Little discussion on universal health coverage, treatment cost on the rise
There have been some discussions on universal health coverage (UHC) and projects are being taken up but nothing happens in reality. After Awami League came to power in 2009, professor AFM Ruhal Haque became the health minister and discussions on UHC first began in the country during his tenure. Mohammad Nasim succeeded Ruhal Haque; Zahid Maleque became the state minister for health. After that, a pilot project titled Shasthyo Surokhsha Karmasuchi (SSK) started in three upazilas of Tangail in 2016.
Zahid Maleque is the health minister now. And, a team of independent researchers is evaluating the SSK. The project evaluation report filed in March found many flaws and discrepancies. On the other, people’s health cost is on the rise in the country. Yet, one of the main objectives of the UHC is to reduce personal spending on treatment. Experts said no one including policymakers, professionals and people have a clear idea on universal health coverage (UHC). No discussion or debate was held in the parliament either.
Syed Abdul Hamid, professor of the Institute of Health Economics at the University of Dhaka, told Prothom Alo the depth and comprehensiveness of the idea on universal health coverage is not clear to many people. Many claimed everyone has access to health coverage and everyone has opportunities to receive treatment. In reality, not all people receive services and those who have access to it are not getting the quality service either. Many people are losing everything to receive treatment, he added.
Idea of universal health coverage
The World Health Organization (WHO) first published a report on universal health coverage in 2010. Everyone must have access to healthcare when necessary. People will spend on health according to their capacity. People will not be deprived of healthcare services due to the want of money. No one will refrain from receiving it. No one will lose everything due to spending on healthcare.
WHO included disease prevention, health improvement, treatment, and rehabilitation and tranquillising services. It has to be adequate and quality services. Necessary services during environmental disaster, chemical or nuclear disaster and pandemic situations will also be included in healthcare.
The 2010 report also stated several alternative ways including formation of future fund and introduction of insurance for the service recipients. WHO said currently, 20–40 per cent of health spending are being wasted. Lack of commitment of health workers, overlapping of services, illogical or excessive use of medicine and technology cause this waste. If this stops, it will be possible to bring more people under health coverage.
The concept of equity in health sector finance lies at the root of universal health converges. People will bear the healthcare cost during illness as per their capacity. He or she contracts what sort of disease or how much severe, that is not considerable. The treatment cost will be spent from prepaid money or from the fund of pooled contribution.
Going to opposite direction
The universal health coverage (UHC) has been dominating the talks on the global health for over a decade. The government of Bangladesh highlighted the importance of universal health coverage in the national health policy in 2011. Documents of various programmes in health, nutrition and population sectors have also mentioned about UHC. The sustainable development goals (SDGs) of the United Nations also emphasise the universal health coverage.
The health ministry’s Health Economics Unit framed a strategy paper in 2012 to achieve the universal health coverage. It had three main goals: creation or collection of more funds for healthcare; making healthcare more accessible to poor people in addition to establishing equity in health sector, and increase of capacity in fund allocation and its usage.
The strategy paper set a target to reduce personal spending on healthcare. At the time, individuals had to bear 65 per cent of health cost. The strategy paper states personal spending on healthcare would reduce to 32 per cent by 2032 due to various steps taken by the government.
But the reality is opposite. This means personal healthcare cost has been increasing gradually. According to the Health Economic Unit, personal spending on healthcare stands 67 per cent in 2015. Even researchers of the Health Economic Unit at discussion in Dhaka on 21 November revealed personal healthcare cost rose to 69 per cent now. This means neither the government has taken any initiative to reduce personal healthcare cost nor initiative that was taken has been effective.
SSK and its evaluation
Three upazilas of Tangail districts were included in the 2012 strategy on the UHC formulated by the health ministry’s Health Economics Unit. A pilot project titled Shasthyo Surokhsha Karmasuchi (SSK) was supposed to be taken up for the people living under poverty line.
It took four years for the health ministry to start the project. Implementation of SSK began in Kalihati, Ghatail and Madhupur upazilas of Tangail in 2016. Families living under poverty line were identified in these three upazilas and each of them was provided with a health card. Members of the families having a card enjoy free healthcare ranging from the hospital admission to treatment of 78 diseases. These services are provided from the upazila health complexes.
Expenditure on disease detection, medicine and treatment comes from the project fund. Patients are shifted to the district hospital, if necessary. Project fund covers the transport and treatment cost. The expenditure limit of card is Tk 50,000 a year. An insurance company maintains the account on services and expenditure.
Little renovation work has been carried out at three upazila health complexes from the project fund. Several cleaners and security guards have been recruited. Several trainings were also conducted. The Health Economic Unit is implementing and monitoring this project.
Researchers from several institutions including International Centre for Diarrheal Disease Research Bangladesh (icddr,b) and Institute of Health Economics at the University of Dhaka, carried out an evaluation of the project and filed a report to the government in March this year.
Many people were interested in SKS at the beginning. The health ministry has also been trying to carry out publicity for several years that it has been doing important work to achieve the universal health coverage. Top officials of the health ministry visited the project area frequently. Newspersons from Dhaka visited too. But the evaluation report found various flaws and discrepancies.
Flaw has been found in the process to identify families living under poverty line. Ninety villages were selected for collecting data on the research. Of which, there was no list of families living under poverty line in 18 villages. That means one-fifth of total families were not covered under the research.
On the other hand, 42 per cent of the families receiving health card were not poor. That means rich or influential families enjoyed this financial privileges.
Researchers found there was no caesarean section (C-section) and nutrition services at Kalihati upazila health complex due to lack of human resources. Service on disease detection lacked at all three upazila health complexes. Researchers also found a lack of quality and effective measure on prevention of disease transmission at Kalihati and Madhupur upazila health complexes.
Researchers said involvement of local people is weak in SSK service. This service failed to attract people. Researchers also mentioned others problems in the SSK. Those are unfriendly behaviours of service providing people, unavailability of fixed services, and fear over transport cost to shift patients to the district hospital, and closure of SSK booths at night and on holidays.
Besides, there was a lack of junior consultants at the upazila health complexes and senior consultants at the district hospitals. Eighty per cent of junior consultant positions were vacant in these three upazilas.
Speaking to Prthom Alo on condition of anonymity, a field level official of the Directorate General of Health Services (DGHS) said, the DGHS and the civil surgeon oversees the recruitment process but they were not effectively involved in the SSK. Various discrepancies including recruitment process started appearing due to not involving the DGHS in providing the health services.
People concerned told Prothom Alo there has been little change to the project following the evaluation. Several physicians have already been appointed. The Institute of Health Economics started the process to identify the families living under poverty line and revoke the health card belonging to families that are not poor.
Speaking to Prothom Alo, director general of the Health Economics Unit Mohd Shahadt Hossain Mahmud said, “We have started working to overcome the limitations that have been found out in the evaluation report. Besides, SSK has been expanded to Tangail’s all upazilas including Tangail town. And, the project has been revised and increased to some extent. We have held several workshops and consulting meetings with experts. And what we are going to do have been verified at field level.”
What are the way forwards
People concerned said SKK would be implemented across the country gradually. Officials observed it would be possible to bring the people living below poverty line under a health protection. But no one could clarify any specific timeframe on how many years it would take.
Another important issue in treatment is to reduce personal healthcare expenditure. Even the government bears the healthcare expenditure of the poor, people with middle and lower-middle income brackets will remain at risk. According to the government’s statistics more than 8.6 million join the poverty every year in order to meet their healthcare expenditure and 16 per cent of the total households holds back from receiving healthcare service.
Discussions on health insurance have been going on for long. Health insurance has been introduced in several private companies separately. Some people receive healthcare expenditure through insurance companies but that is very less comparing to the total population.
According to the government officials, introduction of the national health insurance will require a law. Besides, separate authorities will be necessary to introduce this special insurance and operate it. Financial management will not be possible by the health ministry. No work has started on the formulation of law or formation of any authority as yet, although these issues have been mentioned in the 2012 strategic paper.
*This report appeared in the print and online edition of Prothom Alo and has been rewritten in English by Hasanul Banna