‘Bangladesh can pursue universal health coverage’

Bangladesh has all the prerequisites to adopt the idea of universal health coverage (UHC) to protect its people from slipping into poverty and tackle new challenges with regard to the changing population, the Managing Director of Rockefeller Foundation, Jeanette Vega, has said. 

“You have great achievements in health, a vibrant civil society and a very good government system – all the conditions necessary to adopt universal health coverage,” she told bdnews24.com in an interview during her Bangladesh visit. 

Vega, who is also implementing the foundation’s Transforming Health Systems Initiative, said budget is not the problem to launch the relatively new idea, “if a country has a clear political commitment.” 

According to her, due to heavy out-of-pocket expenditure, preventive aspects of health remain ignored among Bangladeshi people, who eventually have to pay more for late arrival in the hospitals. 

“It’s (UHC) a very simple concept. It says people should have access to healthcare without getting into financial catastrophe. In other words, people should have access to care with financial protection.” 

“And it is something that is true in several countries in the world,” she said on Wednesday before leaving Dhaka. 

According to the World Health Organisation, where Vega earlier worked as a Director and oversaw equity in health system, prepaid health financing mechanisms, such as health insurance, is the key route to the UHC

Health officials in Bangladesh are also contemplating the idea for the country where despite a robust health infrastructure, people have to spend 65 percent out-of-pocket for care, which in turn pushes 5 percent of them into poverty every year. 

Though people get free drugs from hospitals, they have to pay a bit for every single service from an X-ray to a blood test – an amount government collects as ‘users’ fee’. 

But Senior Secretary of Health Ministry Mohammad Humayun Kabir at a function on Tuesday asked UHC promoters to go slow as he feared it could need additional money from the national exchequer for implementation. 

Vega, also a former junior minister for health in Chile, said people sometimes think health insurance is possible only in countries with more resources. 

“But it’s not true. It’s also possible in countries like Bangladesh,” she said citing instances of Sri Lanka, Kerala in India, Rwanda and Ghana where the system has been developed within a decade. 

“Budget is always a constraint. You can still advance.” 

She said extracting users’ fee from hospital patients has, in fact, worked as a deterrent. “There is plenty of evidence to prove that it discourages people from coming to hospitals.” 

The government could instead collect that money and form a pool to introduce a prepaid system, Vega suggested. 

She said the out-of-pocket expenditure should not be more than 20 percent for any service. “And in a catastrophic situation like long stays in Intensive Care Unit (ICU), it should not be more than 40 percent of household salaries.” 

The Rockefeller Foundation MD said Bangladesh has made huge advancement in the field of health, but it still needs to introduce the UHC as most of the advances are related to general well-being and in the area of maternal and child health. 

“But the problem is population is changing. You are going to have new challenges and for this it’s not enough to have clean water or to have rural sanitation, for example non-communicable diseases like cardiovascular diseases. 

“To tackle those challenges you need to have a very well-functioning health system not only at the primary care level, but all levels.” 

“And building that is very expensive. So you need to find ways of getting into revenues and resources in logical ways and distributing resources also in logical ways by spreading the risks.” 

She said by spreading the risk, one can have more efficient services with the same amount of money. 

“But you have to have a clear political commitment to achieve universal health coverage. 

“It means having plan and having timelines, and studying what mechanisms will fit.” 

Explaining the ways of health insurance, she said, different countries have different models of prepaid health financing mechanisms. “Bangladesh can find its own through studies.” 

She said countries like Germany, Costa Rica, Mexico and Singapore are pooling a part of salaries to use for financing health services. 

“But it is possible in countries where a big percentage of population is under formal employment. 

“There is another option … by using part of the general taxes or specific taxes like imposing sin tax on tobacco products.” 

But when these systems do not exist in countries like Bangladesh where most people are employed in informal sector, “there are some alternatives like community health insurance.” 

Vega said the community health insurance is a mechanism where you get people in the communities to pool resources together, and they create their insurance mechanism. 

“And to convince people nationally, you can create a national premium.” 

She said in the community level, “you can create a system where people on an average will pay.” 

“People with more resources can pay more. Then you need to convince the population to become part of the system. 

“And in some places in the world that is mandatory and there is legislation that makes it obligatory. 

“But in most places people enrol, when they see it works, if they see it benefits.” 

“That’s why you need to be clear and precise on what is being covered and make sure whatever you cover is good quality care. 

“Why would you put in money if you are, at the end of the day, not getting care?” 

She also suggested incorporating some screening and yearly detection of diseases in this system because “that will be preventing more acute and more complicated cases.” 

As Health Minister AFM Ruhal Haque has on different occasions said they are trying to introduce a prepaid card for the poorest of the poor so that they get confidence and go to the hospital to avail free health services, Vega said it could be a good beginning. 

The Rockefeller Foundation is funding different organisations including the Ministry of Health and Family Welfare to find out best mechanisms for health insurance in Bangladesh

She said they want Bangladesh to be a part of the global movement so that countries could advance to universal health. 

“Unless the government is convinced and committed, not much can happen.”