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«Annex 1 Expanding Social Protection for Health: Towards Universal Coverage Health Care Financing Strategy 2012-2032 September 2012 Health Economics ...»

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Annex 1

Expanding Social Protection for Health: Towards Universal Coverage

Health Care Financing Strategy 2012-2032

September 2012

Health Economics Unit

Ministry of Health and Family Welfare

Government of the People’s Republic of Bangladesh

Annex 1





Executive Summary

1. Introduction

1.1 Scope of the Strategy

1.2 Strategy Development Process

2. Key Challenges in Health Financing

2.1 Inadequate Resources in the Health Sector

2.2 Inequity in Health Financing and Utilization

2.3 Low Levels of Efficiency in Healthcare Financing

3 Health Financing Strategy

3.1 Vision and Goal

3.2 Strategic approach

3.3 Strategic Objectives

3.4 Strategic Interventions

3.5 Population coverage

3.6 Sequencing

4 Strategic Level Objectives Indicators

5 The way forward


Annex A: NHA Data

Annex B: Strategic Matrix

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Preface Bangladesh has achieved remarkable success in PHC services delivery though it has the lowest per capita health expenditure in the SAARC region. However, it is now facing the further challenge of increasing health care costs due to rising awareness of the people seeking health care, continued attempts at empowering disadvantaged people for accessing to heath care, aging population, and new methods of treatment and diagnosis that enable the treatment of previously untreatable conditions and untreatable patients.

This country has been plagued with the burden of unacceptably high out of pocket expenditure at the level of 64% of total health expenditure (THE); government spending is around 26% only;

there are no mentionable health insurance programs; the economically vulnerable population of the country is threatened with impoverishment in case of catastrophic illnesses, and the percentage of that population is rather too high. THE level, itself, is also quite low. Only 3.4% of GDP is spent on health. This calls for focusing on the concerns for deepening and broadening the resource base for health in the country.

Bangladesh will require more than just increased financial resources for health; it will require improved ways of organizing resource mobilization, allocation and expenditure in order to obtain the maximum value for money to ensure equitable and sustainable financing and financial protection against health expenditures for the entire population. This is the foundation stone and guiding principle of the proposed health care financing strategy. Hitherto, Bangladesh had no formal health care financing strategy. This is the first one.

The proposed health care financing strategy provides an overview of the vision, and the goals, followed by the strategic objectives, each with their associated strategic interventions that respond to the goals of health financing in Bangladesh. It attempts at providing the framework and direction for increasing the level of funding for health, ensuring an equitable distribution of the health financing burden, improving access to essential health services, reducing the incidence of impoverishment and catastrophic health care expenditures and improving quality and efficiency of service delivery.

An action plan for possible implementation in the short term has been set out. Timely implementation of the action plan following the strategy will strengthen the country’s health system to succeed in improving the wellness of its citizens.

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Acknowledgments The Health Care Financing Strategy has been developed over a period of a year since the adoption of Health Policy 2011 and HPNSDP (2011-2016). The development was through a participatory process. That process has been led by Health Economics Unit under the full support and proactive guidance of the Ministry of Health and Family Welfare.

Since the beginning of the development process of the strategy document, Senior Secretary Mr.

Md Humayun Kabir actively contributed to the drafting and in carrying forward the consultation process. He has taken the process to its logical conclusion.

Health Economics Unit under the stewardship of Mr. Prasanta Bhushan Barua, former Joint Chief, have drawn up the road map for developing the strategy, constituted 3 Technical Working Groups, and steered the preparation of 3 thematic papers by the TWGs. Joint Secretary Mr.

Ashadul Islam succeeded Mr. Prasanta Bhushan Barua as the head of HEU and with due diligence took the process to its programmed conclusion. Both Mr Barua and Mr Islam have been ably supported in the process by Mr. Md Hafizur Rahman, Dr Ahmed Mostafa and Mr.

Mohiuddin. They acted as the facilitators of the TWGs. The secretarial support to development process has diligently been provided by Mr. Abdul Hamid Moral with the assistance of the HEU team.

Mr. Waliul Islam, Lead Consultant facilitated the strategic development process, coordinated the TWG, and organized the regional and national consultations with the assistance of Event Manager Mr Ahmed Mollah Mahmood. Special mention must be made of the Focal Points of the 3 TWGs, Dr Tanvir M Huda and Dr Jahangir Khan, both of ICDDR, B, and Ms Nahid Akhter Jahan of Institute of Health Economics of Dhaka University, who in addition cofacilitating the TWG work, produced the first drafts of the thematic papers and contributed to the development of the strategy document.

Mention need be made of members of TWGs, especially Ms Nargis Khanam of Planning Wing of MOHFW, Dr Rumana Huque, Associate Professor of Dhaka University, Mr. Hossain Adib of BRAC, Dr Nadira Sultana of Access Health International, Professor Sushil K Howlader of Institute of Health Economics of Dhaka University, Dr Khairul Islam of Water Aid and Dr Zahirul Islam and Ms Ylva Sorman Nath of Sida for their contributions in the development of the strategy document.

Special thanks to Mr. Mukesh Chawla of the World Bank for leading the redrafting workshop.

Thoughtful comments and recommendations on various drafts were received from Mr. Joe Kutzin of WHO, Mr. Chris McDermott of USAID/Bangladesh, Mr. Birger Forsberg for SIDA, Mr. Paul Rueckert of GIZ, Mr. Bertold Liche of KfW, Ms. Catherine Connor of Abt Associates, and Dr. Michael Adelhardt of Providing for Health.

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Ms Eleonora Cavagnero of World Bank, HCFS Road Map Implementation Co-facilitators Ms Tahmina Begum (consultant World Bank), Yann Derriennic (Health Systems 20/20/USAID) deserve thanks for contributing in the process leading to the development and drafting of the strategy.

Finally, thanks are also due to USAID and World Bank for actively supporting and assisting the development of the HCFS document, especially Dr. Bushra Alam and Ms. Khadijat Mojidi.

Last but not least the participants in the different consultations deserve special mention for their contributions in making the strategy document focused to the real health care needs of the population..

It is the product of the collaborative effort by many professionals inside and outside of HEU and MOHFW All the actors [only a few has been mentioned by names here] in the health care financing strategy development process deserve thanks for their respective contributions.

–  –  –

CBHI Community Based Health Insurance CMH Commission on Macroeconomics and Health CCT Conditional Cash Transfers CSR Corporate Social Responsibility

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HFRTG Health Financing Resources Task Group HIES Household Income and Expenditure Survey NHSO National Health Security Office HPNSDP Health, Population and Nutrition Sector Development Program HPNSP Health Population and Nutrition Sector Program MDG Millennium Development Goals

–  –  –

Executive Summary The Health Care Financing Strategy 2012-2032 provides a framework for developing and advancing health financing in Bangladesh. The strategy is aligned with the vision of the Health, Population and Nutrition Sector Development Program (HPNSDP) 2011-2016, the universal coverage as defined by WHO, and the National Health Policy 2011 that recognizes the importance of bringing more funds to the health sector and pooling the resources more adequately.

Rising incomes and aging population, with its growing burden of chronic diseases, will progressively add to the demand for complex and expensive health care. At the same time, the impressive performance of preventive and primary care has to be maintained and be available for the population. The high out of pocket spending and the catastrophic impact of the health care, especially on the poor and vulnerable, must be decreased and financial protection for health must be increased. The strategy needs to meet the financing challenges confronting the health sector now and in the future.

The challenges posed by health financing in Bangladesh are many and can be summarized under three broad categories. These are: (i) inadequate health financing; (ii) inequity in health financing and utilization; and (iii) inefficient use of existing resources.

The strategy recognizes the importance of other building blocks of the health system; however, discussions on those and their impact on this strategy have been beyond the scope of this document.

This strategy document has been developed through a participatory process, led by the Health Financing Resource Task Group with the Senior Secretary of the Ministry of Health & Family Welfare (MOHFW) in the chair. Thematic papers on the financing challenges were drafted by technical working groups with representatives from the academia, research organizations, NGOs and public sector; integrating the thematic papers, a preliminary draft was shared with representatives of stakeholders in regional consultation workshops. A national consultation with the principal stakeholders on the redrafted document was held to arrive at the final draft.

The Strategy is designed to address these challenges and presents a compelling case for an increase in public resources dedicated to health while outlining an actionable mechanism to capture private spending and channel it efficiently in prepayment and pooling arrangements. It puts emphasis on extending financial protection to all segments of the population.

The goal of the national health financing strategy is to strengthen financial protection and extend health services and population coverage especially to the poor and vulnerable segments of the population, with the long-term aim to achieve universal coverage. The role of health financing is to: (i) provide all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to be effective; and (ii) ensure that the use of these services does not expose the user to financial hardship.

The proposed 20-year health financing strategy devises 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.

Recognizing the need for increased engagement and strengthened stewardship role of MOHFW, this strategy document aims at maximizing the complementary role of private sector, both for profit and non-profit, through public private partnership, and a continuing the engagement of Development Partners’ in financing the health sector. The proposed strategy has designed its interventions and actions targeted to increasing people’s engagement and participation.

To begin with, this strategy proposes to cover the poor and the formal sector, including government, private and NGO employees, and progressively extending the coverage to the remaining segment of the population by 2032.

To cope with the challenges and increase financial protection for the entire population and decrease out-of-pocket payments at point of service, the following three strategic objectives are


Generate more resources for effective health services • Improve equity and increase health care access especially for the poor and vulnerable • Enhance efficiency in resource allocation and utilization •

Strategic interventions and supportive actions:

1. Design & implement Social Health Protection Scheme

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3. Strengthen national capacity Support information exchange platform/knowledge hub/resources pool Develop the capacity to design and manage the social health protection scheme Strengthen Financial Management and Accountability Improve monitoring and evaluation Introduce mechanisms to support the production of additional key staff (nurses, paramedics and medical technicians)

–  –  –

The entire population of Bangladesh will have access to the public health services; and in addition, they will benefit from the increased financial protection for health.

The strategy will be implemented in three phases, - short, medium and long. The short term one will be up to the end of HPNSDP; in that phase SSK pilot rolls out, and NHSO and other key elements of the social health protection scheme will be designed. The medium term will be up to 2021 when the activities launched during the preceding phase (SSK, NHSO and social health protection programs) will be appropriately scaled up. In the long term, the next 11 years, Bangladesh will move ahead to achieving universal health coverage building upon the achievements of the short and medium terms of sequenced implementation of the strategic interventions proposed here The HCFS is comprehensive in its inclusion of a logical framework and a set of indicators. This analytical framework will make it easy for all stakeholders to assess the on-going and proposed interventions in the light of the defined objectives of this strategy.

This Strategy points the way to the long-term objective of universal coverage. What is important is to begin and take active steps to protect ALL Bangladeshis from the financial risk of seeking or obtaining care.

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