About Healthcare system of Bangladesh: Health care delivery is a daunting challenge area of the Bangladesh’s healthcare systems. The Health care system in Bangladesh falls under the control of the Ministry of Health and Family Planning. The government is responsible for building health facilities in urban and rural areas.

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Introduction:
Bangladesh, officially the People’s Republic of Bangladesh, is a country in South Asia and one of the
most densely populated countries in the world. It is a unitary state and parliamentary democracy.
Health and education levels are relatively low, although they have improved recently as poverty levels
have decreased.
Health care delivery is a daunting challenge area of the Bangladesh’s healthcare systems. The Health
care system in Bangladesh falls under the control of the Ministry of Health and Family Planning. The
government is responsible for building health facilities in urban and rural areas. For example, in the
late 1980’s in Bangladesh, the rural health facilities that existed in the rural areas were mostly sub-
district health centers, rural dispensaries and family welfare centers. Unfortunately, they were poorly
administered. For example, a sub-district health center had only thirty hospital beds. Most of its
services were useless because of staff problems like few medical professionals and because the
hospitals had no support service. Urban health centers also had problems with inadequate medical
supplies. In many urban centers today, health services are provided by nongovernmental institutions.
During dangerous months like monsoon season and other natural disasters, the Bangladesh health
system isn’t capable of managing the number of victims. In Bangladesh, the majority of the country’s
population lives in rural areas, while the majority of health professionals work in urban centers. Also,
the rapid growth of the private medical system meant that fewer professionals remained in the public
sector to take care of the masses. Private systems are mostly out of reach for poor people who can
barely afford to live day by day. The health system in Bangladesh is supply-side financed, meaning
that poor households can have access to medical treatments or at least to essential medical care. Still,
there is a large gap because community financing programs are missing. Some NGO’s have started to
offer micro-credit medical programs in order to help develop a national insurance program. One third
of the national health system is publicly financed, meaning that the government pays for it from taxes
and international subsidies. This means that the poor population is forced to pay for medical expenses
while they can barely afford to put bread on the table because of the immense lack of jobs.
Healthcare System:
A healthcare system, is the organization of people, institutions, and resources that deliver health care
services to meet the health needs of target populations. There is a wide variety of health systems around
the world, with as many histories and organizational structures as there are nations. Implicitly, nations
must design and develop health systems in accordance with their needs and resources, although
common elements in virtually all health systems are primary healthcare and public health measures.1
According to the World Health Organisation a health system consists of all organisations, people
and actions whose primary intent is to promote, restore or maintain health. This includes efforts to
influence determinants of health as well as more direct activities that improve health. A health system
is, therefore, more than the pyramid of publicly owned facilities that deliver personal health services
but include the institutions, people and resources involved in delivering health care to individuals for
example;
֍ A mother caring for a sick child at home;
֍ A child receiving rehabilitation services within the school setting;

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֍ An individual access vocational rehabilitation services within the work place;
֍ Private providers, behaviour change programmes, such as vector-control campaigns.
֍ Health insurance organisations, occupational health and safety legislation which includes inter-
sectorial action by health staff, for example, encouraging the ministry of education to promote
female education, a well-known determinant of better health.2
Donabedian Model of Health System:
The Donabedian model is a conceptual model that provides a framework for examining health services
and evaluating quality of health care. According to the model, information about quality of care can
be drawn from three categories: “structure,” “process,” and “outcomes." Structure describes the
context in which care is delivered, including hospital buildings, staff, financing, and equipment.
Process denotes the transactions between patients and providers throughout the delivery of healthcare.
Finally, outcomes refer to the effects of healthcare on the health status of patients and populations.
Avedis Donabedian, a physician and health services researcher at the University of Michigan,
developed the original model in 1966. While there are other quality of care frameworks, including the
World Health Organization (WHO)-Recommended Quality of Care Framework and the Bamako
Initiative, the Donabedian Model continues to be the dominant paradigm for assessing the quality of
health care.3
The WHO Health Systems Framework:
WHO framework that describes health systems in terms of six core components or “building blocks”:

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(i) service delivery,
(ii) health workforce,
(iii)health information systems,
(iv)access to essential medicines,
(v) financing, and
(vi)leadership/governance
The six building blocks contribute to the strengthening of health systems in different ways. Some
cross-cutting components, such as leadership/governance and health information systems, provide the
basis for the overall policy and regulation of all the other health system blocks. Key input components
to the health system include specifically, financing and the health workforce. A third group, namely
medical products and technologies and service delivery, reflects the immediate outputs of the health
system, i.e. the availability and distribution of care.
Inevitably, any type of division of a complex construct such as the health system is fraught with
problems. This is also true for the framework, which focuses on health sector actions and underplays
the importance of actions in other sectors. It does not take into account actions that influence peoples’
behaviours, both in promoting and protecting health and the use of health-care services. The framework
does not address the underlying social and economic determinants of health, such as gender inequities
or education, and also does not deal with the substantial and dynamic links and interactions that exist
across each component. On the other hand, focusing on these separate components helps put
boundaries around this complex construct and permits the identification of indicators and measurement
strategies for monitoring progress.4
Building Blocks of Health System:
 Through functional responsive health systems healthcare goals can be achieved. Capacity
building add skills, fill gaps, generate efficiencies, thereby creating sustainable health systems.
This ensures reliability and resilience even during adverse emergency situations.
 Health systems components are interdependent, however, may face unique challenges. Through
adaptive holistic approaches, capacity building needs to not just focus on healthcare workers in
clinical care but also cut across all the pillars of a health system including governance and
leadership, human resource, customer care, health commodities etc.

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 Identification of facility or case-specific gaps is useful in distinguish a health institution or
facility needs including the specific pressing training needs. Needs assessment offers reference
points for pin-pointing key priority areas and tracking of progress especially in low resource
settings.
 Continuous learning for healthcare workers is fundamental. Apart from professional education,
additional learning for pharmacists and the various staff at the different levels of healthcare
facilities is required to maintain, improve their skills, adapt to changing trends of the healthcare
systems and also improve quality of healthcare services delivery.
 While learning is an active process, it requires not only listening, watching or reading, it also
involves reacting and feedback. People learn through combination of ways, and it is an important
consideration for FBOs to use different learning approaches to deliver training lessons in order
to ensure effective delivery of information.5
Classification of Types of Goals for Health Care System:
Types of Health Services:
Health
Services
Finance by Govt
Service provided by Govt
Bangladesh, India, Nepal etc.
Finance by Govt
Service provided by Pvt
NHS, UK
Finance by Pvt
Service provided by Pvt
USA
Finance by Pvt
Service provided by Govt

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The System in Bangladesh is Pluralistic.
Health System Models: 6,7,8,9
While globally each country has some variation in their health care systems, overall they tend to follow
general patterns with four main models forming the basis for most health care systems globally;
•The Beveridge Model of Health Care, named for William Beveridge, the social reformer who designed
Britain’s original National Health Service. Like other public services such as the police or education
systems, this model of health care is both provided and financed by the government through tax
payments. In this system, healthcare facilities can be owned by the Government, but may also be
privately owned with Government funding, with the majority of health staff in this model composed of
government employees. These systems tend to have low costs per capita, because the government, as the
sole payer, controls what healthcare providers can do and what they can charge with benefits generally
standardised across the country.
•Countries using the Beveridge Model or variations on it include Great Britain, where the Beveridge
Modelwas developed, Spain, most of Scandinavia and New Zealand.
Beveridge
Model
•The Bismark Model of Health Care also referred to as a "Social Health Insurance Model" was named for
the 19th Century Prussian Chancellor, Otto von Bismarck, who developed a welfare state with
compulsory insurance for all working individuals as part of the unification of Germany in 1883. It is a
health insurance plan that in principle must include all citizens, and is non-profit in nature, although in
practice tends to be available only to the working population with the allocation of resources to those
who contribute financially, so as such does not provide universal health coverage. It is predominantly
funded jointly by employers and employees through payrolldeductions.
•Generally, it is a mixed model health system that incorporates a mix of private and public providers and
allows more flexible spending on healthcare. Providers and hospitals are generally private, while
insurers are generally public. Some countries like France or Korea have a single insurer, while other
countries like Germany have multiple competing insurers although pricing is controlled by the
government as is also seen with the Beveridge Model. This model is found in Germany, France,
Belgium, the Netherlands, Japan, and Switzerland.
Bismark
Model
•This system combines elements of both the Beveridge and Bismarck Models of Healthcare. Generally,
funding comes from a government run insurance program that every citizen pays into, as we see in the
Beveridge Model, but it predominantly uses private sector providers. This model provides universal
insurance that doesn't make a profit or deny claims and as such with no requirement for marketing, no
financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and
much simpler administratively than For-Profit or Private Insurance Models.
•The single-payer tends to have considerable market power to negotiate for lower prices; Canada’s
system, for example, has negotiated such low prices from pharmaceutical companies that Americans
have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also
control costs by limiting the medical services they will pay for, or by making patients wait to be treated,
which is the primary criticism of these models. The potential for long waiting lists and delays in
treatment can be considered a serious health policy issue. This model is found in Canada, Taiwan and
South Korea, and theMedicare Modelin the United States of America are based on this model.
National
Health
Insurance
Model
•Disparities in health care due to socioeconomic status and ethnicity are found in all countries. Currently,
there are a limited number of countries globally that have established national health care systems, with
the majority of countries providing ad hoc national medical care, which is provided on a private or pay
for treatment basis. This typically means that those with access to money get access to health care, while
those that do not have money do not have health care access. In many isolated or rural regions of the
world, hundreds of millions of people can go their whole lives without ever accessing health care
services. In this typeof model Healthcare is still driven by income.
•This model of healthcare is found predominantly in isolated communities and is particularly seen in rural
areas in India, China, Africa, South America, and among uninsured or underinsured populations within
the United States of America.
The Private
Model

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Guiding Principles of Health System in Bangladesh:
Constitution:
(i) Article 15(a): Ensure basic necessities of life (Including medical care) to its citizens.
(ii) Article 18(1): Raise the level of nutritional status and improve public health.
SDGs:
SDG-3: Ensure healthy lives and promote wellbeing for all at all ages by 2030 (13 Targets and 28
Indicators)
MDGs: Achieve by 2015
(i) MDG 4: Reduce Child Mortality
(ii) MDG 5: Improve Maternal Health.
(iii)MDG 6: Combat HIV/AIDS, Malaria and other Diseases
Health Population and Nutrition Program (1998-2021): Sustainable improvement in health,
nutrition and family welfare.
National Health Policy(NHP)-2011: 15 Principles. Ensure quality health, nutrition and family
welfare services which is affordable, attainable and acceptable to its citizens.
Bangladesh National Population Policy-2012: Lower the Total Fertility Rate (TFR) to 2.1,
achieve NRR=1 to achieve stable population by 2060.
National Drug Policy-2014
Vision 2021: Digital Bangladesh and improving Human Development Index.
National Nutrition Policy 2015
(i) Healthcare Financing Strategy 2012-2032: Expanding Social Protection for Health Towards
Universal Coverage
(ii) Bangladesh Health Workforce Strategy 2016-2021
Agreement on International declarations:
(i) The Alma Ata Declaration (1978)
(ii) The World Summit for Children (1990)
(iii)International Conference on Population and Development (1994)
(iv)Beijing Women’s Conference (1995)
Organization of the Health System in Bangladesh:
The health system of Bangladesh is pluralistic, with four key actors that define its structure and
function: Government, the private sector, NGOs and donor agencies. The Government or public sector
is the first key actor who, by constitution, is responsible not only for setting policy and regulation but
also for providing comprehensive health services, including financing and employing health staff. The
Ministry of Health and Family Welfare, through the Directorates General of Health Services (DGHS)
and Family Planning (DGFP), manages a dual system of general health and family planning services
through 53 District Hospitals, 425 Upazila Health Complexes, 1469 Union Health and Family Welfare
BangladeshIs HavingA MixedModel Of PublicAnd Private Provision
And Financing In Health System.

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Centres, and 12 248 community clinics at ward level. In addition, the Ministry of Local Government,
Rural Development and Cooperatives manages the provision of urban primary care services.
[Source: Asia Pacific Observatoryon Health Systems and Policies]
The quality of services at these facilities, however, is quite low, due mainly to insufficient resources,
institutional limitations and absenteeism or negligence of providers. Since 1976, to compensate for the
government’s limited capacity to provide basic health services, the private sector and NGOs have
established a network of facilities to provide health and family planning services. The private sector
consists of the formal sector, which provides both western and traditional (Unani and Ayurvedic)
services through a range of facilities from hospitals to clinics, laboratories and drug stores, and the
non-formal sector, which consists of largely untrained providers of western, homeopathic and
traditional (kobiraj) medicine. However, private services are poorly regulated, while the formal sector
is concentrated in urban areas, and the informal sector is the principal provider in rural areas. In
response to the low quality of service provision by Government and its inability to reach the entire
population, particularly the poor, a vibrant and large NGO sector has emerged as a “third sector” of
health providers in Bangladesh. The role of NGOs is growing as donors channel significant and
increasing amounts of funding directly to them. In 2007, 9% of total health expenditure (THE) was

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managed by NGOs, up from 6% in 1997. As a response to both external and internal pressures, there
have been partnerships between government and NGOs in the areas of financing, planning, service
delivery, capacity building, and monitoring and evaluation that have produced some health gains.
Bangladesh’s public health system remains highly centralized, with planning undertaken by the
Ministry of Health and Family Welfare and little authority delegated to local levels. The Health
Information System suffers from the bifurcation of the Ministry into the DGHS and the DGFP, with
separate and distinct reporting systems for each. While there exist a number of Acts and Ordinances
to regulate the health system, including regulation of different types of providers, practice facilities
and NGOs, many of these legal instruments date from several decades ago. Separate councils for the
registration and licensing of medical practitioners, dentists, and nurses have been established, but their
authority to investigate and discipline providers is weak. A number of initiatives have been undertaken
through the joint Government-donor pooled programmes to encourage and support community
empowerment and accountability, with limited success. However, a number of NGOs remain active in
public reporting on government handling of the health sector.
Health Service Delivery Organizational Structure in Bangladesh:
Administrative structure of the statutory health system: The Ministry of Health and Family
Welfare implements its programmes and provides services through different executing and regulatory
authorities. The executing authorities include five Directorates of the Ministry and some other
organizations. The Directorates are: the DirectorateGeneral of Health Services (DGHS); Directorate
General of Family Planning (DGFP); Directorate General of Drug Administration (DGDA);
Directorate of Nursing Services (DNS); and the Health Engineering Department (formerly known
as the Construction Management and Maintenance Unit). The DNS and the DGDA are attached to
the health wing of the Ministry of Health and Family Welfare.

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[Source: Asia Pacific Observatoryon Health Systems and Policies]
Public sector health services: The Ministry of Health and Family Welfare has an extensive health
infrastructure. The service delivery structure follows the country’s administrative pattern, starting from
the national to the district, upazila, union and finally to the ward levels. It provides promotive,
preventive, and curative services such as outdoor (outpatient), indoor (inpatient), and emergency care
at different levels- primary, secondary and tertiary. The chart below (Figure above) summarizes the
organization of the Ministry of Health and Family Welfare service delivery structure.
Private sector health services: In the private sector, providers can be grouped into two main
categories. First, the organized private sector (both for-profit and nonprofit) which includes qualified
practitioners of different systems of medicine. Apart from modern medicine, traditional medicine is
widely practiced in the private sector.
Second, the private informal sector, which consists of providers not having any formal qualifications
such as untrained allopaths, homeopaths, kobiraj, etc., known as Alternative Private Providers. These
informal/traditional private service providers mostly serve the poor in rural areas. On the other hand,
the formal, for-profit or nonprofit service institutions are mostly located in urban areas. Private
facilities including medical colleges, hospitals, clinics, laboratories, and drug stores are being
established in increasing numbers in the capital city as well as other divisional headquarters. This
causes geographic inequity in health service provision. The private facilities are often staffed with
public sector health personnel.
Diagnostics: Along with private clinics and hospitals, the number of diagnostic centres in the private
sector is growing. In 2000, approximately 838 laboratories and other diagnostic centers were registered
with the Ministry of Health and Family Welfare. This number has risen to 5122 in 2012 (MOHFW,

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2012). In the private for-profit sector, there are some large diagnostic centers in the cities (Lab-aid,
Popular Diagnostics) providing laboratory and specialized radiological tests. Some of these facilities
maintain a high standard. In the nonprofit private sector, there are centres like the International Centre
for Diarrhoeal Diseases and Research, Bangladesh, located in Dhaka, which has a modern laboratory
providing research facilities and extends laboratory services to the general community.
NGOs: The NGO sector has emerged as the third sector, providing new options and innovations.
Bangladesh is known worldwide for having one of the most dynamic NGO sectors, with over 4000
NGOs working in the population, health and nutrition sector. NGOs have been active in health
promotion and prevention activities, particularly at the community level, and in family planning,
maternal and child health areas.
Donors: Multiple donors, both multilateral and bilateral, have been actively engaged in health-care
financing and planning. The main bilateral donors to the health and population sector in Bangladesh
are the governments of Australia, Belgium, Canada, Germany, Japan, Netherlands, Norway, Sweden,
the United Kingdom and the United States. The multilateral donors include the World Bank, European
Union, UNICEF, ADB, Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and the
GAVI Alliance.
Professional groups: In Bangladesh there are a number of professional organizations who address
the rights of medical professionals at different levels, such as the Bangladesh Medical Association
(BMA), Bangladesh Private Medical Practitioners Association (BPMPA), Public Health Association
of Bangladesh, Bangladesh Paediatric Society and the Nephrology Society of Bangladesh. However,
there is no organized body, either in the public or private sector, for overseeing the interests of patients.
The Consumers Association of Bangladesh is an NGO addressing the rights of consumers in general,
and does not have a separate agenda on health focusing on the rights of consumers as patients.
Main Regulatory Authorities in the Health Sector in Bangladesh:
National health policy provides for the promulgation of appropriate laws, rules and regulations
regarding the control, management and quality of services of medical colleges and private clinics.
Parliament has enacted various Acts in relation to health services. These can be mainly categorized
into communicable disease control acts, drug control acts, medical education acts, health practice acts
and environmental health acts. In addition to the Acts, the Parliamentary Standing Committee
constituted for the Ministry of Health and Family Welfare under the Rules of Procedure of Parliament
(Rule 246) serves as a watchdog of the Ministry. According to Rule 248, the Standing Committee
should meet at least once a month to review works relating to a Ministry which falls within its
jurisdiction, and to inquire into any activity or irregularity and ensure compliance in respect of the
Ministry.
Name of Agency Function
Ministry of Health and Family
Welfare
Set standards
Director General Health Services  License health facilities to function
 License the administration of controlled medicines
 Approve non-medical and non-nursing health care training
institutions
 SOPs for operation of laboratory and diagnostic centres
Director General Family Planning License the administration of controlled family planning
methods

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Director Drug Administration  License pharmacy cadres
 Quality assurance and registration of pharmaceuticals
Joint Secretary Development and
Medical Education
Approve medical colleges
Director Homeopathy and Traditional
Medicines
Accredit training
Civil Surgeons Inspectors for health and safety in factories
Bangladesh Medical and Dental
Council
 Accredit medical colleges for the training of doctors and
dentists
 Register medical and dental officers
Pharmacy Council of Bangladesh Accredit training institutions for pharmacy cadres
Bangladesh Nursing Council Register nursing cadres Accredit nursing training institutions
Ayurvedic, Homeopathy and Unani
Board
 Register practitioners
 Quality assurance and registration of traditional
medicines
Level of Health-care System in Bangladesh:
The health care are designated to meet the health needs of the community through the use of available
knowledge and resources. The services provided should be comprehensive and community based. The
resources must he distributed according to the needs of the community. The final outcome of good
health care system is the changed health status or improve health status of the community which is
expressed in terms of lives saved, death averted, disease prevented, disease treated, prolongation of
life etc.
Health care delivery system in Bangladesh based on PHC concept has got various Level of
service delivery:
A. Home and Community level
B. Union level, Union Sub Centre (USC) or Health and Family Welfare Centre (HFWC); this is
the first health facility level
C. Thana level, Thana Health Complex (THC): This is the first referral level
D. District Hospital: This is the secondary referral level
E. National Level: This is the tertiary referral level
֍ Primary level health care is delivered though USC or HFWC with one in each union
domiciliary level, integrated health and family planning services through field workers for every
3000-4000 population and 31 bed capacities in hospitals.
֍ Secondary level health care is provided through 100 bed capacities in district hospital.
Facilities provide specialist services in internal medicine, general surgery, gynecology,
pediatrics and obstetrics, eye clinical, pathology, blood transfusion and public health
laboratories.
֍ Tertiary level health care is available at the medical college hospital, public health and
medical institutes and other specialist hospitals at the national level where a mass wide range of
specialized as well as better laboratory facilities are available.

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The referral system will be developed keeping in the view of the followings:
A clearly spent-out linkage between the specialized national institutes, medical college and
district hospitals to ensure proper care and treatment of patients from the rural areas served by
lower level facilities.
Patients from the rural areas referred by lower level facilities to district und medical college
hospitals and specialized institutions should get preferential treatment after admission.
The system will be a two-way process under which patients from the rural areas will be sent into
higher institutions while at the same time specialists from the district hospitals, may visit the
Thana health complexes for providing better quality services on the spot.
Health-Care Services Provided By Public Facilities in Bangladesh:
Level of
care
Service facility Services
Ward
Community clinics  Maternal and neonatal health care
 Integrated management for childhood illness
 Reproductive health and family planning services
 EPI
 Nutrition education and supplement
 Health education and counselling

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Primary
level care
 Severe illnesses like tuberculosis
 Malaria
 Pneumonia
 EmOC
 Life-threatening influenza, anthrax etc.
 Treatment of minor ailments and first-aid
 Referral to union level facilities
 Upazila health complexes and district hospitals
 Out-Patient Services
Union
 Hospitals
 Union Sub-
Centre
 Union Health
and Family
 Welfare Centre
Out-Patient Department (OPD)
Secondary
level care
Upazila (Sub-district)
Health Complex
 Comprehensive emergency obstetric care
services (EOC)
 Gynaecology
 Anaesthesia
 Nursing and basic laboratory facilities
District hospital
General hospital
 Medicine
 Surgery
 Orthopedics
 Eye
 ENT
Tertiary
level care
Medical College
Hospitals
 Medicine
 Surgery
 Orthopedics
 Eye
 ENT
 Eye and ENT
 ARI
 Reproductive care etc.
Infectious disease
hospital
Treatment of infectious diseases
Specialized hospital Selected services
Chest disease/TB
hospitals
Chest disease
Leprosy hospital Leprosy
 Specialized
centers
 Specialized
hospital affiliated
with
postgraduate
Selected relevant services
Other hospitals
[Source: Asia Pacific Observatory on Health Systems and Policies]
Financial Flow in the Bangladesh Health System:

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Figure below describes the pathways of health-care funds from financing sources to health-care
providers through financing agents. The Ministry of Finance collects taxes (income, corporate, value-
added etc.), tariffs and fees from the citizens of Bangladesh. The main source of finance for the national
budget is taxes. MOF allocates funds from the tax-financed national budget annually to the Ministry
of Health and Family Welfare and other ministries. The Ministry of Health and Family Welfare then
allocates the health budget to health-care providers at different levels, from primary to tertiary and
from national to community levels. Other ministries such as Defence and Home Affairs operate health
facilities for their employees. Ministries such as Health and Family Welfare, Local Government and
Social Welfare channel funds to NGOs to provide health services. Spending on health by other
ministries is financed from their respective budgets.
Foreign development partners contribute to the development budget of the Ministry of Health and
Family Welfare that finances their health programmes and health facilities. They also finance NGO
health services, either by directly providing funds to NGOs or through the Ministry of Health and
Family Welfare or the Ministry of Local Government.
Corporations (state-owned enterprises) and autonomous bodies (for example, national universities)
finance health care spending from their own budget. Some corporations and autonomous bodies
operate their own health facilities, some reimburse employees’ medical treatment costs through
voluntary health insurance schemes, and some finance health programmes of NGOs as part of their
corporate social responsibility.
NGOs allocate funds from their own sources to finance NGO health programmes and health facilit ies,
primarily for providing health care to poor and low-income people. NGOs receive funding directly
from development partners and from the Government through ministries such as the Ministry of Health
and Family Welfare, the Ministry of Social Welfare and the Ministry of Local Government. NGOs
also receive funds from corporations and enterprises to provide health services, especially for target
groups such as poor and vulnerable populations.

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Some private firms/enterprises develop health funds, which are often transferred to private or voluntary
insurance schemes, to secure health care for their employees. Besides financing health insurance, some
enterprises operate their own health facilities to provide health care to their employees or finance NGO
health activities as part of CSR. The health funds of NGOs and corporate firms also go to private
health-care facilities (hospitals/clinics/diagnostic tests) and drug and medical goods retail outlets to
provide services on NGOs’ and firms’ behalf.
The health funds described above are generally pooled funds, with scope for risk-pooling. Individuals
and households fully or partially share the costs of their health care through out-of-pocket payments.
When receiving care from public facilities, the patients pay a small user charge; for treatment from
private providers, the payments are often fully borne by the patients.

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Physical & Human Resources:
Bangladesh has an extensive PHC infrastructure in the public sector but these are not adequately
provisioned for human and other resources such as drugs, instruments and supplies. During 2007–
2013, there has been a steady increase in the number of both hospitals and total number of beds in the
public sector. The number of beds in PHC facilities at upazila level and below reached 18 880 across
472 facilities in 2013, and 27 053 in 126 facilities at secondary and tertiary level. In the private sector,
there were 2983 registered hospital and clinics, with 45 485 beds. Taken together, there is now one
bed for every 1699 population which is still inadequate. Meanwhile, to bring health facilities closer to
the doorstep of the population, there is a community clinic for every 6000 people (n=12 527) providing
primary health-care services.
Population per bedin public sector (medical college and secondary and tertiary care) hospitals in different
divisions of Bangladesh
Bangladesh Medical and Dental Council (BMDC) registered health workforce in 1997, 2007 and 2012
There is a large cadre of health-care providers in the informal sector. This comprises semi-qualified
allopathic providers (such as community health workers, medical assistants and trained midwives),
unqualified allopathic providers (e.g., drug shop retailers, rural doctors), traditional healers
(practitioners of Ayurvedic, Unani and homeopathic medicine) and faith healers. They are not part of

17. 17
the mainstream health system but a major health-care provider for the poor rural population, especially
in remote and hard-to-reach areas.
In the public sector, the Central Medical Store is responsible for procurement and supply of medical
and surgical equipment and products including drugs. Public sector health facilities in Bangladesh are
poorly equipped with medical equipment and instruments. Many of the lower level facilities lack basic
instruments like clocks and height measuring scales. Supply of drugs is also inadequate and the supply
chain is frequently disrupted. On the other hand, the private sector, especially the recently emerging
high-cost hospitals and clinics in the urban areas, have all the major state-of-the-art diagnostic
equipment and facilities.
Rural-urban distribution of health-care providers by type (per 10 000 populations)
The Bangladesh health workforce is characterized by “shortage, inappropriate skill mix and inequitable
distribution” of health workforce. At present there are 64 434 registered doctors, 6034 dentists, 30 516
nurses, and 27 000 nurse-midwives in the country (cumulative figures unadjusted for attrition due to
deaths, retirements, migration, change of profession or inactivity). In addition, the health workforce is
skewed towards doctors with a ratio of doctors to nurses to technologists of 1:0.4:0.24, in stark contrast
to WHO recommended ratio of 1:3:5. The engagement of the health workforce in the private sector is
increasing, as revealed by an estimated 62% of the medical doctors working in the private sector in
2013. The formal health workforce (doctors, dentists, nurses) is mostly concentrated in the urban areas,
with variation among the different regions. Retention and absenteeism of health workers are two major
problems facing rural areas.
The Health Status in Bangladesh:
“Health is a right, not privilege. It needs to be delivered with equity.” Well, no denying the fact that
health is a basic right requirement to improve the quality of live. National economic and social
development depends a lot on the state of health services. Access to health service is also guaranteed
in our constitution and is accepted as a basic human right. However, a large number of Bangladeshis,
particularly in the rural areas, have little access to healthcare facilities. It may seem that access to
healthcare services for the insolvents, poor and the destitute continues to remain a day dream.

18. 18
01. Area -1, 47,570 sq. kilometers
02. Population - (as per 2011 census) about 15 crore (unconfirmed)
03. Population growth rate - 1.40 (2008)
04. Population density/sq.km - 980 (2008)
05. Fertility rate - 2.40 (2008)
06. Contraceptive prevalence - 57%
07. Life expectancy at birth - 65.61 Female- 67.96
08. Per capita income in US$ - 690 (2008-9)
09. Per capita health expenditure On H&FP (BDT) - 600 (2010)
10. Maternal mortality rate per 1000 live births) - 2.9 (MTR.2009)
11. Infant mortality rate (per 1000 live births) - 41.26 (2008, BBS)
12. Child mortality under five per 1000 live births) - 53.84 (2008, BBS)
13. No. of public medical colleges- 18 including Army Medical College
14. Govt. medical colleges hospitals- 17+1= 18 (2010)
15. No. of private medical col. & hosp. - 46 (2010)
16. % of population using safe drinking water – 98.23 (2008 BBS)
17. % of population using sanitary latrines - 62.23 (2008 BBS)
18. Prevalence of night blindness among pre-school children - 0.04 (IPHN-DGHS)
19. % of birth attended by skilled personnel - 24.4 (BBS 2009)
20. % of women received at least one ante-natal care - 51.7 (BDHS)
21. % mother received PNC from a trained provider within 24 days of delivery - 21.3 (BDHS 2007)
22. Number of registered physicians - 51,993 (BMDC, 2010)
23. Number of registered dentist -3,913 (BMDC, 2009)
24. No. of beds in public sector- 38,251 (MIS, 2008)
25. No. of beds in private sector- 40948 (DGHS, 2010)
26. No. of non-govt. hospital - 2397 (DGHS, 2010)
27. No. of private dental college- 12 (DGHS, 2010)
28. No. of registered nurse - 25,018 (BNC, 2010)
29. No. of nurses in public sector- 13,473 (DNS, 2010)
30. No. of registered midwives - 23,472 (BNC, 2010)
31. Population per physician - 2,785 (DGHS, 2010)
32. Population per bed - 1,860 (DGHS, 2010)
33. Population per nurse - 5,782 (DGHS, 2010)
34. Physician to nurse ratio - 207:1 (DGHS, 2010)
35. Malaria incidence rate/1000 population- 0.63 (DGHS, 2010)
36. TB. Incidence rate/100000 population- 100 (BBS, 2008)
37. % full vaccination coverage (BCG, DPT, Hep B3, OPV3, measles) - 75.2 (EPI/2009)
38. % BCG vaccination - 99
39. % vitamin A coverage- 97
40. Non polio AFP rate per 100- 2.57
The above health indicators and statistics show that we have achieved considerably in the health field.
However lot more remains to be done. All our developments will go in vain unless we can develop a
sustainable primary health service delivery on a solid footing and make it accessable to all irrespective
of cast, creed, sex, colour or culture. We have progressed reasonably in attaining millennium
development goal in the health related sector. However much remains to be done. We must put lot of

19. 19
thrust to cut down maternal mortality and child mortality to achieve millennium development goal.
For this we have to put more and more emphasis on reproductive health and MCH. If run and managed
properly with adequate human and other resources the community clinics may go a long way in
delivery of primary healthcare at the grass root level.
Women Health Status in Bangladesh:
All the info gathered from 1980 about Bangladesh women's health, education, nutrition and economic
power has indicated that women in Bangladesh are still inferior to men. In custom and practice, women
in Bangladesh have an inferior social status than the social status of their male counterparts. Women's
possibilities are limited by their traditional role in the society. They have limited or no access to
markets, education, health services and government jobs. The traditional role that women had to play
in Bangladesh society forced them to have high fertility rates. Usually, high fertility contributes to
malnourishment and poor health because too many children are challenging the well-being of a family
that can provide for a limited amount of members. Poverty rates are the highest among women and
children who are not capable of taking care of themselves because they have no access to education,
jobs and professional medical advice. In Bangladesh, almost 80 percent of women live in rural areas,
with no prospects for a brighter future. Women in Bangladesh are responsible for most of the hard
work that is done in rural areas. They keep livestock, poultry and small gardens and they also do all
the post-harvest work. Women in cities can't advance further than a manufacturing job. The high
population rates meant less working places and more candidates. Another discriminatory feature of the
social situation in Bangladesh is the fact that female wage rates are typically lower than male wage
rates. Usually, they are between 20 and 30 percent of male wages. Violence against women is also
omnipresent in Bangladesh. In 2008 only, there were almost 600 cases of violence against women.
These victims were killed, beaten and even killed after being raped. Many women in Bangladesh even
reach the point where they decide to commit suicide because of extreme domestic violence.
Maternal Mortality:
In spite of the fact that maternal mortality has declined from nearly 574 per 100,000 live births in the
1990 to between 320 and 400 in 2001, the Maternal Mortality Ratio (MMR) in Bangladesh remains
one of the highest in the world. It is estimated that 14 percent of maternal deaths are caused by violence
against women, while 12,000 to 15,000 women die every year from maternal health complications.
Some 45 percent of all mothers are malnourished. The population of Bangladesh is relatively young,
with a third falling within the age group of 1024 years. Nearly half the adolescent girls (15-19 years)
are married, 57 percent of them become mothers before the age of 19, and half these adolescent
mothers are acutely malnourished. Thus, MMR among adolescent mothers is 30-50 percent higher
than the national rate. The chief causes of maternal deaths are hemorrhage, unsafe abortion, and the
‘three delays dynamics’. The first delay, arising mainly from poverty, is in seeking professional care;
the second delay is logistical as most of the health centers and private clinics are located in district
towns, whereas 70 percent of the population are rural based; the third delay arises from the lack of
adequate human recourses and trained personnel at the service centers.
Total Fertility Rate:
There has been significant decline in the total fertility rate (TFR) from 6.6 in the mid-1970s to 3.3 in
the mid-1990s with regional variations in the reduction pattern. However, in spite of a steady increase
in contraceptive prevalence rate from 45 percent in 1994 to 54 percent in 2000 to 58 percent in 2004.

20. 20
Several measures have been taken to address these problems. The Essential Obstetrics Care (EOC)
programme through the Maternal and Child Welfare Centres (MCWC) was introduced in the early
1990s. Subsequently, a more holistic approach was adopted through the National Maternal Health
Strategy 2001, which takes a rights-based approach to maternal health with Safe Motherhood as its
central theme. The Strategy has been integrated into the Health and Population Sector Programme
(HPSP 1998-2003), and into its follow-up, the Health, Nutrition and Population Sector Programme
(HNPSP 2004-2006). Interventions such as Safe Motherhood Services that provide iron, folic acid and
vitamin A supplements to the target population have been included in the HNPSP, with the objective
of reducing maternal malnutrition to below 20 percent by 2015. Other interventions under this project
include training programmes for skilled health personnel. Both the Government of Bangladesh and the
donors are giving priority to the promotion of safe motherhood from the grassroots level upwards,
through antenatal care, safe delivery, pre-natal care, essential obstetrical care and family planning.
Limitations of Health Care System:
Healthcare is a limited commodity. Its limitations are defined by the numbers of professionals
supplying it and their physical limitations on the number of patients they’re able to treat, on availability
of biomedical equipment and technology, on availability of physical space to safely provide medical
care and, underlying all of these, on the funding for such. And so, not everyone can get all care they
need or want. And, it is true; no system will even be able to supply such. There will always be
limitations. And there will always be some rationing Health-related services include public goods such
as public sewerage and water supply systems, which would be undersupplied if left to the market.
Services, such as immunization, have positive externalities in that an individual’s consumption confers
benefits on others so that decisions based only on individual needs are likely to result in suboptimal
funding. Markets tend to under-insure against major health expenditure because they cannot control
costs effectively and there is little incentive for a healthy person to join an insurance scheme. Markets
may not adequately reflect the greater willingness of the population to finance basic health care than
other non-health goods and services. Markets can worsen distributive outcomes and hence health
inequities. Markets for goods and services that embody expert knowledge produce information
asymmetry between providers and clients that can make clients vulnerable to abuse of provider power.
The nutritional status of children and women in Bangladesh is very poor and needs special attention
in order to improve the overall health status of the population. Despite various interventions designed
under National Nutrition Project (NNP) low birth weight and malnutrition continue to be important
causes of infant and under five mortality. A significant proportion of pregnant women is also iodine
deficient and develops night blindness during pregnancy. Improvement in births attended by skilled
health personnel is not satisfactory. Only on average 480 CSBA are produced annually by the
Obstetrical and Gynecological Society of Bangladesh (OGSB) and a total of 3000 have been trained
so far compared to the target 13,000 (MTR 2008). The availability of comprehensive EmOC services
in public facilities, especially at district level and below, is also not up to the target level. Limitation
of the data on HIV/AIDS prevalence is a major obstacle in tracking the MDG targets.
In Bangladesh public health care is facing a shortage of personnel. Approximately 12,000 physicians
work in the public sector. Chaudhury and Hammer report that more than 26 per cent of positions in all
categories of health personnel are vacant in public health facilities. The vacancy rate for doctors is 41
per cent. This figure represents more than 2,000 public physician positions. The vacancy rate is higher
in rural and poor regions. Moreover, the public health services are gradually tending to have more
specialists, rather than mid-level health personnel including paramedics, nurses and auxiliary health
personnel. Furthermore, the health system is urban biased in facility development and resource

21. 21
distribution. There were 15,706 beds available in the urban areas and the share of the rural areas was
11,297 in 1990 and the comparative figures in 1998 were 14,037 and 12,292 respectively. It is also
seen that all the specialized and super-specialized hospitals and 14 medical colleges, are located in the
city centres only.
The public health system is facing a problem with manpower shortage. There are only 12,000
physicians working in the public sector and more than 2,000 physicians’ posts laying vacant in the
same sector. It is difficult to provide services with the existing manpower. On the other hand,
corruption is rampant in the public health care system of Bangladesh. A study confirms the widespread
collection of unofficial fees at various level health facilities is a "common form of rent seeking
behaviour in Bangladesh". The Transparency International found that the health sector is the second
most corrupt sector after the police sector. The survey found that 48 per cent admitted to government
hospital by alternative methods including 56 per cent paid money, 22 per cent used influence, and 18
per cent sought help from hospital staff. An editorial of an English daily commented that Bangladesh
experiences show "more than their number, corruption and lack of integrity of the doctors are perhaps,
more important factors that explain the poor quality of services at the government run hospitals". So
the shortage of manpower as well as corruption makes the public sector in a bad shape. Moreover poor
management, planning and lack of control make the public sector a defunct system. The public health
care system has lost its credibility and people have limited confidence in it. This has resulted in the
proliferation of private for-profit oriented health care system.10,11
Ideas to Improve Bangladesh’s Health Systems and Access
 Establishing a level of service delivery affordable by the poor through government regulations
on private clinics/hospitals.
 Making private sector health service accountable to DGHS.
 Decentralization of health professional’s recruitment process from doctors to nurses.
 Install and use MIS through central level for greater transparency and accountability.
 A structured referral system, starting with a prescription from the Community
Clinic/Community Health Worker, linked with a national level health database.
 Invest to establish the referral linkage – from Community Clinics to urban level public, private
specialized hospitals.
 Access to quality healthcare through a digitized service delivery system.
 Quality assurance/monitoring of drug companies.
 Creating a National Health Service database with patients’ medical history to reduce the need
for multiple diagnostic tests.
 Increase doctor-patient counseling hours.
 Ensuring primary health care for the urban poor.
 Subsidize primary healthcare.
 Deal with malaria in Bandarban and other Hill Tract areas.
 Provide universal health insurance coverage.
 Incentives for public doctors working in hard-to-reach areas.
 Health awareness campaigns through SMS.
 Private clinics and hospitals to allocate a certain percentage of free beds for the poor.
 Private sector to allocate a certain percentage of their profits for serving the poor.
 Clarifying the roles of public and private sector as per the middle-income country (MIC) vision.

22. 22
 Monitoring compliance of the village and district level hospitals/clinics with DGHS’s
regulations.
 LGED and MoHFW to coordinate working on urban health care system.
 More public health specialists, not doctors, for better administration and coordination.
 Better primary healthcare - more and better doctors in rural areas, more front line health
workers.
 Retaining service providers at the Upazila level through incentives for career development.
 Ensure accountability of doctors at the Union level through available means (e.g. mobile
phones, social media, UDCs, etc.).
 Develop institutional health system arrangements for respective Hill District Councils.
 Financial support for Community Clinics to reduce donor dependency.
 Use of electronic records to supplement the national health/medical database.
 Utilizing existing informal sector of health service delivery particularly for hard-to-reach areas.
 For containment of population (i) focus on long acting permanent method (LAPM); (ii) target
newly-wed couples, particularly adolescents to delay the first birth.
 Continue and expand counseling on population control and reproductive health and behavior
in health care centers.
 Make effective use of government trained Community Skilled Birth Attendants (CSBAs) and
deployment of newly trained midwives in newly created posts at union and upazila.
 Building strategic partnerships with NGOs and private sector for strengthening and expanding
newborn care.
 Expansion of medical waste management to cover all medical installations.
 Tribal-friendly health services through appropriate initiatives.
 Incorporate counseling, health rights and ethics in all medical, nursing and other education
curricula along with proper sensitization initiatives for the existing health service providers.
 Capacity building of health managers at district and sub-district levels on data analysis, health
planning and monitoring.
 A population based database for community health management information system.
 Strengthening Bangladesh Medical Research Council to steward and coordinate all health
sector research.
 Strengthen BSMMU’s research capacity to make best use of its resources.
 Address maldistribution of health personnel across regions.
 Steps for empowering women’s decision making over reproductive health through proper
education and information.
 A 'disability' budget for each ministry.
 Increase public expenditure to US$ 54 per capita to cover a basic package of services, including
interventions targeting NCDs.
 Free healthcare for RMG workers.
 A comprehensive mental health service delivery plan to address the growing psychological
needs.
 Expand TB diagnosis and treatment.
 Shorten multi-drug resistant TB treatment to 9 months from current 24 months (to be able to
treat more MDR-TB patients).

23. 23
 Continue implementation of Health, Population and Nutrition Sector Development Program
(HPNSDP) to strengthen and expand nutrition specific interventions among pregnant and
lactating women, newborn babies, under-5 children and adolescent girls.12
Some Facts About Healthcare In Bangladesh:
Healthcare in Bangladesh is not as sophisticated as in more developed countries; however, the country
is working to improve and provide further funding to its healthcare system. So far Bangladesh has
made great strides in increasing healthcare access for its people, but there is still a long way to go.
Here are seven important facts about healthcare in Bangladesh.
Bangladesh has a pluralistic healthcare system. This healthcare system is highly decentralized.
As a result, it is regulated and controlled by for-profit companies, NGOs, the national government and
international welfare organizations. This shared power has caused many problems, including unequal
treatment programs between social classes. Even though the laws and overall system are spearheaded
and steered by the Ministry of Health and Family Welfare, other organizations have considerable
influence on the decision-making.
There is a shortage of physicians, specialists and clinical equipment. In Bangladesh, the
number of physicians per 10,000 people is only about 3.06, which is significantly low. The number of
nurses per 10,000 people is even lower, standing at 1.07. Additionally, only 35% of health and clinical
facilities in the country have more than 75% of sanctioned staff working and there is a 36% vacancy
in sanctioned healthcare workers. There is also a 50% vacancy in alternative medicine providers. These
numbers are one of the reasons that Bangladesh’s quality of healthcare is low compared to many other
Asian countries.
Non-communicable diseases are the leading cause of death in Bangladesh. Most deaths are
caused by cardiovascular diseases, cancers, diabetes, chronic respiratory diseases and malnutrition.
There are almost no alcohol-related deaths due to alcohol consumption and sale being illegal in the
country. A 2016 study by the World Health Organization (WHO) found that tobacco usage has
decreased for both men and women, with only 23% of the population using tobacco products. Obesity
has remained low, rising slightly, but still only affected 2% of adolescents and 3% of the adult
population. However, poor nutrition is still prevalent, leading to diabetes and high blood pressure.
Most physicians and healthcare workers are concentrated in urban areas. Rural areas often
do not have proper healthcare facilities. To remedy this, the national government has set up many
government-funded hospitals in rural areas that provide cheaper treatment for rural citizens. However,
these hospitals are often poorly funded, understaffed and overly crowded due to a limited number of
healthcare options in rural areas.
Enrollment in medical colleges and healthcare training facilities has increased. This will
benefit the country by increasing the number of healthcare workers in proportion to the population.
However, this is only a recent trend and these future healthcare workers must complete their education
and training before being able to fully practice their professions. The HPNSDP (Health, Population
and Nutrition Sector Development Program) have already begun drafting and implementing a plan to
further increase the number of nurses and midwives through training and education facilities.
Socioeconomic inequality affects healthcare in Bangladesh. One area this can be seen in is
infant mortality. The infant mortality rate for the lowest income quintile is 35 deaths per 1000 births,

24. 24
while infant mortality for the highest income quintile is only 14 deaths per 1000 births. One of the
main reasons for this inequality is that most poor Bangladeshis live in rural areas that do not have
adequate hospital facilities. However, even in urban areas, socioeconomic inequality has a large
impact. A person with more money is generally able to receive better healthcare than someone who is
poorer and cannot afford certain treatments or services. This is due to the fact that the healthcare system
is decentralized and partially run by for-profit healthcare and pharmaceutical companies.
Limited government funding has led to high out-of-pocket payments. One of the other
reasons poorer citizens in Bangladesh cannot afford certain treatments or services is high out-of-pocket
costs. On average, Bangladeshi citizens must pay 63.3% of the total cost, while the government pays
the rest. This system creates a significant financial burden for impoverished families, sometimes
forcing them to either forego treatment or go into debt. To reduce this burden, the government must
increase healthcare funding.
These facts about healthcare in Bangladesh illustrate some of the barriers that Bangladesh must
overcome to provide high-quality healthcare across the nation. The Bangladeshi Government’s
constitution upholds that all citizens will be provided with equal treatment, including in healthcare. To
achieve this, the government needs to address the current inequality and continue to make healthcare
a focus of its efforts.13
Future Health System (FHS) of Bangladesh:
The inadequacies of the formal healthcare sector in Bangladesh has resulted in a widespread increase
in informal providers as an alternative source of care providing basic and essential outpatient health
services to millions of poor people in the rural areas. Close proximity to clients, availability to the
community day and night, sympathetic behavior, well established relations within the community, and
flexible payment methods have made the village doctors a popular source of care. Findings from our
initial studies confirmed that the village doctors (VDs) provide care of questionable quality with
considerable over-prescription of drugs, including the prescription of drugs that are mostly
inappropriate and potentially harmful. Regardless, the widespread existence of VDs and their
significance as an integral contributor of healthcare within rural communities in Bangladesh
necessitates an effective regulatory arrangement that improves and ensures a minimum standard in the
quality of services provided.
Phase-1: In the first phase, FHS Bangladesh established the ShasthyaSena intervention, which
employed a combination of three strategies to improve healthcare services in rural Chakaria,
Bangladesh. All of the 157 village doctors (VDs) practicing in the intervention areas were invited to
participate in a free training in managing common illnesses such as pneumonia, diarrhea, hepatitis,
malaria, tuberculosis, viral fever, and various complications related to labor and delivery. A small
booklet with information on what to do and what not to do for eleven common illnesses was distributed
as a source of future reference. As members of the SS network, qualified village doctors were awarded
crests containing the SS logo. A memorandum of understanding outlining the responsibilities and
objectives of SS was signed between each joining member and the network. The study has shown that
training and branding has acceptability among village doctors although their behaviour has had no
drastic changes due to the lack of financial incentives. The ShasthyaSena intervention has also resulted
in a change in the attitude of the government toward informal healthcare providers.

25. 25
Phase-2: In Phase 2, FHS Bangladesh is pursuing branding and social franchising mechanisms and
marrying them to new technologies such as telemedicine and the “health box”. This will show and
guide the informal healthcare providers how to treat and manage many common illnesses through the
use of computer-based diagnostic algorithms. These components together will create a brand with
serious content that is attractive to village doctors and even more attractive to customers through
improvements in the quality of care. The intervention will further link village doctors with formal
healthcare providers for more complicated illnesses. While over-the-counter drugs can be dispensed
by the village doctors themselves, dispensing prescription drugs will be guided by linking them with
qualified physicians. Dispensing of medicines will be part of the profit made by village doctors and
will provide them with a financial incentive. All the above activities will be ensured and supervise d
by the project. If acceptability and efficacy of the intervention can be shown, a stronger case can be
made that shows that using informal healthcare providers will be profitable in a country that has a huge
shortfall in the health workforce.11
Conclusions:
Bangladesh has made enormous progress in health in recent years, surpassing its neighbors in raising
life expectancy, and reducing fertility and the mortality of mothers and infants. But maternal and
neonatal mortality is still quite high, there are emerging and re-emerging infectious diseases (e.g.,
dengue, swine and bird flu), mass arsenicosis is a lingering concern, an emerging burden of NCDs, an
epidemic of road accidents, miserable health and sanitation conditions in the urban slums, and fallouts
from the effect of climate change on health. Through the sixth Five Year Plan, the country implemented
all health reforms with a very low national health budget and the health status of the nation remained
generally poor despite various donor-supported vertical programmes. A number of factors played
important roles in hindering expected improvement in the overall health status of the country.
the complexity of the mixed health systems and poor governance
inadequacy of health resources and impact on quality of care
inadequate and uneven health service coverage
health-care financing through catastrophic OOPP by households
inequitable access to health services hindering universal health coverage
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