Bangladesh’s battle for health care

With middle-income status and a growing demographic dividend, the country’s people are demanding more and better medical care. The question is: will they get it?

Bangladesh’s battle for health care AFP Photo/STR/NurPhoto

More than 160 million people live in Bangladesh, making it one of the world’s most populous countries and densely populated markets. As many as 25 million people live in the capital, Dhaka, alone. Bangladesh is also one of the fastest-growing economies in the world and has been dubbed the next Asian tiger by the World Economic Forum, The Economist and others – a far cry from the “basket case” that Henry Kissinger dubbed it at its birth in 1971.

A dynamic, growing middle class of nearly 40 million people has already propelled Bangladesh to “middle-income” status, according to the World Bank. Remarkably, Bangladesh is one of the few countries that met almost all of the Millennium Development Goals. Until recently, most attention given to the country by the international media has been focused on floods, cyclones, allegedly deplorable labor conditions in the garments industry and poor governance. However, the last decade has drawn attention from development practitioners. Zahid Hussain, lead economist for South Asia at the World Bank, aptly summarized the recent internal and external shocks the country has weathered and amid which its economy has flourished: “Since 2006, Bangladesh has faced political uncertainty (2006-2007); two major floods, the disastrous Cyclone Sidr and avian flu (last half of 2007); food and energy price crises (first half of 2008); the global financial meltdown and recession (2008-2009); political transition followed by mutiny (first half of 2009); and rapid deterioration of the power and gas supply
situation (first half of 2010). These exogenous shocks resulted in a decline in the efficiency of investment, but the private investment rate itself managed to grow at a rate faster than the growth of gross domestic production, while the public investment rate declined. The economy has demonstrated resilience time and again. Several factors explain Bangladesh’s resilience to global shocks. These include strong fundamentals at the onset of the crisis, the resilience of its exports and remittance, relatively underdeveloped and insulated financial markets, and pre-emptive policy response.”

Bangladesh’s recent economic growth, equivalent to some of the best-performing Asian economies, has contributed to a substantial decrease in poverty from 40 percent in 2005 to less than 30 percent today. Its growth rate was 5.6 percent in the 10 years from 1998-2007 and accelerated to 6.3 percent in the 10 years from 2008 to 2017. 

Bangladesh’s economy was the secondfastest growing economy in the world at a GDP growth rate of 7.1 percent in 2016, which further accelerated to 7.3 percent in 2017, and the International Monetary Fund expects Bangladesh to again be the secondfastest growing economy in 2018. According to the IMF, “The Bangladesh economy’s strong growth comes with stable inflation, moderate public debt, and greater resilience to external shocks. The country continues to make steady progress in reducing poverty and improving social indicators.”

Demographics have already helped Bangladesh to climb into the ranks of the world’s largest economies; the larger proportion of working-age to total population has contributed to growth since the 1980s, along with improvements in labor productivity. The World Bank estimates that Bangladesh is poised to reap the benefits of a “demographic dividend,” even suggesting it may be “the next China.” The demographic dividend is defined by the United Nations as “the economic growth potential that can result from shifts in a population’s age structure, mainly when the share of the working-age population (15 to 64) is larger than the nonworking-age share of the population (14 and younger, and 65 and older).” More than 65 percent of Bangladesh’s population is between 15 and 64, the period of life that is considered to be one’s average productive working years, compared to 52 percent for the same category in 1980.

Bangladesh is now passing through a critical phase of demographic transition with declining birth and death rates. Replacementlevel fertility refers to a total fertility rate (the average number of children born per woman) of roughly 2.1, at which point a population exactly replaces itself from one generation to the next. In a country like Bangladesh, replacement-level fertility occurs when fertility rates decline and life expectancy increases. According to the World Bank, the fertility rate in Bangladesh has declined to 2.1 in 2015 from 6.4 in 1980, bringing Bangladesh very close to reaching replacement-level fertility, at which point population growth will level off to zero.

From a development perspective, reaching replacement-level fertility enhances growth in income per capita because it means that there are fewer dependent children relative to working adults in the population. For Nigeria, achieving replacement-level fertility yielded a rise in income per capita by 5.6 percent during a horizon of 20 years and by 11.9 percent during a horizon of 50 years. In East Asian economies, one-third of economic growth between 1965 and 1990 is attributed to similar demographic shifts.

On other social development indicators, in fact, Bangladesh is doing better than any other country in South Asia. Infant and maternal mortality rates have fallen by at least half since 1990, and life expectancy has risen by 13 years to 72, four years more than in India and three more years than Indonesia. Bangladesh has also outperformed similar countries in terms of female primary and secondary schooling, although it still lags behind at the tertiary level. Between 2006 and 2010, Bangladesh was enrolling over 7 percent more girls in primary education than other economies at the same level of income.

Progress on these social development indicators is especially remarkable given that Bangladesh’s public spending on both health and education as a proportion of GDP has remained lower than normal even for comparable levels of per capita income.

Against this backdrop of rapid economic growth, social infrastructure and specifically health care are still lagging dramatically. In June 2018, the IMF recommended further public investment in infrastructure, including health care service delivery. The urgent need for investment in health care is twofold: 1) there is simply too much demand in the market for health care in Bangladesh, and not enough supply to match the growing needs of a population that has more disposable income and wants more and better health care, and 2) Bangladesh’s continued growth as a nation depends on a healthy, resilient population.

Unlike most of the rest of the world, private health spending in South Asia is close to two-thirds of total health expenditure. Since 1999, private/out-of-pocket health expenditure has consistently represented more than 60 percent of Bangladesh’s total health expenditures, compared to the 37 to 44 percent range for similar low- and middleincome economies. Total health expenditure in Bangladesh has grown annually at an average rate of 8.3 percent from 2003 to 2013, but most of the growth in the sector is driven by private health expenditure. In fact, government spending has barely kept up with the inflation rate. With the public health system understaffed and overstretched, private health facilities are left to fill this gap.

For countries that are growing as quickly as Bangladesh, health spending increases at a rate even faster than income – as incomes rise, health spending grows disproportionately. As people have more disposable income, they demand better and more health care services. The same trend has been seen throughout Asia, where the health care sector is booming. Asia’s share of global health spending rose from 21 percent in 2012 to 24 percent by 2017, due to

With the public health system understaffed and overstretched, private health facilities are left to fill the gap.

population growth and rising income levels in the region. The fascinating paradox of health care
service delivery in Bangladesh is that the progress seen on health indicators is largely due to impressive advances made at the rural level, where the government has to some extent abdicated responsibility for public health care service delivery to nongovernmental organizations. But the services available in the urban setting are not radically better than that. (This is in particular contrast to neighboring India, where you can access some of the best health care services in the world in the cities, but the services in the rural areas vary dramatically from state to state and are often very limited.)

There are nearly 3,000 registered private hospitals and 5,000 private diagnostic centers in Bangladesh, but the government currently lacks capacity to regulate and monitor all of these facilities, and so there are serious questions about quality due to a lack of enforcement of existing rules and regulations.

Bangladeshis who want world-class health care, international-standard diagnostics or specialty and tertiary care often feel that they need to travel outside of the country. Even the most expensive facilities in Dhaka do not consistently maintain international standards – money does not necessarily guarantee access to world-class health care in one of the world’s fastest-growing economies, so the rich are often traveling to Bangkok, Singapore or beyond. The middle class is most often traveling to India, which is a relatively more affordable trip, but it remains a stretch for many. The number one reason a Bangladeshi middle-class family falls back into poverty is a health incident. Still, all of us will pay any price we can possibly manage to access health care for ourselves and our loved ones. Every single day, India’s embassy in Dhaka issues between 1,000 and 2,000 medical visas. That is half a million people a year without huge amounts of disposable income leaving their home country to access better health care. And the half a million figure likely undercounts the volume of Bangladeshis accessing health care in India, because many are traveling for tourism and visiting hospitals and clinics while they are in the country.

Consistently, patients complain that the biggest problem with health care in Bangladesh is a lack of trust. We originally hypothesized that the reason so many middle-class Bangladeshis were making a trip to neighboring India to access better care may be due to the lack of tertiary care or the fact that there is only one internationally accredited laboratory in Bangladesh. However, when we actually asked people why they were traveling abroad to access health care and what was missing back home, we were somewhat surprised to learn that the primary response was that doctors in Bangladesh generally do not spend adequate time with their patients, or answer their questions or even look them in the eyes.

Interestingly, many Bangladeshi patients are not necessarily traveling for tertiary or specialty care, but just to see a doctor who will spend time to help them understand what they are suffering from. Many Indians who hear this scoff, as they feel similarly about their own health care system. However, we are pushing up against certain margins. The British Medical Journal published a study in November 2017 in which it surveyed 67 countries to find out how much time doctors were spending with patients, on average, globally. Bangladesh ranked 66 at 48 seconds per patient, in contrast to two minutes per patient in India.

Inadequate Time with Patients
Average length of primary care physician consultations

In fact, patients actually feel better when their doctors spend time getting to know them. “Patient-centered care” improves patients’ clinical outcomes and satisfaction by enhancing the quality of the doctor-patient relationship, while at the same time decreasing overall

The number one reason a Bangladeshi middle-class family falls back into poverty is a health incident.

health care costs and wastefulness of diagnostic testing, prescriptions, hospitalizations and referrals. Patient-centered care is a holistic approach to health care. It goes beyond educating patients about their diagnosis and potential treatment by involving them in key decisions about their health, taking into account their personal circumstances and preferences. Patient-centered care requires open communication and consideration of patients’ cultural traditions, personal preferences and values, family situations, social circumstances and lifestyles. It demands every doctor get to know every patient personally.

There is a fundamental power imbalance between the doctor, who has the medical knowledge to understand what is happening in the body, and the patient, who is suffering but may not understand why. It is the responsibility of the doctor to alleviate that inequality by providing compassionate care. Every patient should be treated with dignity and feel confident that their health concerns will be taken seriously and addressed appropriately.

Praava Health is a network of family health centers in Bangladesh where patients come first. We are building a better patient experience that starts with family doctors, is enabled by user-friendly technology and offers access to a full range of diagnostics services. The Praava Health team is building a health system where patients come first: an outpatient network of health centers with family doctors as well as quality, reliable diagnostics. Because between 80 and 90 percent of all health care needs can be addressed by a family doctor,

Praava’s family doctors’ unit is the first point of entry for our patients. Praava Health features a group practice of family health professionals, including doctors with advanced training in family medicine, gynecology, pediatrics, dentistry and ophthalmology, as well as allied health providers such as psychologists, nutritionists, physiotherapists and health coaches. To accommodate patients who may need to see specialists, Praava also has a team of visiting specialists within our centers.

Proper care depends on accurate diagnosis. The diagnostics services we offer in-house include six laboratories for basic and advanced pathology, including Bangladesh’s first molecular cancer diagnostics lab in certain cancers like breast, cervical and colon cancer; and imaging services, including X-ray, ultrasonogram, DXA (bone marrow density), CT and MRI scans. Praava maintains international standards for our laboratories
and has commenced the process of obtaining
international accreditation, which we hope to
complete within two years.

We launched our first family health center in August 2017 and the full network will be rolled out in the coming decade based on a “hub and spoke” concept, with four hubs between Dhaka and Chittagong and spokes focused in the cities and beyond to peri-urban and rural areas. Our hub and spoke model aims to bring care to the community level and offer an array of services under one roof. Over time, harnessing technology and data, and creative alternative financing models, Praava Health expects to be able to offer world-class health care to tens of millions of Bangladeshis. The future of health care is based in technology, and Praava has already brought Bangladesh its first fully integrated hospital
information system, and is placing health literally in the palm of patents’ hands through an unprecedented patient portal. We are further experimenting to harness technology to improve diagnoses and access to specialty care. However, we do not believe that technology will ever replace the family doctor.

We hope to play a small part in Bangladesh’s development story, based on our belief that private sector infrastructure investment is essential to alleviating poverty, and that a healthy populace is a precondition to achieving and maintaining a sustainable growth trajectory.

Sylvana Q Sinha is the founder and chief executive officer of Praava Health, which is carrying out innovative and revolutionary work in Bangladesh’s health care system.

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