Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most

of the health indicators across social, economic, and demographic parameters. This study explores the

existing health policy environment and current activities to further the progress towards Universal

Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved

document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes:

activities around UHC, implementation barriers, suggestions) was done using the manual coding

technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health financing strategy and staged recommendations for pooling of funds to create a national health

insurance scheme and expand financial protection for health. Progress has been made in a number of

areas including the rollout of the essential package of health services for all, expansion of access to

primary health care services (support by donors), and the piloting of health insurance which has been

piloted in three subdistricts. Political commitment to these areas is strong. However, there are barriers

pertaining to the larger policy level which includes a rigid public financing structure dating from the

colonial era. While others pertain to the health sector’s implementation shortfalls including issues of

human resources, political interference, monitoring, and supervision, most key informants discussed

demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of

empowerment. To overcome these, several policies have been recommended, e.g., redesigning the

public finance structure, improving governance and regulatory mechanism, specifying code of conduct

for service providers, introducing health-financing reform, and collaborating with different sectors. To

address the implementation barriers, recommendations include improving service quality, strengthening

overall health systems, improving health service management, and improving monitoring and

supervision. Addressing demand-side barriers, such as patient education and community

empowerment, is also needed. Research and advocacy are required to address cross-cutting barriers

such as the lack of a common understanding of UHC.

1. Introduction

Universal Health Coverage (UHC) implies that all people have access to quality health services they need,

without financial hardship [1]. UHC received a fresh momentum with the adoption of Sustainable

Development Goals (SDG), the eighth target of the third goal of which states, “Achieve UHC, including

financial risk protection, access to quality essential healthcare services and access to safe, effective,

quality and affordable essential medicines and vaccines for all” [2].

The health system of Bangladesh is experiencing a double burden of diseases, low service coverage, and

a lack of effective financial risk protection mechanism. Bangladesh has a pluralistic healthcare system,

which is highly unregulated and consists mainly of four key actors: government, for-profit private sector,

not-for-profit private sector (mainly the nongovernmental organizations ), and the international

development organizations [3]. Public healthcare is steered by the Ministry of Health and Family

Welfare, through its different Directorate Generals: Health Services, Family Planning, Drug

Administration, Nursing and Midwifery, Health Economics Unit, etc. [4].

Private healthcare encompasses for-profit private, not-for-profit private (mainly the NGOs), and informal providers (village doctors and other vast arrays of different unqualified providers). The public healthcare services are organized along four levels: community-level healthcare (provided by the domiciliary health providers and community 

clinics), primary level healthcare (provided in Rural Health Centers, Union Subcenters, Union Family

Welfare Centers and Upazila Health Complexes), secondary level healthcare (provided in District

Hospitals, General Hospitals, Chest Disease Clinics, Tuberculosis Clinics, and Leprosy Hospitals), and

tertiary level healthcare (provided in Post Graduate Medical Institutes, Specialized Healthcare Centers,

Medical College Hospitals, and Infectious Disease Hospitals). The private sector also has health facilities

ranging from individual doctors’ offices to high-end tertiary level international standard hospitals [4].

Public healthcare is highly subsidized by the government, with nominal payments required from

patients, especially for outpatient care. Health insurance, both national and private, is practically

nonexistent. Health financing is underfunded; only 2.64 percent of gross domestic product (GDP) is

spent on health, which is the lowest in the south Asia region [5]. Health financial coverage is so sparse

that nine percent households face catastrophic health payment, 5.6 percent face impoverishment, and

seven percent face distress financial with experience in UHC related academic activities in Bangladesh,

personnel from an international Nongovernmental Organization involved in UHC advocacy, and a senior

leader of an international NGO involved in implementing public health programs and health systems

strengthening). The list was supplemented by snowball recruitment techniques as the interviews

progressed.

Key informants were sampled purposively, aiming for maximum variation [23] in terms of their sectoral

alignment. In total, 15 respondents were interviewed from different sectors, broadly categorized as

follows:

(1) Public sector (central level): 1

(2) Public sector (district level): 5

(3) Multilateral organization/donor: 2

(4) NGO/implementation organization: 4

(5) Academia/research: 2

(6) Civil society (health journalist): 1

Interviews were conducted in the interviewees’ office, by two public health experts (one male and one

female). The key informants were assured of strict anonymity regarding the content of their interviews.

All the interviews were digitally recorded; however, they were provided the option of speaking ‘off the

record’, should this be preferred. Manual note-taking was also employed for all interviews in order to

prevent the risk of data loss due to technical issues.

Although a key informant guideline was used for data generation, adequate probing was used to clarify

the views expressed by the respondents. Follow-up questions were asked to ensure maximum and in-depth information. Each interview lasted between 25 and 45 minutes. The interview tool included

questions on activities carried out by the respondent’s institution in light of UHC across the three dimensions of UHC: population coverage, access to services, financial protection [1], perceived barriers

towards carrying out those activities, and suggestions to overcome those barriers.

Verbatim transcriptions were done by professional transcribers once the interviews had been finished.

The transcripts were subsequently read carefully and matched with the records, to determine missing

information. The thematic analysis of texts was done using manual coding. Texts were organized across

three main themes: (1) activities around UHC, (2) barriers to implement UHC, and (3) suggestions to

progress towards UHC. Appropriate quotations were extracted to substantiate the thematic analysis.

Member checking was done through a seminar presentation with the key informants to ensure that

their views are correctly and adequately reflected. To increase validity, the first and the second authors

independently coded the dataset. The third author was involved where a third opinion was warranted to

reach consensus or resolve controversial issues.

3. Results

3.1. Policy Scan

The document review, aiming at understanding the existing policy environment, included 22 documents

and a renowned journal’s special series on UHC issues in Bangladesh. Among the 22 documents,

the majority (n = 16) were published by different entities of the Government of Bangladesh (GoB), especially

Ministry of Health and Family Welfare (MoHFW). The remaining were published by multilateral

international organizations, civil society consortiums, and private academic and research organizations

(complete list and findings in supplementary information file 1).

In order to address inequities and foster UHC, the GoB has taken several policy initiatives. Besides,

various multilateral organizations, civil society consortiums, and academic and research organizations

based in Bangladesh developed documents with policy directives for UHC in Bangladesh. We classified

the GoB policy documents as follows: (1) overarching documents, not specific to the health sector; (2)

overarching documents specific to the health sector, but not specific to health financing; (3) documents

specifically related to health financing; and (4) documents not directly related to, but with implications

for UHC (supplementary information file 1).

The most important policy document, specifically focusing on UHC in Bangladesh, is the ‘Health Care

Financing Strategy 2012-2032: Expanding Social Protection for Health towards Universal Coverage’,

published by the Health Economics Unit (HEU) of MoHFW [24]. Aligned with other important policy

documents (e.g., National Health Policy 2011 [25], Health Population and Nutrition Sector Development

Program (HPNSDP) 2011-2016 [26], etc.), this strategy document acknowledged the importance of

bringing more funds to the health sector and pooling the resources effectively. It summarized challenges

of health financing in Bangladesh as (1) inadequate health financing; (2) inequity in health financing and

utilization; and (3) inefficient use of existing resources. Designed to address the health-financing issues

for the next 20 years, this document also proposed ways to combine funds from tax-based budgets with proposed social health protection schemes (including for the poor and the formal sector), existing

community based and other prepayment schemes and donor funding to ensure financial protection

against health expenditures for all segments of the population, starting with the poorest. It recognized

the importance of and proposed collaboration with the for-profit and not-for-profit private sector,

development partners, and the community people, to resolve the health-financing challenges. It

proposed a gradual process to achieve universal coverage, starting from the poor and the formal sector

(public, for-profit private, and not-for-profit private), progressively to remaining segments of the

population by 2032.

Apart from this crucial document, a few other important policy documents provided important policy

directions for UHC in Bangladesh. For example, the ‘Seventh Five-Year Plan Fiscal Year 2016-2020:

Accelerating Growth, Empowering Citizens’ [26] expressed commitment to ensure that poor and

marginalized people are able to access and utilize health services. Acknowledging the existing deficiency

in per capita health expenditure, the share of the national budget for health, quality of care, and high OOP, it

proposed a health-financing reform to address these issues. In light of these proposals, the ‘National

Social Security Strategy of Bangladesh’ [27] suggested some specific reforms and action plans and listed

relevant ministries to collaborate with. It expressed the commitment of the GoB to introduce a national

health insurance scheme. These reforms require budgetary allocation, the insufficiency of which has

been recognized by the ‘National Health Policy’. It not only recommended increasing the allocation but

also proposed ensuring equitable care for the disadvantaged, poor, marginalized, elderly, and the

disabled population. In alignment with the National Health Policy’s recommendations, the ‘Health

Population and Nutrition Sector Strategic Plan 2011 – 2016’ [27] dedicated a chapter on ‘health sector

financing’, where it proposed a health-financing framework, advocated demand-side financing and

proposed a resource allocation formula. The ‘Health Nutrition and Population Strategic Investment Plan

2016-2021’ [27] identified 10 driving forces, the final one of which suggested greater investment in

health, ensuring a focus on managing demand, increasing efficiency, and developing the evidence base

for future health funding. It also identified the Essential Service Package (ESP) as the first milestone on the

road to UHC. It proposed three guiding principles for attaining UHC: quality, equity, and efficiency across

health services. Apart from these government documents, many non-government ones, such as

‘Bangladesh Health Watch Report 2011: Moving Towards Universal Health Coverage’ [28], and ‘The Path

to Universal Health Care in Bangladesh: Bridging the Gap of Human Resources for Health’ [29],

advocated for creating greater demand for UHC and quality primary health care (PHC) among the

community through support from the civil society.

3.2. Current Activities towards UHC in Bangladesh

The information presented in this section has been obtained through both document reviews and the

key informant interviews.

Public Sector. ESP has been identified as the basis for UHC activities in the public sector of Bangladesh. ESP

is currently in the process of implementation, even at the lowest unit of health service delivery facility, 

the Community Clinic (CC) level. A pilot health-financing scheme, Shasthyo Suroksha Karmasuchi (SSK),

has been introduced by HEU in three Upazilas (Kalihati, Ghatail, and Madhupur) of Tangail District [30].

Initially, the below-poverty population has been included in the scheme (includes treatment for 50+

disease conditions) with the government paying for their premium; the above-poverty population is also

intended for gradual inclusion in the scheme.

At the district or implementation level, information, and communication technologies (ICT) are used

extensively to improve population coverage. Services are delivered through health centers as well as

through household visits. Social and behavioral change communications (SBCC) and Expanded Program

on Immunization (EPI) activities are carried out as preventive measures. Curative programs include

Integrated Management of Childhood Illnesses (IMCI), maternal and neonatal health activities, demand-side financing programs (DSF) with vouchers, Emergency Obstetric Care (EOC), and indoor and outdoor

services, in most areas, if not all. The family planning directorate of the MoHFW is also engaged in sexual

and reproductive health care, in addition to their role in family planning. The government has started

shifting focus from just quantity to the quality of services as well. Medicines are given free of cost from

health centers, which reduces the financial burden of the patients to some extent.

NGO Sector. NGOs are mainly engaged in increasing service coverage and that with service quality. In

terms of service coverage, their emphasis is on newborn health, maternal health, nutrition, health

system strengthening, etc. at the PHC level. In terms of population coverage, their main focus is on

the hard-to-reach areas and the population therein. They are focusing on community engagement and

SBCC activities, which may go a long way to demand generation among the population for UHC and also

decrease the financial burden for curative care. A respondent from an international NGO clarified this

concept:

“If we strengthen the preventive care, if we strengthen the SBCC components, that actually is the best

way to bring down the cost of treatment in the future.”

They also advocate with the government for modifying policies, many of which directly or indirectly

contribute to the UHC journey.

Multilaterals and Donors. Multilateral organizations, such as the World Health Organization (WHO), are

more into generating a common understanding of UHC among the stakeholders. They are also providing

technical support to the government in implementing UHC. Generating information and strengthening

the health system are their larger approach to contribute to UHC activities. Highlighting the importance of

multisectoral action for UHC, a representative of a multilateral organization remarked,

“It is a big area where our organization wants to work and make changes. We try to engage all the

concerned ministries, often through dialogues.”

Donors supported the HEU in developing the Health Care Financing Strategy 2012-2032 and also its

implementation [24]. Raising awareness and a common understanding of UHC has also been the main

focus.

Academia and Research. Academia and research organizations’ role is to familiarize the concept of UHC

to the relevant stakeholders. A professor of a school of public health remarked:

“We are trying to bring them (stakeholders) to the consensus so that they are clear about what this

(UHC) is, why is it necessary, what to do in order to achieve it, and how they all can contribute to this

cause.”

They are organizing short courses to develop capacity, conduct research work on UHC related issues,

and do policy advocacy through roundtable discussions, TV talk shows, etc. Research organizations are

also involved in planning, monitoring, and evaluating GoB health programs relevant to UHC.

Media. The media is also involved, as expected, in awareness building about UHC, especially among the

common mass. Media has been involved since the beginning of the UHC agenda in Bangladesh, starting

from a grant from Rockefeller Foundation made to the quasi-governmental autonomous organization,

Press Institute of Bangladesh (PIB). Journalists received training on UHC, are writing extensively on

different aspects of UHC, and visited the SSK project. Some journalists even went to other countries

(e.g., Thailand, Nepal, Bhutan, Philippines) on an exposure tour. A senior health journalist said:

“These exposure tours helped me develop an idea about what other countries are doing in terms of

UHC. All I have been writing in newspapers, and what I am telling you now, are in light of these visits.”

PIB is regularly organizing training and orientation sessions for journalists, and TV talk shows on

different aspects of the UHC agenda [31].

3.3. Barriers towards Achieving UHC in Bangladesh

The information presented in this section has been obtained through key informant interviews. The

barriers to progress towards UHC can be felt at different levels. The barriers have been categorized

across three levels, which are again crosscut by one important barrier, the lack of a shared understanding of UHC. The three levels are (1) larger policy-level barriers, often beyond the jurisdiction

of the health sector alone, (2) implementation barriers in the health sector, and (3) demand-side barriers (Figure

1).

Larger Policy-Level Barriers (Health Sector and Beyond). Public financial management has been designed

such that only health sector finance is very difficult to alter separately. Ministry of Finance needs to

change all its mechanisms and rules of procedures for all other ministries if it wants to do something for

one particular ministry. Bangladesh has traditionally been practicing supply-side budgeting, whose

changing is complicated, has crosscutting ramifications, and, therefore, demands much broader or

revolutionary commitment for whole system change. An expert from an international NGO on health

systems strengthening said

“This is the legacy of British colonial bureaucracy, which no one dares changing, despite how much they

want.”

As a result of all of these, the overall healthcare expenditure is increasing, which requires more funding

to address. Eventually, the implementation of UHC is becoming progressively expensive. This is happening in

the context of a country that chronically allocates the least share of its national budget for health. On top of

all these, health insurance, if we consider as a means to UHC, itself is resource-intensive.

The regulatory mechanism is not adequately functioning to regulate the private sector. There is

currently no such structure for the functional mediatory mechanisms, to resolve or mediate the complaints

of the service seekers. Unqualified providers often continue harmful medical practices, capitalizing

loopholes in the regulatory framework, and its implementation.

In addition, there is a deficiency in health systems governance and stewardship. Accountability and

transparency are difficult to ensure in the public sector, especially in the presence of a highly centralized

system. One key informant from a multilateral organization said,

“With the very centralized system, it is difficult for the managers to be able to act on the information or

data they have. So, they don’t always make decisions for their community, for their catchment area–

based on the local data.”

Implementation Barriers in Health Sector. Poor human resource management, including shortages,

deficient training, low motivation, retention issues, skill-mix imbalance, and quality service provision is

staggering. Recruitment mechanisms by Bangladesh Civil Service (BCS) are also criticized for taking too

long to deploy physicians into vacant posts in time. Political interference is often adding insult to injury,

like recruitment, retention, and disciplinary measures become difficult for managers to exercise. One

local level government health official said

“There are some bad areas near Hobiganj, where I cannot retain any physician. As soon as I deploy

someone, phones keep coming from the honorable minister, secretary, political leaders, Awami League

(ruling party) secretary, petit leaders, so-and-so, requesting not to keep his doctor there.”

The same bureaucrat also reflected on difficulties of disciplinary actions against his employees due to

political interference:

“Yesterday, going to an Upazila Health Complex I discovered, the physician had not come to his duty on

time. I asked him to show the causes of his absence. Since evening I had received at least 10 phone calls,

vouching for him that he had genuine reasons to remain absent that day. If I tend to take disciplinary

actions, they would say, ‘why are you making too much of it?’”

Deficient monitoring mechanisms often exacerbate the shortage of human resources, as the existing

service providers cannot be ensured to stay in their posted positions.

There is no agreed-upon protocol for treatment, referral, follow-up, and even general service

management. As a result, uniform care with sufficient quality is difficult to provide. Lack of proper

training of service providers results in a lack of quality of care and responsiveness towards the service

seekers. Since the service providers are trained in a certain way, convincing them to do it differently

overnight is challenging. Implementers of SSK in three Upazilas faced this problem, as reported by a key

informant from the central level of the government:

“They (service providers in SSK facilities) are trained in a certain way. When we are giving direction to do

something different for the sake of the project, they are saying, ‘why should I do it like this?’ Now, no

one is willing to go to those centers, despite those being close to Dhaka. Someone even told me, if he

has to stay there, he would rather leave the job.”