Out-of-pocket payments in Bangladesh continued to remain predominantly financed by patients in spite of the fact government’s expenditure on health care services has steadily increased manifold. A recent operational research conducted by ICDDR,B on Health Expenditure and Financial copying Survey revealed the fact that patients in urban areas, especially population residing in disadvantaged locations and slums of Dhaka City North and South Corporations had to pay at least 65% of payments out of their own pocket for treatment of diseases of any nature.
Even in government hospital, where everything is free but had to pay about Tk. 1700 on average to get treatment.
Different studies from 1997-2007 also testified that out of pocket payment comprises 11% for In-patients and for out -patients care 12%, ancillary services 7% ,Medicines 63%, medical goods 3% of their total health expenditure. There were direct payment made at private and NGO facilities and also to informal providers and non-state sector used to provide primary health care, particularly for reproductive health services. A study based on exit patients reported that out-patients paid directly and inpatients made informal payments to get health care services. (Rannan- Eliya RP et at 2012).
According to these studies, patient made informal payments to obtain medicine, ensure doctors and nurses visit the patients and quality laboratory test or x-rays done fairly and transfer of the patients from floor to bed. A reality check conducted by SIDA revealed that patients are to pay at least Tk. 20 to get a trolley in a government hospital like Barisal Medical Colleges and Hospital.
Alternate source of financing for health care in Bangladesh is very inadequate. Government employees are eligible for Group Insurance benefits and even retired ones get medical allowances of Tk. 1000.00 per month. Health Insurance is being implemented in three Upazila on pilot basis by KFW in Jamalpur district. Private Insurance is limited to a small proportion of overall funding and is only .0.003% of the formal sector.
Currently, there are about 64 firms listed as Insurance companies mainly focusing on general, life and accident insurance. According to Bangladesh Bank reports (2012) corporate social responsibility (CSR) from commercial banks for health activities increased tenfold.
Very recently city dwellers were in great crisis and had to pay enough money out of their own pocket to get recovery from a viral disease named Chikungunya. For the last two months, May and June, public at large of Dhaka North and South City Corporations were severely affected by Chikungunya virus and so adversely that turned to be an epidemic and High Court of Judicature had to issue a Rule Nisi to make authorities responsible and brought to the book for their indifference. Only on 14 July, 2017, both Mayors of Dhaka City Corporations appeared before media but accused the public that they were careless about their own safe drinking water, sanitation and hygiene. Sarcastically, a popular Mayor stated that city health department is not duty bound to visit every house to house to kill the Mosquito spreading this vector borne diseases. (Although he apologized for this remark later)
Due to Chikungunya, huge numbers of city dwellers were sick with high fever, muscle pains, headache, nausea, fatigue, rash and total debilitating joint pains making a patient totally incapable of discharging his normal duties. City health department did not come out with Mosquito killing or opening emergency out-lets and arranging any media campaign to make the public aware of getting remedy from such debacle. Health Department knows it fully well that Aedes Aegypti mosquito is the carrier of both Chikungunya and Dengue Viruses but did not take any step to control its bites by “larviciding and fogging” at least to demonstrate their good wishes and build awareness among city dwellers .
In the meantime, many poor people living slums and disadvantaged locations spent enough money taking high powered anti-biotic drugs and making payments out of pocket. Some physicians and clinics took the advantage to earn a lot from the public. Some poor could not pay to get recovery from such ailments and approached traditional healers to get rid of such painful health hazards with water therapy. Social media started to highly accuse Mayors and health department and the government to become so indifferent to public health. Mayors are very serious about clean city and green city but not about healthy city but why? In fact, Municipal concept developed to look after the health of city dwellers with sanitation and solid waste management.
These are distinct and visible areas of our weakness in Urban Health care delivery system although we propagate about our capability to overcome any challenge and emerge as role model. Government health departments and city health units are not prepared to make any rapid response to tackle or deliver remedies quickly to people until they spend enough money from their own pocket. The Institute of Epidemiology, Disease Control and Research (IEDCR) failed to issue any public alertness about such vector borne diseases and they are not serious about waterborne diseases to give advises to city health departments and public at large. Of late, IEDCR in a newsletter stated that 519 cases detected in their laboratory test and 30 to 35 people contacted per day with this disease. It is true, Chikungunya is largely non-lethal but it may turn to be fatal if person diagnosed with the diseases is simultaneously found to have immunodeficiency or carries another disease infection.
Not only about 65% health care services are being availed by public by spending from their own pocket but about 64 % of the patients infected by any disease do not consult doctors or skilled services providers and straightway approach to the quacks and traditional healers for recovery. More than 70% percent of the public purchase medicine from pharmacy counters without any prescription. Unfortunately, prescriptions are written in such a manner that many people fail to understand for which High Court has issued instructions to write prescription legibly so that others can understand. This is surprising that judiciary had to intervene to advice doctors/physicians how to write a prescription. This is in fact total aspersion to the medical professionals and health department as a whole.
Local Government Division with its 11 City Corporations and 327 Municipalities must take step to make their Urban Local Bodies capable of responding rapidly by strengthening their Health Departments/ Units with sufficient budget allocations for public health and primary health care so that they can discharge their responsibilities as provided under the Local Government Act, 2009.
There must be measures to reduce the out-of pocket expenses to get health care services free while country is committed to ensure Universal Health Care and achieve the targets of Sustainable Development Goals 2030.
The writer is a former secretary to the Government