The health system of Bangladesh has undergone a number of reforms and has established an extensive health service infrastructure in both the public and private sectors during the past four decades. Bangladesh has achieved impressive gains in population health, achieving the Millennium Development Goal 4 target of reducing under-five child mortality by two thirds between 1990 and 2015, and improving other key indicators such as maternal mortality, immunization coverage, and survival rates from malaria, tuberculosis, and diarrhoea diseases.

1. Health Systems in Transition
Bangladesh
Health System Review

2. 2
Authors:
Editors:
Health Systems in Transition: Bangladesh
Health System Review
Syed Masud Ahmed Bushra Binte Alam
Iqbal Anwar Tahmina Begum
Rumana Huque Jahangir AM Khan
Herfina Nababan Ferdaus Arfina Osman
Aliya Naheed Krishna Hort
Suggested citation: Ahmed SM, Alam BB, Anwar I, Begum T, Huque R, Khan JAM, et al. Bangladesh Health System Review.
Vol.5 No.3. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.

3.  Bangladesh: Socio-demographic profile
 Overview of health system
 Service delivery network
 Governance and administration
 Financing
 Major reforms
 Infrastructure
 Human Resources
 Main findings
 Progress made
 Remaining challenges
 Future prospects
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Presentation outline:
This map is an approximation of actual country borders
Source: https://www.who.int/countries/bgd/en/

4. 4
Socio-demographic profile
Area 147570 sq. km
One of the highest densities
in the world
Population • 151 million (2010)
• 85.6% Rural population
• 2.3 TFR (2010)
Life expectancy at
birth m/f
68/69 (2010)
GDP per capita: $1464 (PPP, constant
international $)
HDI 146
Expenditure on
health % GDP
3.7% (2011) Source: http://publications.worldbank.org/WDI/indicators
Trends in population/demographic indicators

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Pluralistic health system
1.1. Provision of basic health services [and nutritional status] a
constitutional obligation
2.2. Key actors: Government, private sector, NGOs and donor
agencies
3.3. Government-led regulation and policies
4.4. MoHFW regulates both public and private sector health
services.
5.5. Family planning: separate division under MoH
Overview: Health system
1. High OOP payments
2. Fragmented coordination in funding and operations
3. Worker shortage/informal provider majority

6. Overview: Service delivery
MoHFW implements programmes:
 Executing authorities include five Directorates and some
other organizations
 GoB delivers health-care via NGOs as well
MoHFW has extensive infrastructure from the national to the
ward level
 Patient pathways: No structured referral system
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4th Oral Cholera Vaccination campaign in Cox's Bazar, Bangladesh
©WHO Bangladesh/Catalin Constantin Bercaru
Private sector:
 Organized private sector: for-profit and nonprofit. Includes qualified practitioners of different
systems of medicine
 Private informal sector: providers without formal qualifications, example: untrained allopaths,
homeopaths, kobiraj, etc., known as Alternative Private Providers
 NGO: Dominant sector; 9% of THE managed by NGOs (2007). Good coordination between NGOs &
Government
Outpatient care:
 Primary care delivered by public and private sectors and NGOs.
 Community clinics are a flagship government programme providing a wide range of primary
health care including: MNCH, nutrition, IMCI and some CD/NCD services

7. Overview: Service delivery
Outpatient care:
 Secondary and tertiary facilities dominate outpatient care in urban areas
 Public sector facilities are poorly equipped with medical equipment including basic
instruments such as clocks. The private sector has state of the art diagnostic equipment and
facilities
Inpatient care:
 Primary, secondary and tertiary facilities and the informal sector all provide inpatient care.
 Most of the medicines available at public facilities are provided to inpatients.
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• MOHFW oversees policy, regulation, funding, service implementation
• MOHFW split into a dual system: Health Services and Family Planning
• MoLGRDC manages urban primary care services
National
• MOHFW: field-level health administration is responsible for implementing
government programmes
• MoLGRDC: local bodies have a small role in service delivery
Local
• NGO and private sector expansion to fill service gaps
• Donor involvement in health care financing and planning.
• Professional organizations: BMA, BNC, BPMPA
• No group advocates for patient interests.
Other
Overview: Governance and Administration

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Overview: Health Financing
• 64% OPP expenditure on health
(MoHFW, 2010)
• Bangladesh National Health Accounts
(BNHA) health expenditure (per capita
THE US$16.20 in 2007) estimates
different from WHO (US$26.60)
• THE doubled from 1997-2007 to $2.3
billion USD
• Chronic underspending leads to
resource utilization inefficiency and
occurs every year in MOHFW
Source: MOHFW, 2010; World Bank 2012a
Trends in health expenditure, 1997-2011

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Overview: Health Financing
Source: MOHFW, 2010
Sources of revenue as a % of THE on health by financing agent: 1997-2007
• GGHE and MOHFW revenue have decreased by 10% of THE
from 1997-2007. OOP and NGO/donor dependency have
increased during this period.
• OOP payments are primarily made towards pharmaceutical
and medical goods

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Overview: Major reforms
• HPSP (1998-2003)
• SWAp
• Essential Service Package and Community Clinics
• Unification of Health and Family Planning Wings
• HNPSP (2007-2011)
• Bifurcation of Health and Family Planning Wings
• Decentralization of health services
• Maternal Health Voucher Scheme
• HPNSDP (2011-16)
• SWAp-based funding, donor-harmonization
• UHC and Health-care Financing Strategy alignment
• Health-care Financing Strategy (2012-2032)
• To provide direction in achieving universal health coverage

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Source: Bangladesh Health Watch, 2011
Overview: Infrastructure
Bed occupancy rate by division in public hospitals
• Health care facility network follows administration structure
• Extensive primary health care structure lacks physical and human resources
• Private sector has more facilities than public sector but equal amount of beds
• Hospital beds to population ratio low at 1 to 1699 people

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Overview: Human resources for health
Source: Bangladesh Health Bulletins 1997, 2007 and 2012
Density of health-care providers per 10000 population
• Informal providers: provide
majority of health care
• Professional workforce shortage:
52463 doctors, 257585 nurses and
445751 technologists according to
WHO recommended ratio
• Impact of feminization of health
workforce on HRH planning:
Many female doctors, nurses and
medical technologists no longer
practice after marriage, depleting
needed human resources. In
addition, poor infrastructure and
socio-cultural norms limit posting
of women to rural and remote
areas.

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Achievements and progress made: Health status
• Notable gains in life
expectancy, child
immunization, and literacy
rate for young women
• Significant drop in
communicable disease and
injury-related mortality
• Narrowing equity in access to
health services between
highest and lowest quintile
households
Source: Global Burden of Disease Study 2010 http://ghdx.healthdata.org/record/
bangladesh-globalburden-disease-study-2010-gbd-2010-results-1990–2010
Leading causes of death from 1990-2010

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Achievements and progress made: Public health
programmes
TB program:
national coverage
HIV prevalence<1%
for high risk
population
Leprosy prevalence:
0.24/10000
population
Malaria: Integrated
services, NGO
coordination
Health institutes:
surveillance,
emergency
outbreak assistance
• TB and Leprosy
programmes provide
national coverage
• The majority of MOHFW
health programmes have
adopted a behavioural
change approach to
stimulate informed
demand

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Achievements & progress made: MCH
• Maternal mortality rate halved
between 1990 and 2013
• Successful maternal voucher
scheme: 89% safe delivery rate,
maternal mortality rate of
12/100000 live births
Source: BDHS
Trends in child mortality, 1989-2011
Maternal mortality by stage of pregnancy
Source: BMMS, 2001 & 2010
• 86% child immunization rate by
2011
• Infant mortality rate halved
between 1990 and 2011. Child
mortality reduced by almost
40% during this period

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Achievements & progress made: NGOs and donors
• 24-27% funding for
health sector
programme budget
•Fund priority vertical
programmes, e.g. TB
•Specialist services,
training and education
courses
•Mass promotion
activities compensates
for low human
resources
•NGO and Donor
cooperation: Service,
planning and funding
coordination
•Urban health program
contracted to NGOs
•Planning, service
implementation,
financing, capacity
building
•80% of funding from
donors
NGOs
Government
relationship
Donor
reliance
Filling in
gaps

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Achievements & progress made: Pharmaceutical
sector
Aim:
quality
essential
drugs at
affordable
prices
NDP
(1982)
Domestic
production
75% of
total drug
sales
Exports to 84
countries
Contributes
1% of GDP
100-fold
industry
growth
over 30
years
• National Drug Policy 1982
• access to quality
essential drugs at
affordable price
• First low-income country
to have an indigenous
pharmaceutical industry
• 3rd highest contributor to
government revenue

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Remaining challenges: Risk factors health
Morbidity and risk factors for health status
Source:: Global Burden of Disease study, Bangladesh
country analysis: http://ghdx.healthdata.org/
record/bangladesh-global-burden-disease-study-2010-
gbd-2010-results-1990–2010
• 59% of mortality caused by NCDs
• Risk factors: water and sanitation,
under-nutrition all showed significant
improvements
• Smoking, high blood pressure, diabetes
and dietary risks all increased from
1990-2010
• Limited facilities and surveillance on
NCDs and services create large gaps in
service provision.

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Remaining challenges: Quality of care
• Institutional limitations, absenteeism, negligence
from providers
• Low levels of professional knowledge
Public and
private sector
• Lack of human and physical resources and supplies
• Lack of recognition or incentives
• Lack of appropriate training in informal sector
Supply-side
• Richest 40% pay 60% of OOP
• Poorest often forgo necessary medical care
Social
inequities
HIS
• Little coordination between directorates, BoS
• Poor quality data, managers and policy planners
rely on survey data

21. Remaining challenges: OOP
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Source: MOHFW, 2010
• Highest incidence of
catastrophic payments in
the Asia Pacific region
• Lack of investment,
service availability, staff
and health insurance
options contribute to
66% of THE being from
OOPP0
10
20
30
40
50
60
70
80
90
100
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
%
Households' OOP by provider, 1997-2007
Hospitals Drugs and medical goods retail outlets Medical and diagnostic facilities

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Remaining challenges: Poor regulation
Source for both tables: Nomura S et al., 2017
Legal instruments
may be decades
old
Parliamentary
watchdog
inefficient
Low regulation on
physician quality
of care
Strict regulation
over funding
allocation
Ill-equipped lab
testing: low quality
drugs flood market
• Parliamentary watchdog:
irregular meetings, poor
attendance, politically
maligned leads to decreasing
oversight and compliance
• Funding: spent in accordance
with rules rather than needs
• Ill-equipped lab testing:
market flooded with expired,
counterfeit and low-quality
drugs

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Remaining challenges: Workforce
Source: Bangladesh Health Watch 2007
Rural-urban distribution of health-care providers by type
• Unqualified health
professionals: higher in rural
areas where 86.6% of the
population resides
• Dual practice: 80%
government physicians engage
in dual practice
• Vacancies: 20% of all public
sector posts for doctors,
dentists and nurses are vacant

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Remaining challenges: Medical equipment
Functioning diagnostic equipment
X-ray: 65% of DHs and 52% of Upazila HCs
Ultrasonograms: 61% of DHs, 57% of Upazila
HCs
Laboratory items
Less than 60% of Upazila HCs had 19/34 basic lab items
Public sector medical equipment
No height measurement in 50% of MCWCs
25% of hospitals had no clock or minor surgical
tools

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Future prospects: Bangladesh
Achieving UHC
• Prepayment mechanism to increase social protection, decrease OOPPs and external
donor dependence
Mobilize informal workforce to strengthen HR
• Focusing on informal sector to increase UHC, health workforce
HIS/eHealth
• Expand on facility access, increase decision-making capability
• Telehealth to expand access to rural, remote areas
Evaluate Urban Health-care program
• Develop strategy to extend model to rural areas
• Link to social health insurance mechanism to lead to sustainable health care system

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Based on the Health Systems in Transition
The Bangladesh Health System Review, 2015

27. http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/hit_bangladesh/en/
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