What role can the private sector play in creating a healthy nation?
Bangladesh, under the able stewardship of the present government, has made huge strides in socioeconomic indicators. The role of the private sector in this journey was pivotal, and the health sector is no exception. The open market economic policies since 1990, which created more disposable income, also made an important contribution to this.
The private healthcare industry has grown to be one of the largest sectors of the country, both in terms of revenue and employment. Private enterprises cover roughly 60 percent of the health sector in Bangladesh, employing approximately 70,000 doctors with roughly 100,000 hospital beds, providing employment to around 12 lakh people and with a combined investment of around Tk two lakh crore. This sector receives preference from patients due to its quality, efficiency and reliability of services.
However, when it comes to spending, almost 67 percent of medical costs are spent out of pocket due to low budgetary allocations. Per capita healthcare spending stood at USD 42, as of 2018. To add to the perspective, total allocation (after increase) in the 2021 budget was Tk 292.5 billion (USD 3.4 billion), which is about 5.14 percent of the total budget and less than one percent of GDP (while total healthcare expenditure is about 2.34 percent of GDP). This percentage-wise allocation is lower than that of our other South Asian neighbours. Health is a central tenet in Sustainable Development Goal Three or the Global target (as formulated by the UN) to "ensure healthy lives and promote well-being for all at all ages" by 2030.
On that note, we can analyse the challenges that the private sector in healthcare faces in general, followed by a host of solutions that can be considered to achieve our goal of a healthy nation.
The first of these challenges is the centralised nature of the health system, along with a weak governance structure. There is also a lack of advanced health technology information and integrated services, which reduces people's confidence in the sector's customer care. Costs and out-of-pocket expenses tend to increase regularly, and the payment process can be difficult. Additionally, there is a lack of skilled healthcare professionals (nurses, technologists, etc.), alongside various ethical challenges. Regulatory bodies with haphazard regulations and high capital expenditures in comparison to neighbouring countries only add to this.
Thankfully, there are many solutions that can be implemented to deal with these challenges. There is a need for transparent healthcare policies for both public and private healthcare services, with a separate Directorate for private healthcare. A separate Directorate, by providing one-stop services (such as, for the purpose of licensing, which at present is provided from 17 different offices) will help the private sector facilities run smoothly.
There is also a pressing need for strong regulatory bodies with accountability. Setting up bodies, where applicable, and empowering bodies like the Bangladesh Medical and Dental Council will enhance much-needed transparency. The grading of services, as well as monitoring of service providers with a grading system for hospitals, clinics, etc. into A, B, or C categories, along with proper fee structures (in comparison to those of neighbouring countries like India, Thailand, etc.) will ensure standardisation and quality.
A national accreditation system and the implementation of mandatory two-yearly accreditation and quality processes for service providers will rapidly enhance the quality of this sector. Non-branded (Generic) drugs would also be of use—if hospitals categorised in grades B or C get the opportunity to provide non-branded medicines, it will cut their costs of service while also preserving quality.
In both the public and private sector, we need clear career pathways for health professionals, who should be categorised according to their type of work—academic, administrative and practicing. This should be coupled with continuous medical education training and research and development (R&D). Private sector R&D is critical for the future development of the health sector. Research findings can be applied at the policy level to make changes to costing, accountability and governance. This will be critical for dealing with emergencies like the Covid-19 pandemic.
At this point, it is crucial that we have a digital healthcare platform so we can incorporate electronic medical records with National ID Cards (NID) to ensure that the basic health information of people is recorded, along with sociodemographic information. This way, doctors can access necessary medico-lifestyle information easily, allowing for swift and safe treatment.
Implementation of health insurance (in phases) is necessary for universal access to healthcare. We also need to have geographically distributed, zonal health workers such as family physicians who will be responsible for the health of a local community. They should be connected through a referral system to the district hospitals for specialised advice. In this way, the burden on specialist medical professionals will be minimised. However, for greater access to health coverage, local community clinics must be strengthened as well. One way to do this is by organising them under committees, comprising members from local authorities and public representatives, that are led by medical professionals. Private sector players can support the clinics in a social enterprise model.
Another crucial need for the present is health education en masse. Every person needs to take care of their physical, mental, social and spiritual health. NGOs, which are already covering many of these areas, can play a pivotal role here. Some of their interventions like literacy programmes, nutrition, social awareness, primary and preventive healthcare, skills-building, mass counselling in high-risk industries (such as ship-breaking), etc. can be strengthened by more investments.
Another way forward is through public-private partnerships, such as the Aarogyasri programme in India. The private sector, as we know, carries the majority burden of healthcare in Bangladesh. With proper support and conducive conditions, this sector can be made more efficient and effective in bringing better quality healthcare and outcomes for citizens. Some estimates suggest that as much as USD 1,000 crore is being spent abroad by Bangladeshis every year for the purpose of health treatment. This huge amount of foreign currency can be saved by building people's trust in our own health sector.
We also need a strong association for the voices of healthcare providers. This can not only promote the voice of the sector, but can also enhance self-accountability and healthy competition among members. Finally, environmental, social and corporate governance (ESG) elements should be the three central factors in measuring feasibility and societal impact, which in turn will make the healthcare industry more sustainable.
Dr A M Shamim is Managing Director, Labaid Group.