, drawing on a comprehensive framework for change: Strengthening equity in the health sector: Although the GoB has made commendable strides in promoting equity in health care, disparities persist among poor people who face greater health needs but receive fewer health care benefits. Inequitable distribution of health facilities, gender disparities, and urban-rural discrepancies further impede equity. 14 This report recommends introducing more targeted and integrated programs; allocating resources based on needs; expanding PHC in cities; and subsidizing medicine schemes for vulnerable groups. Increasing social protection programs, providing maternal health care services to lower socioeconomic groups, and ensuring more women hold managerial health care positions are also essential steps. Making health expenditure more efficient: Very high out-of-pocket (OOP) payments for health care can cause financial hardship and diminish access to care. These payments are an increasingly inefficient source of financing for Bangladesh's total health expenditure (THE). Medicines, often sold without a prescription by untrained drug shop salespeople, account for a significant portion of OOP expenses. The diminishing share of government health spending, adjusted for inflation, reflects a declining emphasis on health care. This report recommends that the country increase health financing, strengthen multisectoral collaboration, engage the private sector through public-private partnerships (PPPs), access corporate social responsibility (CSR) funds, and explore earmarked health taxes. Investments should focus on strategic purchasing readiness, One Health, pandemic preparedness, PHC, and NCD management. Strengthening primary health care to address a growing non-communicable disease burden: Bangladesh’s disease burden is shifting from infectious diseases to NCDs, which are associated with economic development and a rise in lifestyle-related risk factors. NCDs are a leading cause of death and disability, responsible for nearly two-thirds of cost per disability-adjusted life years (DALYs) and over three-quarters of deaths. With high OOP health costs and productivity losses from disease, NCDs threaten to strain the health system and undermine social and economic development gains. The report recommends evaluating and enhancing service delivery models to strengthen integrated, PHC- based NCD services, improve outcomes, and facilitate referrals across the system. The country should strengthen public primary-level facilities for screening and treatment, ensure adequate financing, reduce financial barriers to NCD care, and enhance health promotion and prevention of NCDs. Ensuring health services in urban areas: Urban disparities persist, particularly among slum dwellers who trail behind rural counterparts in health outcomes. Urban PHC systems are less developed than rural ones, largely because of inconsistent legal frameworks leading to ambiguity in responsibilities between the Ministry of Health and Family Welfare (MoHFW) and Local Government Institutions (LGIs) and insufficient resources for LGIs. Consequently, the urban poor often use private providers, resulting in high OOP expenses. This report recommends developing and regulating urban health services through sustainable financing, establishing a people-centered integrated care system, and implementing comprehensive monitoring and evaluation for effective decision-making. Building on key gains in nutrition outcomes: Despite notable advancements in maternal and child nutrition indicators such as stunting, inadequate nutrition remains a major public health issue. Some malnutrition indicators such as child wasting are worsening, while others, such as underweight children, are stagnating. Slums fare worse than other urban areas. Bangladesh's diverse health care system offers certain benefits for addressing malnutrition, as public, private, and non-governmental organization (NGO) facilities can collaborate to address challenges. The report recommends expanding nutrition services through community strategies and awareness campaigns, with dedicated budgets and clear roles; strengthening adolescent nutrition; enhancing 15 nutrition in the Essential Services Package (ESP); increasing social and behavior change communication (SBCC); investing in information and communication technology (ICT); and training frontline workers. Catalyzing development of the private health sector: Only 10 percent of people use government facilities. Insufficient human resources, medication, equipment, and physical infrastructure in the public sector drive people to seek care in the private sector, underscoring its significance. While diverse private facilities provide services from PHC clinics to specialized tertiary hospitals, coordination with the public sector is severely limited. The substantial growth of the private health sector has led to significant disparities in care quality compared to the public sector, largely from lax regulation, complex PPP structures, and limited financing. The report recommends strengthening the GoB’s regulatory capacity and oversight of the private health sector; fostering dialogue between sectors; improving data collection; and co-designing a private-sector health strategy. Addressing regulatory gaps will ensure effective oversight and alignment. Improving quality, availability, and affordability in the pharmaceutical sector: Medicine quality suffers from lax regulation, compounded by unlicensed pharmacies often staffed by untrained salespeople. While public hospitals provide free medicines, they lack variety and sufficient quantity. Limited price controls and high prices for non-essential medicines cause high OOP expenses, driving patients to private providers. The significant dependence of pharmaceutical manufacturing on imported active pharmaceutical ingredients (APIs) requires greater domestic production. This report recommends enhancing regulation of medicines and vaccines, addressing suboptimal drug outlets, conducting antimicrobial resistance (AMR) awareness campaigns, revising laws for API improvements, developing a new Essential Medicines List (EML), and reducing OOP medicine expenses. Transforming and integrating digital health to improve service delivery: Bangladesh has made significant progress in optimizing its use of digital health, driven by strong leadership at the MoHFW. However, governance and coordination with other Ministries involved in digital health can be improved. Software services and applications face insufficient integration/interoperability between systems, and there is limited focus on data sharing, information exchange, and infrastructure issues. The report recommends enhancing the MoHFW’s ICT project coordination and financing, prioritizing data sharing, adopting patient-to-provider digital tools, supporting national digital health architecture, expanding ICT systems, collaborating with the Ministry of Energy for infrastructure planning, and integrating digital health workforce improvements with broader health workforce strategies. Equipping the health sector to address climate change impacts on health: The topography of Bangladesh makes it especially susceptible to climate change. As climate conditions worsen, there is growing concern about adverse health effects, especially a rise in waterborne diseases such as diarrhea and cholera; vector-borne illnesses such as malaria and dengue; respiratory ailments; and mental health issues such as depression and anxiety. These effects are likely to be most pronounced among vulnerable groups such as children, the elderly, and poor people living in cities. The report recommends improving weather data accuracy, enhancing infectious disease surveillance, reducing greenhouse gas emissions, adopting a multisectoral research approach, innovating in vector control, prioritizing mental health, and enhancing health service delivery during climate change events. Breaking the cycle of panic and neglect for pandemic prevention, preparedness, and response: 16 Bangladesh remains highly vulnerable to (re)emerging infectious disease outbreaks and health emergencies from rapid urbanization, unsustainable agricultural practices, and extreme exposure to environmental hazards and climate change. The likelihood of a pandemic on a similar scale to COVID-19 in our lifetime is significant. Bangladesh has no time to waste in preparing for such an event. This report recommends building fit-for-purpose institutions, adopting a whole-of-society and One Health approach, embracing regional and global collaboration, and adopting tools to measure performance for pandemic prevention, preparedness, and response (PPR). Now is the moment for transformation To unleash economic progress and achieve Bangladesh’s development goals, this is the time to introduce transformative changes in its health sector. It will require improving equity, efficiency, quality, resource distribution, accountability, and readiness for future challenges. Bangladesh can build on four cross- cutting strengths to address these challenges—its strong community health workforce, a demographic dividend thanks to declining mortality and fertility rates, a pluralistic health system, and robust digital health platforms. By leveraging these enablers of progress and exerting strong political leadership at the highest levels of the Government, along with continued commitment from partners and stakeholders, Bangladesh can realize the health transformations necessary to improve the health of its people. 17 Chapter 1 Introduction and setting the scene By Atia Hossain and Mickey Chopra In the bustling city of Dhaka, the heartbeat of Bangladesh, a mother taking her young child to the local PHC facility to check on his growth and immunization status stands as a testament to resilience and progress. As the sun rises over the city, casting its warm glow on the crowded streets, a story unfolds, reflecting both challenges and opportunities for shaping a healthier future for the people of Bangladesh. The country’s journey in improving health and nutrition outcomes has been nothing short of remarkable, as has been its overall development progress. Tackling the root causes of poverty by investing in its human capital, focusing on public health, and building resilience to natural disasters, Bangladesh has made rapid social and economic progress in recent decades. It achieved lower-middle-income (LMIC) status in 2015 and aspires to become an upper-middle-income country (UMIC) by 2030. The country has improved maternal and child health, infectious disease control, and nutrition. This data-driven review of Bangladesh's health and nutrition achievements showcases the tangible strides made—and the challenges that remain. Thanks to advancements in public health, life expectancy has increased from 64.5 years in 2002 to 72 years in 2021.1 Bangladesh has driven a decline in maternal mortality rates from 574 deaths per 100,000 live births in 1990 to 123 deaths per 100,000 births in 2020, according to World Bank data. Investments by the GoB in antenatal care (ANC), skilled birth attendance, and family planning have played a crucial role in achieving this positive outcome. Child health indicators also demonstrate substantial progress, with mortality of children under age 5 decreasing from 146 deaths per 1,000 live births in 1990 to 27 deaths per 1,000 births in 2021.2 A commitment to infectious disease control has made progress against diseases such as tuberculosis and malaria. The incidence and mortality rates of tuberculosis have declined, according to the World Health Organization (WHO), and the malaria incidence rate dropped from 6.8 cases per 1,000 people in 2000 to under one case per 1,000 in 2021.3 Efforts to combat malnutrition have also led to noteworthy outcomes. The prevalence of stunting among children under age 5 decreased from 43.7 percent in 2011 to 31.9 percent in 2017-18, according to the Bangladesh Demographic and Health Survey (BDHS) 2017-18. Similarly, the prevalence of underweight children declined from 32.5 percent to 22.4 percent during the same period. These improvements highlight the success of innovative nutrition-specific interventions, including the promotion of exclusive breastfeeding and targeted nutrition programs. The success stories of the GoB’s maternal and child health programs stand as a testament to this comprehensive approach to public health. Immunization drives and family planning initiatives have not only improved health but also laid down a blueprint for tackling other health challenges. Specific disease control initiatives also take center stage. Bangladesh's ability to effectively manage diseases such as tuberculosis and malaria and to eradicate polio, leprosy, and Kala-azar underscore the effectiveness of the Government’s targeted interventions and strategic planning. These successes serve as a wellspring of knowledge, guiding strategies for addressing other infectious diseases and promoting public health. The 1 https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=BD 2 https://data.worldbank.org/indicator/SH.DYN.MORT?locations=BD 3 https://data.worldbank.org/indicator/SH.MLR.INCD.P3?locations=BD 18 achievements in these areas are stepping-stones on the path toward realizing the Sustainable Development Goals (SDGs) on health and well-being and universal health coverage (UHC). At the heart of this story of progress and resilience lies the unwavering commitment of the Bangladeshi people, but especially its women, to a healthy and prosperous future for their families. The determination of the GoB to improve the health sector has also been critical to enabling progress. With a clear vision, nominal but steady increases in budgetary allocations, and the formulation of strategic policy initiatives, policymakers set the stage for progress, recognizing health as a cornerstone of national development. Over the years, the Government has introduced various health programs, including the ongoing sector- wide approaches (SWAps); implemented and improved the ESP; and developed multi-year strategies, programs, and budgets to strengthen the health system's capacity and reach. The GoB’s dedication to improving health outcomes is evident in its focus on strengthening health care infrastructure, improving service delivery, and addressing public health challenges. Civil society organizations (CSOs) complement the Government's efforts by actively engaging in health promotion, advocacy, and service delivery. These organizations play a vital role in reaching marginalized people and addressing specific health issues, contributing to a more inclusive health care landscape. Development partners also have been instrumental in supporting Bangladesh's health sector, providing financial assistance and technical expertise. Bangladesh has a diverse and pluralistic health system that includes a vibrant and rapidly growing private health sector, which plays a key role in delivering health care and improving health outcomes. The private sector provides critical services such as basic health care to people of every economic status, but especially to poor people, women, children, and people living in underserved areas. However, as in any narrative, challenges punctuate the storyline. Bangladesh is the world’s eighth largest country and has one of the highest population densities; its 170 million people live and work together on only 150,000 square kilometers of land, which increases the risk of the spread of infectious and climate-induced diseases. The population is also rapidly aging, and the health sector is not prepared to meet this demographic shift. Focused program approaches will no longer suffice, and a more person-centered PHC system is required to provide integrated care. Health progress has been uneven and, in some areas, stalling, with significant gaps and inequalities in population coverage. For example, the maternal mortality ratio of 123 deaths per 100,000 live births is more than two-thirds as high as the SDG target of 70, and the rate of reduction has slowed. There are also significant spatial and socioeconomic inequities. For example, women in urban areas are twice as likely to receive quality ANC (45 percent) as women in rural areas (25 percent), and only 12 percent in the lowest wealth quintile receive quality ANC. Despite rising incomes, malnutrition remains a critical issue that threatens health outcomes and human capital. Currently nearly one in five women are undernourished,4 one in three women age 15-49 have anemia,5 and one in six babies are born with low birth weight.6 Improving the quality of ANC could help prevent these poor outcomes. Acting now is critical because Bangladesh is especially vulnerable to climate 4 UNICEF Bangladesh, Press release, 07 March 2023. https://www.unicef.org/bangladesh/en/press-releases/malnutrition- mothers-soars-25-cent-crisis-hit-countries-putting-women-and-newborn 5 https://data.worldbank.org/indicator/SH.ANM.ALLW.ZS?locations=BD 6 Islam Pollob SMA, Abedin MM, Islam MT, Islam MM, Maniruzzaman M. Predicting risks of low birth weight in Bangladesh with machine learning. PLoS One. 2022 May 26;17(5):e0267190. doi: 10.1371/journal.pone.0267190 19 change, which threatens to increase malnutrition and worsen health outcomes, including low birth weight, poor neonatal and infant outcomes, childhood stunting, and long-term risks of climate-sensitive NCDs. Many people struggle to manage NCDs such as cancers, stroke, hypertension (high blood pressure), diabetes, and neonatal conditions, in large part because the country performs poorly in providing care for these surging health conditions.7 NCDs are responsible for two-thirds of disease burden (64 percent)8 and mortality (68 percent).9 The prevalence of diabetes (14 percent)10 and hypertension (29 percent)11 among adults is high and rising. There are substantial gaps in NCD service provision in the public sector, with only half of facilities providing services for common NCDs. This has resulted in significant breakpoints across the continuum of care; for example, only half of women and one-third of men living with hypertension are diagnosed, while among those who are diagnosed,12 less than one-third of women and one-quarter of men are being treated and have their hypertension under control.13 Cancer is another example of poor quality of care. Providers screen women for cervical cancer based on visual inspection, with less than 10 percent of women receiving even this insufficient screening. Underpinning these trends is a poor-quality health system. Substandard maternal health services include a lack of midwives at birth, over-use of cesarean sections, poor functioning referral systems to timely care for complications, and the provision of needed Overall, PHC facility performance is about 60 percent. This is a major contributor to a high incidence of preventable complications and high use of more costly and climate-intensive services. These problems are compounded by the inefficient allocation of human resources—over 75 percent of doctors and nurses work at tertiary health care facilities compared with only 10.2 percent and 8.2 percent, respectively, at primary care facilities. Government expenditures on PHC declined from 21 percent to 15 percent of the total government expenditure on health between 2010 and 2020. The financial management system is plagued by a slow release of funds, poor planning, weak capacity to spend, and lack of capacity. Like many governments, the GoB is facing fiscal constraints and economic uncertainty fueled by the war in Ukraine and other conflicts, high debt burden, slowing poverty reduction, moderating but still elevated inflation, and lingering effects of the COVID-19 pandemic, all of which make it difficult to spend more on health to meet population needs. As a result, many Bangladeshis are burdened by extremely high health care costs. In 2020, OOP health expenditures accounted for a striking 68.5 percent of THE,14 largely from 7 GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal healthcare in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease 2015 study. The Lancet. 2017 May 18. 8 Kabir, A., Karim, N. & Billah, B. Preference and willingness to receive non-communicable disease services from primary healthcare facilities in Bangladesh: A qualitative study. BMC Health Serv Res 22, 1473 (2022). https://doi.org/10.1186/s12913- 022-08886-3 9 Chowdhury SR, Islam MN, Sheekha TA, Kader SB, Hossain A. Prevalence and determinants of non-communicable diseases risk factors among reproductive-aged women: Findings from a nationwide survey in Bangladesh. PLoS One. 2023 Jun 9;18(6):e0273128. doi: 10.1371/journal.pone.0273128 10 Hossain MB, Khan MN, Oldroyd JC, Rana J, Magliago DJ, Chowdhury EK, Karim MN, Islam RM. Prevalence of, and risk factors for, diabetes and prediabetes in Bangladesh: Evidence from the national survey using a multilevel Poisson regression model with a robust variance. PLOS Glob Public Health. 2022 Jun 1;2(6):e0000461. doi: 10.1371/journal.pgph.0000461 11 Hossain A, Suhel SA, Chowdhury SR, Islam S, Akther N, Dhor NR, Hossain MZ, Hossain MA and Rahman SA (2022) Hypertension and undiagnosed hypertension among Bangladeshi adults: Identifying prevalence and associated factors using a nationwide survey. Front. Public Health 10:1066449. doi: 10.3389/fpubh.2022.1066449 12 Ibid. 13 Khan MN, Oldroyd JC, Chowdhury EK, Hossain MB, Rana J, Renzetti S, Islam RM. Prevalence, awareness, treatment, and control of hypertension in Bangladesh: Findings from National Demographic and Health Survey, 2017-2018. J Clin Hypertens (Greenwich). 2021 Oct;23(10):1830-1842. doi: 10.1111/jch.14363 14 Source: Bangladesh National Health Accounts (BNHA) 1997-2020 20 the high cost of medicines (64.6 percent of total OOP). While the country has improved equity in health care—most notably, the reduction of the gender gap in life expectancy and more equitable access to health and nutrition services—high OOP expenses disproportionately harm poor people, who may be forced to go without care. Other challenges abound. The presence of contaminated water sources and gaps in sanitation provision, now increasing in rapidly growing cities, contribute to the widespread occurrence of diseases such as cholera, dysentery, and typhoid. This perpetuates the unacceptably high prevalence of malnutrition- related issues such as stunted growth and underweight children. Additionally, food insecurity, exacerbated by frequent natural disasters, compounds some people’s struggle for adequate nutrition. Climate change is affecting Bangladesh particularly harshly. Its geographic location makes it highly susceptible to natural disasters, including floods, cyclones, and riverbank erosion. The Global Climate Risk Index ranked Bangladesh as the world’s seventh most-affected country from 1999 to 2018,15 and the number of extreme weather events increased by 46 percent between 2000 and 2020. 16 Rising temperatures leading to more intense and unpredictable rainfalls during the monsoon season and a higher probability of catastrophic cyclones are expected to result in more tidal inundation. These extreme weather events not only cause immediate injuries and fatalities but also contribute to a rise in vector- borne diseases, such as malaria and dengue fever, and long-term health risks. Displacement, loss of livelihoods, and diminished access to health care services during emergencies intensify the vulnerability of communities and compromise disease prevention and control. Climate change is acting as a risk multiplier, threatening to reverse health and nutrition gains and exacerbate inequities. The poorest and most vulnerable, including women, are affected the most. For example, rural women who have experienced climate-related displacements use fewer ANC services than other women. Deteriorating air quality in urban areas, primarily driven by industrialization and vehicular emissions, also poses a significant threat to public health. Respiratory diseases, including chronic obstructive pulmonary disease and asthma, are rising. Vulnerable populations, such as the elderly and those with pre-existing respiratory conditions, bear the brunt of these adverse health effects. Whatever their health issues, Bangladeshis are highly likely to receive medicines of dubious quality. Unlicensed pharmacies abound, often staffed by untrained, incompetent, and unlicensed salespeople who dispense medicines to unsuspecting consumers. The unregulated sale of medicine in the retail market is a critical threat to health. The shortage of skilled health care professionals, especially in remote rural areas, and inadequate health infrastructure also jeopardize health. With the increasing penetration of mobile phones and internet access, telemedicine can play an important role in delivering health services and information to hard-to- reach populations and help mitigate insufficient physical infrastructure. While the Government has increasingly deployed digital health technology, information technology systems are relatively isolated and not part of an integrated digital health ecosystem. Finally, Bangladesh is highly vulnerable to infectious disease outbreaks of pandemic potential. Like most countries, it was unprepared to respond well to the COVID-19 pandemic. Shortcomings included a lack of 15 Germanwatch (2020) Global Climate Risk Index 2020. 16 O’Leary L, Dasgupta S and Robinson Elizabeth JZ. Impacts of climate change on health in Bangladesh. Policy brief, October 2023. Grantham Research Institute on Climate Change and the Environment, and Center for Climate Change Economics and Policy, The London School of Economics and Political Science, University of Leeds. https://www.lse.ac.uk/granthaminstitute/wp-content/uploads/2023/10/Impacts-of-climate-change-on-health-in-Bangladesh- Policy-brief.pdf 21 a comprehensive and coordinated pandemic management policy, limited laboratory capacity to test for the virus that causes COVID-19, a critically low ratio of intensive care units to the population, and a shortage of essential resources such as health care workers, personal protective equipment (PPE), and ventilators. There is little evidence to suggest that Bangladesh has learned lessons from the pandemic to significantly improve its capacity to prevent, prepare, and respond to future health emergencies. Quite clearly Bangladesh is at a crossroads, and a clear path to transform its health system for better results is urgently needed. The country has an opportunity to build on its commendable progress in key health outcomes to tackle and overcome equally substantial deficits. If Bangladesh is to continue its upward economic trajectory and achieve its ambitious development goals, it must evolve and advance the health sector including in the areas of equity, efficiency, quality, and resilience. In addition to these four critical areas, the country must respond to changing demographic and health needs; address systemic issues such as staff vacancies and absenteeism, low service quality—especially for NCDs such as cardiovascular diseases (Haakenstad 2022), and high OOP health spending; and embrace technological advances in the health care industry to serve people better. Such transformations are crucial for the country to achieve UHC and meet SDG 3. The World Bank's review of the Bangladesh health sector is not intended to be comprehensive, rather, it analyzes several critical aspects of the health system, drawing on the framework shown in Table 1.1 below, and recommends the transformation agenda accordingly. Table 1.1: Framework for determinants of transformation in the health sector Challenges Need for transformation Outcome Cross-cutting and systemic Equity in access and service provision; Reduced shock from issues: Low public sector increased allocation to health sector and catastrophic expenses and allocation, high OOP rational distribution of resources; more equitable access to spending, service delivery efficient service delivery mechanism; health services for better and spending inefficiencies development of the private health results sector; improvements in quality, availability, and affordability in the pharmaceutical sector Unfinished agenda in Expansion of PHC in rural and urban Enhanced health results; maternal and child health areas, improvements in maternal and wider coverage and child nutrition and stunting, equitable access to transformation and integration of digital affordable health services health to improve service delivery Growing burden of NCDs, Stronger PHC to address rising NCDs; Stronger resilience, vulnerability to outbreak of preparedness to address climate change readiness for new and (re)emerging diseases impacts on health; an end to the cycle of emerging trends panic and neglect for pandemic prevention, preparedness, and response 22 The country needs to adopt reforms to address emerging challenges and build a more resilient and responsive health care system to strengthen prevention and preparedness and provide quality, equitable, affordable, and efficient health care to its people. Developing a health system fit for the 21st century will require devising and implementing strategic interventions to enhance efficiency; improving resource distribution; enforcing accountability; preparing for future challenges; and responding to rising health care expectations, global health threats, and technological advancements. Above all, achieving these reforms will require firm political leadership and commitment at the highest government levels. This report provides an in-depth review of Bangladesh’s health sector, its progress and challenges, and a roadmap of reforms that the country can take to accelerate progress. 23 Chapter 2 Strengthening Equity in the Health Sector By Atia Hossain and Tahmina Begum Highlights • Despite the Government’s commendable success in advancing equity in the health sector, lower socioeconomic groups still have fewer health care benefits while facing greater health care needs. • The distribution of health facilities is inequitable. All the specialized hospitals are in the capital city of Dhaka. However, Community Clinics (CCs) in poorer divisions are more accessible than in wealthier divisions. • Although overall access to PHC services has improved, a gender gap and urban-rural differences limit access to services. • More people prefer private-sector practitioners over public providers because of the greater availability of drugs and longer hours, but the relatively high OOP costs put private providers out of reach for many poor people. • Although the gap between total fertility rates (TFR) in rural and urban communities has narrowed, urban women still have lower TFR than their rural counterparts. • The prevalence of NCDs such as hypertension and diabetes is higher in urban than rural areas and among women than men. Nevertheless, the prevalence of both diseases is higher in the richest quintiles than in the poorest ones. Introduction The WHO defines health equity as the absence of unfair, avoidable, or remediable differences in health outcomes among people who may be different socially and economically (e.g., income, educational attainment, occupational status, and access to resources); demographically (e.g., age, sex, gender, race/ethnicity, religion, disability, sexual orientation, language); and geographically (e.g., state, province, and administrative division). Achieving equity in health care is a complex and multifaceted goal, with numerous factors such as access to health services, the political and policy context, social determinants of health, environmental factors, level of income/wealth, and lifestyle choices determining equity in health. Equity in, access to, and use of, health care is the cornerstone of the UHC framework and essential to achieving universal coverage. Since independence, Bangladesh has made significant progress in advancing health equity. The most notable achievement has been the reduction of the gender gap in life expectancy. In nearly every country, regardless of development status, women outlive men because of differences in biology and health behaviors. However, in Bangladesh, men had a longer life expectancy (age 51) than women (age 49) in 1972 because of widespread gender disparities. That changed in 2000, when, thanks to improvements in women’s status from increased female enrollment in secondary education, employment in the ready-made garments sector, and declining fertility and maternal mortality rates, the gender gap in life expectancy reversed: women reached a life expectancy of 66 years, and men, 65 years. In 2022, life expectancy was 74 years for women and 71 years for men.17 As discussed above, 17 https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN?locations=BD 24 Bangladesh has also made remarkable progress in improving health and nutrition outcomes, particularly in reducing child and maternal mortality and child stunting and wasting, reflecting more equitable access to health and nutrition services. In some cases, the country achieved its targets from the United Nations’ Millennium Development Goals early.18 Bangladesh’s success in population control and family planning has made it a role model for countries with similar conservative cultures. The country’s TFR was 1.9 births per woman in 2022, a sharp decline from 6.9 births per woman in 1975.19 It also has decreased the rural-urban disparity in fertility rates. Inequity in child mortality rates, including between boys and girls, poor and rich children, and rural and urban children, has also declined substantially—a notable achievement. Despite these commendable advances, Bangladesh has a long way to go to reduce inequities in most health indicators. In addition, the strong progress in improving nutrition, reducing child and maternal mortality, and decreasing child stunting and wasting can be enhanced. Measures to reduce disease prevalence and improve equitable access to health care and nutrition services, the quality of care, and financing of health care should be strengthened. Challenges Distribution of health benefits Both the supply and demand sides of Bangladesh’s health system contribute to inequity in the distribution of health benefits. As in other LMICs, Bangladesh provides health care through a mix of public, private for-profit (PFP), and NGO providers. In public facilities, patients pay a small fee for health services (services from facilities below subdistrict level are free). However, PFP facilities require a relatively large OOP payment, making them inaccessible to poor people. On the demand side, health care-seeking behavior often varies across socioeconomic groups, linked to such factors as awareness, physical access to health care facilities, and economic hardship. 20 In Bangladesh, although the poverty rate is declining, income inequality is gradually worsening.21 Health care benefits were concentrated among wealthier groups, with little difference between rural and urban people, according to a 2017 benefit incidence study.22 The poorest socioeconomic group had a significant proportion of total health care needs but received a disproportionately lower share of health care benefits than richer groups, reflecting overall inequity. Benefits received from public providers were more equitable than from NGO providers, which exhibited a slight pro-rich bias. Private health care providers significantly favored wealthier individuals. Quality of health care Quality of health care can be assessed by examining four criteria: structure (e.g. facility, human resources, equipment), process (e.g. guidelines/protocol, diagnostic services, waiting time), outcomes (discussed elsewhere in this chapter), and patient satisfaction. Figure 2.1 tracks a number of factors that affect quality of care, illustrating the disparities across different types of facilities: 18 GED (General Economics Division). 2016. Millennium Development Goals: End-period Stocktaking and Final Evaluation Report (2000-2015). GED, Planning Commission, Government of the People’s Republic of Bangladesh. 19 https://www.macrotrends.net/global-metrics/countries/BGD/bangladesh/fertility-rate 20 Amin R, Shah NM, Becker S. 2010. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh : A cross-sectional analysis. International Journal for Equity in Health 9: 11. 21 BBS (Bangladesh Bureau of Statistics). 2023. Preliminary Report: Household Income and Expenditure HIES Survey 2022. BBS, Ministry of Planning, The Government of People’s Republic of Bangladesh. 22 Khan Jahangir A. M., Sayem Ahmed, Mary MacLennan, Abdur Razzaque Sarker, Marufa Sultana and Hafizur Rahman. 2017. Benefit incidence analysis of healthcare in Bangladesh – equity matters for universal health coverage. Health Policy and Planning, 32, 2017, 359–365 doi: 10.1093/heapol/czw131 25 Figure 2.1: Factors affecting quality of care, by facility type (in percentage) 100 98 9996 100 93 90 9390 88 90 80 81 79 8083 78 77 76 75 80 72 64 66 70 62 61 60 48 50 40 4245 40 35 30 30 25 22 2323 22 20 6 10 0.790 2 0 Regular Improved Functioning Functioning Functional Six basic Functional Six to eight electricity water toilet for & separate emergency pieces of X-ray essential sources patients toilet for transport equipment machine medicines female patients District and upazila level (public) Union level (public) CCs (public) NGO clinics and hospitals Private hospitals Source: Bangladesh Health Facility Survey 201723, 24, 25, 26, 27 The number of beds per 1,000 people is an indicator of capacity and access to hospital services. The Ratio of hospital beds to population is not only significantly less in Bangladesh than in LMICs and LICs of Asia-Pacific region, but also disparity exists in the distribution of primary-, secondary- and tertiary- level hospital beds per 1,000 people across administrative divisions. The health workforce's productivity, size, skill mix, competency, and geographic distribution have a significant impact on access to quality health care services. The nurse-to-doctor ratio is not only significantly less in Bangladesh than in LMICs of the Asia-Pacific region, additionally, Bangladesh falls far short of the WHO standard of three nurses per doctor. Availability of preventive and diagnostic/screening services: About 83 percent of public facilities at district and Upazila levels, 54 percent of NGO facilities, and 90 percent of private facilities offer both 23 Flush or pour-flush toilet, a ventilated improved pit latrine, or a composting toilet. 24 A functioning ambulance or other vehicle for emergency transport is stationed at the facility and had fuel available on the day of the survey, or the facility has access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility. 25 Six basic pieces of equipment includes adult scale, child or infant scale, thermometer, stethoscope, blood pressure machine, and light source. 26 Six of eight essential medicines include Amoxicillin tablets/capsules, Amoxicillin syrup, Paracetamol tablets, Paracetamol syrup, Tetracycline/chloramphenicol eye ointment, Cotrimoxazole, Iron tablets, Vitamin-A capsules. 27 Bangladesh has no structured and functional referral system 26 diagnosis and treatment services for hypertension, according to a 2017 facility survey.28 There is a huge discrepancy between facilities in urban (73 percent) and rural (12 percent) areas offering both services for hypertension. Less than one fifth (17 percent) of public facilities at district and Upazila levels reported having guidelines for diagnosis and management of hypertension, compared to 34 percent at NGO facilities and only 1.4 percent at private facilities. Maternal and child care Maternal and child health care at public facilities is more pro-poor than at private-sector facilities. A 2023 study29 found that a higher percentage of women in the poorest quintile (23 percent) received ANC from public facilities compared to the richest quintile (15 percent). Conversely, the richest quintile (26 percent) accessed more ANC from the private sector, while the poorest quintile (13.5 percent) used less. Similarly, when it came to child health care, the poorest group primarily sought care from public facilities for conditions such as diarrhea (14.4 percent) and acute respiratory infections (ARI) (25.4 percent), while wealthier individuals received more private care for diarrhea (34.1 percent) and ARI (26.6 percent). The differences between where poor and rich women give birth and receive care also raise equity issues. Children born at home are at a higher risk of not receiving certain vaccines compared with those born in health facilities.30 However, equity in maternal care, particularly in labor and delivery, has significantly improved, as seen in the ratio between women in the poorest and richest quintile who delivered at a facility. The ratio of facility deliveries between women in the lowest and richest quintile was approximately 1:6.8 for public facility delivery in 2007 but was equal (1:1) in 2022., while the ratio for any facility delivery dropped from 1:9.9 in 2007 to 1:2.1 in 2022 (Figure 2.2). Figure 2.2: Facility-level maternal deliveries A higher proportion of households from the upper two quintiles use district-level facilities (district hospitals and Maternal and Child Welfare Centers) compared to the lower two quintiles. In contrast, households from the poorest quintiles are more likely to visit facilities at the Upazila level and below,31 where services are free or the fee is nominal (e.g., Upazila Health Complex, Union Health and Family 28 National Institute of Population Research and Training (NIPORT) and ICF. 2019. Bangladesh Health Facility Survey 2017. Dhaka, Bangladesh: NIPORT, ACPR, and ICF 29 Sheikh, Nurnabi, Marufa Sultana, Abdur Razzaque Sarker and Alec Morton. 2023. Equity assessment of maternal and child healthcare benefits utilization and distribution in public healthcare facilities in Bangladesh: a benefit incidence analysis. Population Health Metrics. 21:12 https://doi.org/10.1186/s12963-023-00312-y 30 Ibid. 31 Ibid. 27 Welfare Center, and Community Clinics). Private and NGO providers are pro-rich compared to public providers. The higher OOP expenditures in the private sector make it more likely that wealthier individuals will seek maternal and child health care from private facilities, as they have greater financial resources to cover these costs compared to less affluent people. Several studies have measured inequality in accessing child and maternal health care services in relation to social and economic determinants. 32 A recent study showed that maternal education, family wealth, and place of residence determine access to maternal and child health care.33 Coverage and access are lower in rural areas because of the lack of health professionals and awareness of services. In addition, the quality of care is a concern. High maternal and neonatal deaths and stillbirth rates, along with inadequacies of some health care providers and reported dissatisfaction among both providers and patients, indicate that the quality of health care is poor. Significant disparities exist in the quality of ANC based on women's social and economic determinants. About 40 percent of all women sought ANC, according to BDHS 2022.34 Urban and wealthier women are more likely to receive quality ANC, which BDHS defines as four or more antenatal visits, with at least one to a medically-trained provider that includes measurement of weight and blood pressure, blood and urine tests, and receipt of information on potential complications. Women in the highest wealth quintile are nearly five times more likely to receive quality ANC than those in the lowest quintile (39 percent and 8 percent, respectively) and urban women are twice as likely as rural women (33 percent and 17 percent, respectively).35 Child immunization Bangladesh received an award from the Global Alliance for Vaccines and Immunization (GAVI) in 2009 and 2012 for its outstanding performance in improving child immunization rates, but equity remains a concern. Child vaccine coverage is higher in the two richest quintiles than in the poorest one. Incomplete immunization is a significant public health problem, and the poorest children fare the worst. The education and work status of mothers, community awareness, socioeconomic status, and location can affect whether children receive timely and complete vaccination.36 Family planning and fertility rates Over the last 30 years, Bangladesh has made outstanding progress on many indicators of family planning and fertility. However, challenges remain including a plateauing contraceptive prevalence rate of 64 percent among women of reproductive age and only 55 percent of women using modern methods such as birth control pills, IUDs, and sterilization.37 Many couples want to delay, space, or 32 Di Novi, C., Thakare, H. 2022. Inequality of Opportunity in Accessing Maternal and Newborn Healthcare Services: Evidence from the Bangladesh Demographic and Health Survey. Soc Indic Res 164, 1505–1529. 33 Ibid. 34 National Institute of Population Research and Training (NIPORT) and ICF. 2023. Bangladesh Demographic and Health Survey 2022: Key Indicators Report. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF. 35 Ahmmed F, Manik MMR, Hossain MJ. Caesarian section (CS) delivery in Bangladesh: A nationally representative cross- sectional study. PLoS One. 2021 Jul 15;16(7):e0254777. doi: 10.1371/journal.pone.0254777. 36 Sheikh, Nurnabi, Marufa Sultana, Nausad Ali, Raisul Akram, Rashidul Alam Mahumud, Muhammad Asaduzzaman, and Abdur Razzaque Sarker 2018. Coverage, Timelines, and Determinants of Incomplete Immunization in Bangladesh. Trop Med Infect Dis. 2018 Sep; 3(3): 72. Published online 2018 Jun 25.doi:10.3390/tropicalmed3030072 37 National Institute of Population Research and Training (NIPORT) and ICF. 2023. Bangladesh Demographic and Health Survey 2022. Key Indicators Report. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF. 28 limit childbirth,38,39 yet depend on short-term methods (e.g., pills, condoms), which have higher rates of discontinuation and failure than longer-acting contraceptives. From 2004 to 2014, there was a significant increase in the use of contraceptive methods by women in the poorest quintile, rising from 45 percent to 55 percent, reflecting growing equality and strong commitment to reducing fertility among poor people.40 This may explain why the TFR decreased by 1.2 percentage points among women with no education, while it declined more modestly by 0.4 percentage points among women with secondary or higher education between 1994 and 2022. While the gap between fertility rates in rural and urban communities has narrowed, disparities remain. In 1994, the TFR was 3.5 births per rural woman and 2.7 per urban woman, while it declined to 2.4 births per rural woman and 2.1 per urban woman in 2022. Child mortality, stunting, and wasting Significant inequities in child mortality across genders, socioeconomic groups, rural and urban settings, and regions were a major public health concern. These disparities reflected differences in access to health care, nutrition, and other social determinants of health including having multiple births, access to safe drinking water, access to prenatal care, the mother’s age, newborn weight and viability, and breastfeeding status.41,42 Fortunately, disparities began to narrow between 2004 and 2018; the equity gap among the poorest and the richest populations narrowed in neonatal, infant, and under-age-5 mortality. However, inequities remain, with 21 infants in the poorest quintile dying per 1,000 live births compared to 15 per 1,000 live births in the richest quintile. Bangladesh has achieved its target of reducing stunting among children under age 5 to 25 percent by 2023. According to the latest nationwide survey, 24 percent of children under age 5 are stunted, while 22 percent are underweight, and 11 percent are wasted. However, much of the improvement may be explained more by national achievements such as rising household wealth, smaller family size, greater gaps between births, increasing access to health services, place of residence, and parental levels of education than by public nutrition programs.43 There were disparities in under-age-5 stunting, with lower rates in urban (22 percent) than in rural settings (24 percent), but higher rates of stunting in urban slums (34 percent) in 2021. Most child health and nutrition outcomes are worse for those living in slums than in other urban areas and in rural areas. Non-communicable diseases NCDs result from a combination of genetic, socio-demographic, biochemical, and behavioral factors, but the rise in NCDs largely stems from several behavioral risk factors: unhealthy diets, insufficient 38 Hossain, S., Sripad, P., Zieman, B., Roy, S., Kennedy, S., Hossain, I. and Bellows, B., 2021. Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh. Journal of Global Health, 11. 39 Rahman, M., Haider, M.M., Curtis, S.L. and Lance, P.M., 2016. The Mayer Hashi large-scale program to increase use of long-acting reversible contraceptives and permanent methods in Bangladesh: explaining the disappointing results. An outcome and process evaluation. Global Health: Science and Practice, 4(Supplement 2), pp.S122-S139. 40 Cezar, A. M. and Alam, B. B., 2019. Equity in Access to Maternal and Child Health Services in Bangladesh (2004 –2014). HP Discussion Paper. World Bank. 41 Hong, R., 2006. Effect of multiple birth on infant mortality in Bangladesh. Journal of paediatrics and child health, 42(10), pp.630-635. 42 Mondal, M.N.I., Hossain, M.K. and Ali, M.K., 2009. Factors influencing infant and child mortality: A case study of Rajshahi District, Bangladesh. Journal of Human Ecology, 26(1), pp.31-39. 43 Cezar, A. M. and Alam, B. B., 2019. Equity in Access to Maternal and Child Health Services in Bangladesh (2004 –2014). HP Discussion Paper. World Bank. 29 physical activity, and the harmful use of tobacco and alcohol.44 Both mortality and morbidity from NCDs are increasing globally and in Bangladesh, and disparities exist across genders, rural and urban settings, socioeconomic status, and regions. The prevalence of hypertension and diabetes is higher in urban areas than in rural communities and among women than men. There are gender differences in awareness of, and treatment for, hypertension and diabetes. Women are more aware of their condition and more likely to receive medication for treatment than men, both for hypertension (43 percent vs. 29 percent) and diabetes (38 percent vs. 35 percent). Screening, diagnosis, and management of NCDs, particularly hypertension and diabetes, at PHC facilities are crucial for their prevention and management, especially among poorer people. A study estimated that, compared to NGO and private health facilities, facility readiness for diabetes services was lower in rural settings, districts with high social deprivation, and public facilities, especially at union-level facilities and CCs. 45 In these facilities, diabetes diagnostic equipment and medications were largely unavailable, which discouraged visits by poor and marginalized people. Access to health care services In LMICs, health care access and utilization are influenced by demand and supply-side factors. Studies have reported that the factors associated with poor use of services include poverty, location, race/ethnicity, sex, age, language, and disability status. The ability to access care—including whether it is available, timely, convenient, and affordable—affects health care utilization.46 Physical access to health care has largely improved in rural areas through a network of about 14,000 CCs, with each clinic serving approximately 6,000 people and providing essential services close to people's homes, particularly for underserved populations. In addition, community health workers (CHWs) provide basic health care and education to people at home. About one in 10 people received health care services from government providers (including CHWs and facilities) in 2022, according to HIES. 47 There is a slight gender gap, with a greater proportion of men (12 percent) consulting government providers than women (10 percent). In contrast, a higher proportion of people (53.5 percent) visit private-sector pharmacies/retail drug outlets, with more men (55 percent) than women (52 percent) consulting them when ill; 10.4 percent visit private clinics and hospitals, and only 1 percent visit NGO providers. This has strong implications for equity in terms of cost and quality of care. The most frequently cited reasons for choosing a health care provider include location, perceived quality, and affordability.48 People say that they choose private-sector pharmacies over public-sector health care providers when they are ill as their first point of contact for care because of the wider availability of medicines in pharmacies.49 44 WHO. Surveillance of chronic diseases: risk factors: country-level data and comparable estimates (surf reports 2): Bangladesh, 2005.Available: http://www. who. int/ infobase/ surf2/ html_files/SEARO/Bangladesh. pdf 45 Seiglie JA, Edson Serva´n-Mori, Tahmina Begum, James B. Meigs, Deborah J. Wexler, Veronika J. Wirtz. 2020. Predictors of health facility readiness for diabetes service delivery in low- and middle-income countries: The case of Bangladesh. Diabetes Research and Clinical Practice. Volume 169, Nov 2020. 46 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Health Care Utilization and Adults with Disabilities. Health-Care Utilization as a Proxy in Disability Determination. Washington (DC): National Academies Press (US); 2018 Mar 1. 2, Factors That Affect Health-Care Utilization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500097/ 47 BBS. 2023. Household Income and Expenditure Survey (HIES) 2022: Final Report. Dhaka:BBS, Statistical and Informatics Division, Ministry of Planning, Government of the People’s Republic of Bangladesh 48 Bangladesh Health Watch. 2023. 50 Years of Bangladesh: Advances in Health. Edited by Chowdhury AMR, Yasmin Ahmed, Khairul Islam ad Shishir Moral. Dhaka: University Press Limited 49 Kasonde, Lombe, Hui Sin Teo, Andreas Seiter, Bushra Alam, David Tordrup, Tahmina Begum. 2017. Overview of the Pharmaceutical Sector in Bangladesh. The World Bank, South Asia 30 While nearly all facilities in Bangladesh reported offering ANC services, only 4 percent have the level of readiness necessary to provide quality services, including having the appropriate guidelines, trained staff, equipment, diagnostic capacity, and medicines. Roughly 45 percent of public-sector district hospitals are ready to offer ANC services, compared with only 2 percent of private hospitals. About 46 percent of public facilities at district and Upazila levels, 38 percent of NGO clinics/hospitals, and 17 percent of private hospitals reported that staff received in-service training on ANC during the 24 months preceding the survey.50 Health financing Significant disparities exist in the financing of health services. Per capita public expenditures on health care are not equitable across regions (e.g., administrative divisions). In 1997, for example, per capita public spending on health care was highest in Rajshahi, a poorer division, followed by wealthier divisions such as Chattogram. Yet, three years later, the highest per capita public spending on health care was in the Dhaka division, a wealthier division, followed by Barishal, a relatively poorer division. Government expenditures are influenced by the number of facilities and health care staff rather than population needs. More recently, allocation decisions started considering use of facility services. On financing targeted at women, in FY2023-24, the MoHFW allocated 31.7 percent of its budget for women’s services, which is lower than women’s share (34.4 percent) of the total national budget.51 Households bear the largest share of health expenditures in the country, reflecting widespread inequity in the health sector. In 1997, families’ OOP expenditures were 56 percent of Bangladesh’s THE, which grew to 68.5 percent in 2020. Households in richer quintiles spent a larger share of overall consumption expenses on OOP health care costs, according to the report Bangladesh National Health Accounts (BNHA) 1997-2020.52 However, the impact of OOP is disproportionately borne by poorer people. Even a relatively modest health expenditure can have devastating financial consequences for individuals or families with limited financial resources, compelling them to cut back on essential expenses such as food, housing, or their children's education. Substantial health expenses can lead to financial calamity and insolvency, even for wealthier households.53 When families spent 10 percent or more of their income on health care, 24.4 percent of households incurred catastrophic health expenditures (CHE) in 2016, up sharply from 14.8 percent in 2020.54 CHE can arise from the high cost of medications and expensive medical procedures or treatments.55 For poorer families, the two-thirds of OOP costs that are spent on medicines can become exorbitant. A patient with co-morbid conditions such as diabetes, hypertension, and hypercholesterolemia (high cholesterol) may spend nearly five days of wages per month on medications, or approximately 25 percent of the gross income of the lowest-paid government worker.56 50 NIPORT and ICF. 2019. Bangladesh Health Facility Survey 2017. Dhaka, Bangladesh: NIPORT, ACPR, and ICF 51 MOF (Ministry of Finance). 2023. Gender Budget Report 2023-24. Finance Division, MOF, Government of the People’s Republic of Bangladesh 52 MOHFW (Ministry of Health and Family Welfare) 2023. Bangladesh National Health Accounts 1997-2020. Health Economics Unit (HEU), MOHFW, Government of the People's Republic of Bangladesh 53 Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. 2007. Protecting households from catastrophic health spending. Health Aff Proj Hope. 2007;26(4):972–983. doi:10.1377/hlthaff.26.4.972 54 WHO. 2022. Health Financing Progress Matrix assessment Bangladesh 2021: Summary of findings and recommendations. Licence: CC BY-NC-SA 3.0 IGO 55 WHO (World Health Organization. 2019. Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/HFWorkingPaper/19.4). License: CC BY-NC-SA 3.0 IGO. 56 Kasonde, Lombe, David Tordrup, Aliya Naheed, Wu Zeng , Shyfuddin Ahmed and Zaheer-Ud-Din Babar. 2019. Evaluating medicine prices, availability and affordability in Bangladesh using World Health Organisation and Health Action International methodology. BMC Health Services Research (2019) 19:383 https://doi.org/10.1186/s12913-019-4221-z 31 Generally, in health sectors that depend heavily on OOP payments to finance health care, a higher number of households experience financial hardship.57 And here, too, the burden is not shared equally in Bangladesh. The likelihood of CHE was higher among households headed by women (age 15–49 years) or including women with less education, elderly members (age 65 and above), and children (under age 15). Urban households and those headed by people with more education and higher socioeconomic status had significantly lower rates of CHE.58 A study by the WHO 59 found that 3.4 percent of Bangladesh’s population—5.2 million people— experienced financial hardship from high OOP health spending and were pushed under the US$1.90/day poverty line. Underscoring regional inequities, of the Bangladeshis facing financial hardship from health expenses, 4.6 million lived in rural communities. The country has made significant progress in reducing the poverty rate—lowering it from 48.9 percent in 2000 to 18.7 percent in 2022.60 However, while health-induced impoverishment dropped from 4.6 percent in 2000 to 2.5 percent in 2010, it increased to 4.2 percent in 2016.61 Human resources The health care workforce reflects gender inequities. Female employees comprise 62 percent of MoHFW staff, however, they tend to occupy lower paid positions such as nurses and CHWs—only 37 percent of doctors are female.62 The proportion of female staff in managerial positions is also skewed. For example, only 5 percent are civil surgeons (district health managers), and only 6 percent are Upazila health and family planning officers (subdistrict health manager). Facility distribution The distribution of health facilities across administrative divisions is not equitable. Almost all the specialized hospitals are in Dhaka city. Even the distribution of CCs is inequitable because, although each CC is supposed to serve 6,000 people in rural areas, CCs serve far more people in each division (Figure 2.3). However, poorer divisions (e.g., Barishal, Rangpur, Mymensingh) have fewer people per CC than wealthier divisions (e.g., Chattogram, Sylhet), which is positive in terms of equity. 57WHO (World Health Organization. 2019. Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/HFWorkingPaper/19.4). License: CC BY-NC-SA 3.0 IGO. 58 Khan, Jahangir A M Khan, Sayem Ahmed and Timothy G Evans. 2017. Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh—an estimation of financial risk protection of universal health coverage. Health Policy and Planning, 32, 2017, 1102–1110 doi: 10.1093/heapol/czx048 59 Wang, Hui, Lluis Vinyals Torresa & Phyllida Travisa. 2018. Financial protection analysis in eight countries in the WHO South-East Asia Region. Bull World Health Organ 96:610–620E | doi: http://dx.doi.org/10.2471/BLT.18.209858 60 BBS (Bangladesh Bureau of Statistics). 2023. Preliminary Report: Household Income and Expenditure HIES Survey 2022. BBS, Ministry of Planning, The Government of People’s Republic of Bangladesh 61 WHO. 2022. Health Financing Progress Matrix assessment Bangladesh 2021: Summary of findings and recommendations. License: CC BY-NC-SA 3.0 IGO 62 DGHS. 2023. Health Bulletin 2021. 32 Figure 2.3: Population per community clinic by division Sources: DGHS, HIES 2022 Recommendations These recommendations will help create a more equitable health sector: Introduce more targeted programs, expand successful targeted programs, and integrate similar programs with those of other Ministries to maximize service and population coverage For example, the Mother and Child Benefit Program under the Ministry of Women and Children Affairs and the Maternal Voucher Scheme under the MoHFW can operated in an integrated way to enhance service and population coverage. Work with other Ministries to include health, nutrition, and population components in their projects About 15 Ministries incur health-related expenditures, and the MoHFW can work with them to include HNP components in their projects, where relevant, and streamline and synergize health expenditures. Introduce needs-based resource allocation to facilities across geographical areas Resource allocation should consider the population's demographic composition, poverty status, and use of health services in the catchment area, which are proxy indicators for population health needs. Design medicine schemes to provide drugs, especially for NCDs, at subsidized prices to vulnerable groups With very high OOP expenditures on medicines and rising NCDs, the MoHFW can design and operate a medicine scheme that provides drugs to poor and vulnerable people at subsidized prices. Introduce more social protection programs that target poor and disadvantaged people 33 Programs and projects that target poor and marginalized people can help them overcome health shocks and health-induced poverty, or at least prevent them from falling deeper into poverty. Make the health budget more gender-responsive Adopting an ex-ante approach to gender budgeting, addressing methodological shortcomings, and conducting regular monitoring and evaluation can make gender budgeting more effective. Expand PHC services to urban areas to reduce disparities and expand hours at public facilities This approach would accommodate the needs of the urban population, especially those working in the informal sector, and likely improve health outcomes. Provide basic maternal health care services to women of lower socioeconomic status The focus should be on women living in rural areas where poverty is more prevalent.63 Since education levels and wealth are positively associated with using basic health care services, economic and educational improvement of low-income mothers would have a positive effect on reducing inequality. Design strong and sustainable maternal and child health care facilities, especially in rural areas This will help address the socioeconomic determinants of child mortality and diminish inequities. Awareness campaigns to reduce fatherhood at younger ages and early pregnancy can also contribute to faster reduction of childhood mortality rates, among other interventions. Ensure deployment of more women in managerial positions Removing the gender imbalance in managerial positions can spark confidence among female staff. References Amin R, Shah NM, Becker S. 2010. Socioeconomic factors differentiating maternal and child health- seeking behavior in rural Bangladesh: A cross-sectional analysis. International Journal for Equity in Health 9: 11. Bangladesh Health Watch. 2023. 50 Years of Bangladesh: Advances in Health. Edited by Chowdhury AMR, Yasmin Ahmed, Khairul Islam ad Shishir Moral. Dhaka: University Press Limited BBS (Bangladesh Bureau of Statistics). 2023. 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Private providers' knowledge, attitudes and misconceptions related to long-acting and permanent contraceptive methods: a case study in Bangladesh. Contraception, 94(5), pp.505-511. Wang, Hui, Lluis Vinyals Torresa & Phyllida Travisa. 2018. Financial protection analysis in eight countries in the WHO South-East Asia Region. Bull World Health Organ 96:610–620E | doi: http://dx.doi.org/10.2471/BLT.18.209858 WHO (World Health Organization. 2019. Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/HFWorkingPaper/19.4). License: CC BY-NC-SA 3.0 IGO. WHO. 2022. Health Financing Progress Matrix assessment Bangladesh 2021: Summary of findings and recommendations. License: CC BY-NC-SA 3.0 IGO WHO. Surveillance of chronic diseases: risk factors: country-level data and comparable estimates (surf reports 2): Bangladesh, 2005.Available: http://www. who. int/infobase/surf2/ html_files/SEARO/Bangladesh. pdf Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff Proj Hope. 2007;26(4):972–983. doi:10.1377/hlthaff.26.4.972 37 Chapter 3 Making health expenditures more efficient By Tahmina Begum, Mengxiao Wang, Atia Hossain, and Mohammad Rafi Highlights • People’s OOP payments for health care represent an inefficient financing source of Bangladesh’s THE that has been growing for decades. Patients spend a major share of their OOP costs on medicines that often are not prescribed by a medical professional. • The declining share of government health spending (in real terms) indicates decreasing priority on health. • A high-level government commitment is needed to increase the health sector’s share of the national budget toward global norms. This spending represents the biggest potential source of fiscal space in Bangladesh over the next few years. • The MoHFW can improve the efficiency of health expenditures by strengthening the capacity of its staff in such areas as planning, budgeting, public financial management, and procurement. Introduction Countries around the world need to invest more in their health care systems, and Bangladesh is no exception. The Bangladesh health sector requires additional resources to meet the increased demand for health services, achieve UHC and SDGs, and better prepare for pandemics. Bangladesh's economy is facing headwinds from multiple crises, resulting in more limited fiscal space for health. When the COVID-19 outbreak became a global health emergency in March 2020, the impact on Bangladesh’s economy was swift. Growth in gross domestic product (GDP) declined sharply to 5.2 percent in FY2020, compared to a record high of 8.2 percent in FY2019.64 Bangladesh is dependent on imports, and its economy has been strongly impacted by the Russia-Ukraine war, with significant economic challenges such as declining foreign reserves, currency depreciation, and soaring import costs, thus constraining government capacity to allocate resources to various sectors including health.65 Given limited fiscal space, the GoB should ramp up its efforts to use available resources more efficiently. The analysis of health expenditures in this chapter uses an efficiency lens to examine how the health sector is financed and resources are allocated and used. The analysis discusses allocative, technical, and process efficiency. Allocative efficiency means whether resources are directed to the right mix of inputs and health interventions consistent with overall goals. Technical efficiency means attaining maximum 64 https://thefinancialexpress.com.bd/views/covid-19-crisis-and-fiscal-space-for-bangladesh-economy- 1610122907#google_vignette 65 World Bank. 2016. Fiscal Space for Health in Bangladesh. Towards Universal Health Coverage 38 output from using a given level of resources or inputs. Process efficiency means eliminating waste, standardizing workflows, and reducing bottlenecks to deliver quality care efficiently and promptly. Allocation of public resources is largely aligned to the Government’s stated strategic priorities, indicating good performance in allocative efficiency. In FY2023, about one-quarter of the national budget was allocated to the social sectors—health (5.4 percent), education (14.7 percent), and social security and welfare (4.9 percent), reflecting the GoB’s priority of human capital development. Successive health sector programs have emphasized proven cost-effective services (estimated as cost per DALY averted) such as maternal, neonatal, and child health (MNCH), immunization, and nutrition services. According to the Disease Control Priorities (3rd edition, 2016), MNCH interventions (cost per DALY averted), such as immunization with six basic vaccines and Hepatitis B (