2014年-世界发展银行全球_Universal_Health_Coverage_for_Inclusive_and_Sustainable_Development___Country_Summary_Report_for_Bangladesh_17页_1mb

Summary of the Country Summary Report for Bangladesh under the Japan-World Bank Partnership Program for Universal Health Coverage

Core Content

This report provides an overview of Bangladesh's progress and challenges in achieving Universal Health Coverage (UHC) as part of the Japan-World Bank Partnership Program. It outlines the current status of UHC, health financing policies, human resources for health (HRH), and the sequencing of reforms. The goal of UHC is to ensure all people can access quality health services, be protected from public health risks, and avoid impoverishment due to illness.

Main Points and Key Information

1. Economic and Social Context

• Country Status: Bangladesh is a low-income country with a GNI per capita of $1,940 (PPP) in 2011.
• Population: 150.5 million in 2011.
• Health Expenditure: Total health expenditure (THE) was 3.8% of GDP in 2011, with OOP spending accounting for 59.8% of THE.
• Health Outcomes: Bangladesh has made significant progress in health-related Millennium Development Goals (MDGs), including a reduction in under-five mortality by half and a sharp decline in fertility rates to 2.2 births per woman in 2011.
• Life Expectancy: 69 years for the total population in 2011.

2. Health Financing System

• Legal Framework: The Constitution mandates the government to provide basic necessities, including medical care, and public primary health facilities are supposed to be free of charge.
• Public Financing: The Ministry of Health and Family Welfare (MOHFW) is responsible for health financing and service delivery. Public spending accounts for 38.2% of THE in 2011.
• Private and Out-of-Pocket (OOP) Spending: Private expenditure is minimal (2.1% of THE), while OOP spending remains the dominant form of health financing.
• Fiscal Constraints: The government is facing challenges in finding fiscal space to fund UHC, and external resources play a significant role in financing health services.
• Health Protection Fund (HPF): The HPF is planned to cover both the poor (noncontributory) and formal sector workers (contributory), with the aim of integrating all households under the national HPF by 2032.

3. Human Resources for Health (HRH)

• Workforce Shortages: HRH is a major bottleneck in the health system, with a severe shortage of skilled professionals.
• Workforce Distribution: A significant portion of the health workforce is concentrated in urban areas, while the majority of the population resides in rural regions.
• Unqualified Professionals: About 94% of the health workforce are unqualified, indicating a need for improved training and regulation.
• Training Initiatives: The MOHFW is focusing on training lower-level health workers, such as medical assistants and community health workers, to address HRH challenges and improve service delivery at the grassroots level.

4. Financial Protection and Equity

• OOP Spending: OOP payments constitute the majority of health spending, leading to high rates of catastrophic health expenditure (7–25% of households annually).
• Poverty Impact: OOP spending drives up to 3.8% of the population into poverty annually, highlighting the need for prepayment mechanisms.
• Inequities in Service Utilization: There are significant disparities in health service access and utilization, with higher-income groups benefiting more than lower-income ones.
• Urban Poor Vulnerability: Slum populations face poor health conditions due to unmanaged urban growth, including contaminated food and water, air pollution, and unsafe housing.

5. Sequencing of Reforms

• Phased Approach: The UHC reform process is divided into three phases:
  • Phase 1 (2012–2016): Pilot a noncontributory health program for the poor (Shasthyo Suroksha Karmasuchi, SSK).
  • Phase 2 (2016–2021): Launch the HPF to cover both the poor and formal sector workers.
  • Phase 3 (2032): Achieve UHC and integrate all households under the national HPF.
• Community-Based Health Insurance (CBHI): CBHI is promoted for households not covered by the HPF during the interim period.
• Health Benefits Package (HBP): The HBP is expected to expand coverage for cost-effective interventions, particularly for the poor, and may include treatments for high-cost catastrophic events.

6. Lessons for Other Countries

• Constitutional Rights: Embedding healthcare access in the Constitution provides strong institutional support for UHC.
• Explicit Targets: Setting clear target dates for UHC helps in mobilizing political support and maintaining focus on the goal.
• Sector-Wide Approach (SWA): Bangladesh is implementing a SWA to harmonize external assistance and ensure efficient use of donor funds.
• Innovative Financing: The introduction of new payroll taxes and social insurance programs may help expand coverage and reduce OOP expenditure.
• Community Engagement: Community participation and activism have been crucial in driving innovation and improving health outcomes.
• Revisiting Traditional Models: Bangladesh needs to revisit traditional HRH models to address the shortage of skilled professionals and improve deployment and remuneration strategies.

Conclusion

Bangladesh is at an early stage in its journey toward UHC and is exploring innovative mechanisms to improve health services coverage and financial protection. Despite progress in reducing under-five mortality and fertility rates, the country faces significant challenges, including fiscal constraints, HRH shortages, and inequities in health service access. The proposed Health Protection Fund and the emphasis on community-based insurance and training lower-level health workers represent important steps toward achieving UHC. The country's experience highlights the importance of political will, innovative financing, and community engagement in the pursuit of UHC.