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Bangladesh Journal of Medical Science Vol. 15 No. 04 October’16

Review article
Healthcare Financing in Bangladesh: Challenges and Recommendations 

Hassan MZ1, Fahim SM2, Zafr AHA3, Islam MS 4, Alam S5

Abstract:
Bangladesh	has	achieved	remarkable	success	in	improving	most	of	the	health	indicators	over	the	
last	couple	of	decades	despite	pervasive	economic	poverty.	However,	for	a	sustainable	growth	
health	sector	should	be	among	the	top	lists	at	Government’s	policy	table.	Unfortunately,	the	
recent	trend	in	budget	allocation	portrayed	just	the	opposite	and	is	concerning	as	expressed	by	
health	experts.	Over	the	last	seven	fiscal	years,	budgetary	allocation	for	health	dropped	from	
6.2%	to	4.3%	of	total	government	expenditure.	Due	to	insufficient	public	spending,	out	of	pocket	
payment	(OPP)	is	much	higher	which	is	about	two-third	(64.7%)	of	total	health	care	spending	
in	Bangladesh.	Inadequate	and	inefficient	public	healthcare	and	profiteering	tendency	of	the	
private	healthcare	sector	are	two	major	factors	behind	such	high	private	spending.	Suffering	
from	a	massive	shortage	of	health	workforce	and	with	such	low	public	funding	it	would	be	very	
difficult	for	Bangladesh	to	fight	against	upcoming	challenges	like	increasing	burden	of	non	
communicable	diseases	(NCDs)	and	emerging	threats	due	to	climate	change.	

Keywords:  Healthcare	Financing;	Health	Budget;	MDGs;	Universal	Health	Coverage;	
Bangladesh

Corresponds to:  Md.	Zakiul	Hassan,	Crescent	Gastroliver	and	General	Hospital,	25/i,	Green	Road,	
Dhaka-1205,	Bangladesh.	Email:	drzakiulbd@gmail.com

1. Md.	Zakiul	Hassan,	Crescent	Gastroliver	and	General	Hospital,	Dhaka,	Bangladesh
2.	 Shah	Mohammad	Fahim,	Lecturer,	IBN	SINA	Medical	College,	Dhaka,	Bangladesh
3. Abu	Hena	Abid	Zafr 

Crescent	Gastroliver	and	General	Hospital,	Dhaka,	Bangladesh
4. Md.	Shoriful	Islam,	Assistant	Professor	of	Finance,	Department	of	Business	Administration,	Northern	

University Bangladesh
5. Shahinul	Alam,	Associate	Professor,	Department	of	Hepatology,	Bangabandhu	Sheikh	Mujib	Medical	

University	(BSMMU),	Dhaka,	Bangladesh

Bangladesh Journal of Medical Science Vol. 15 No. 04 October’16

505

Introduction: 
Bangladesh	has	made	substantial	progress	 in	most	
health	indicators	over	the	last	two	decades1. Under-5 
child	mortality	decreased	significantly	from	144	to	41	
per	1,000	live	births	2,	3 maternal mortality rates have 
dropped	markedly	by	66	per	cent	(194/100,000	live	
births)	and	life	expectancy	jumped	to	nearly	70	years	
at birth4.	Two	years	back,	one	of	the	most	prestigious	
medical	journals,	the	Lancet,	published	a	case-series	
on Bangladesh’s massive success in health and 
termed it a great mystery in global health5. Lancet 
stated	that,	despite	spending	less	on	health	care	than	
other	neighboring	countries,	Bangladesh	now	has	the	
longest	life	expectancy,	the	lowest	total	fertility	rate,	
and	 the	 lowest	 infant	 and	 under-5	 mortality	 rates	

in South-Asia5, 6. Bangladesh is among the only six 
countries	that	are	on	track	to	achieve	MDGs	7. 
But	much	still	remains	to	be	done.	Still	nearly	40%	
of	children	whose	ages	are	under	five	in	Bangladesh	
are	stunted	and	35%	are	under	weight8.  One out of 
every	 24	 children	 dies	 before	 their	 fifth	 birthday,	
60	percent	of	those	within	the	first	28	days	of	life,	
many	 from	 conditions	 which	 would	 have	 been	
easily	treatable	if	they	had	access	to	a	skilled	health	
workers9.	 Therefore,	 to	 sustain	 the	 development	
that Bangladesh has achieved and to get to a middle 
income	status	by	2021,	health	should	be	given	high	
priority.	But	unfortunately,	in	recent	years,	the	health	
budget	reflects	just	the	opposite	picture.	The	sector	
remains extremely neglected in the budget allocation 



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Healthcare	Financing	in	Bangladesh:	Challenges	and	Recommendations

of the government. It is unanimously recognized 
that	public	spending	on	health	must	be	increased	for	
achieving	 the	 MDGs	 in	 developing	 countries	 like	
Bangladesh10.	 However,	 budgetary	 share	 of	 health	
sector	 is	 going	 down	 every	 year	 threatening	 the	
future	of	post-MDG	goals.	The	aim	of	this	review	
is	 to	 highlight	 the	 healthcare	 financing	 features	
of	 Bangladesh,	 identify	 the	 potential	 challenges	
to	 achieve	 sustainable	 development	 goals	 for	 the	
country.
Healthcare Financing Features:
In	 practice,	 the	 government	 of	 any	 country	 has	 a	
prime	responsibility	about	the	development	of	health	
facilities	as	well	as	medical	system	which	should	be	
applied	 through	allocating	a	significant	percentage	
of	total	expenditures	in	health	sector.	Unfortunately,	
the yearly allocation in Bangladesh is far short of 
required	 level	 set	 by	 World	 Health	 Organization	
(WHO)	which	is	at	least	15%	of	total	budget	of	a	
country11	 .	 Figure	 1	 shows	 the	 scenario	 of	 health	
allocation	in	percentage	of	total	expenditure	in	last	
seven	fiscal	years	in	Bangladesh.

Figure	2:	Health	expenditure	in	Bangladesh	in	total	
%	of	GDP14

Health	 spending	 can	 be	 compared	 with	 the	 total	
GDP	and	it	is	remarkably	noted	that	Bangladesh	is	
clearly behind among some other Asian countries in 
this	aspect.	From	the	presented	figure,	it	is	observed	
that	Maldives	hold	the	top	position	and	their	health	
expenditure	 is	 10.8%	 of	 total	 GDP.	 In	 this	 case	
Bangladesh	 is	 in	 lowest	 position	 and	 India	 use	
slightly	higher	percentage	than	us	which	is	4%.
The	total	amount	of	budget	allocated	for	health	in	
this	fiscal	year	is	BDT	12,726	crore15.	Though	the	
amount	is	a	BDT	1,157	crore	hike	from	the	outgoing	
fiscal	 year’s	 allocation16, the sector’s share in the 
total	 budget	 has	 declined	 0.51	 percent15.	 We	 can	
also	compare	the	per	capita	expenditures	for	health	
purpose.	Table	1	shows	the	per	capita	health	spending	
in neighboring countries.

Table 1: Per capita health spending (in USD) 17

Figure	1:	Health	expenditure	in	Bangladesh	as	a	%	of	
total	government	expenditure	during	2009-201612,	13

According to the above mentioned diagram, it can be 
said that during last seven years, Government health 
care	spending	in	proportion	of	total	public	spending	
has decreased gradually. Moreover, the fund allocation 
was	decreased	with	time	whereas	population	as	well	
as	different	type	of	new	diseases	increased	within	the	
same	time	period.	In	fiscal	year	(FY)	2009-10,	 the	
allocation	for	health	was	6.2%	of	total	budget	which	
dropped	to	4.3%	in	2015-16	FY12,	13.
The	 total	 health	 spending	 in	 Bangladesh	 is	 3.7	
percent	 of	 GDP	 whereas	 in	 developed	 countries,	
the	health	sector	constitutes	nine	percent	of	the	total	
GDP14.	Figure	2	shows	health	expenditure	in	total	%	
of GDP in neighboring countries.

Bangladesh’s	per	capita	health	expenditure	 is	$32,	
which	 is	 the	 lowest	 in	 the	 region	 compared	 to	
India,	Afghanistan,	Nepal,	Bhutan,	Pakistan	and	Sri	
Lanka17.	However,	the	spending	is	more	than	three	
times	higher	for	Sri	Lanka	and	nearest	to	double	in	
India.	WHO	recommends	a	per	capita	spending	of	
$54	 11.	The	 government	allocation	 is	 700	 taka	per	
person	per	year	or	1.92	taka	per	person	per	day18. 
With	ever	increasing	health	care	cost,	one	can	easily	
realize	 to	 what	 extent	 the	 allocated	 money	 could	
help.



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Hassan	MZ,	Fahim	SM,	Zafr	AHA,	Islam	MS	,	Alam	S

The	 public	 spending	 on	 health	 is	 currently	 only	
35.3%,	 almost	 one	 third	 of	 total	 health	 care	
spending19.	In	developed	countries	the	picture	is	just	
opposite.	Table	2	shows	the	government	spending	in	
health	in	some	developed	and	neighboring	countries.	

Table 2: Public health expenditure (% of total 
health expenditure) 19  

with	more	effective	drugs	and	interventions	etc.	On	
the	 other	 hand	 non-development	 sector	 indicates	
employees’	 salaries,	 wages	 and	 other	 operating	
costs.	Last	three	year’s	scenario	of	development	and	
non-development	 budget	 in	 Health	 sector	 can	 be	
presented	with	the	following	table-

Table 3: Allocation of Budget (in % of total) 12, 15

Because	 public	 spending	 is	 much	 lower,	 people	
have	to	pay	for	health	from	their	own	pocket	(OPP)	
which	is	about	two-third	(64.7%)	in	Bangladesh.	The	
Global	standard	for	out	of	pocket	payment	(OPP)	is	
less	than	32	percent20. Due to the high OPP, thousands 
of	poor	households	are	being	pushed	 into	poverty	
every	year	which	is	called	catastrophic	expenditure. 
Studies		have	shown	that	6.4	million	(4%)	people	in	
Bangladesh	get	poorer	every	year	due	to	excessive	
health cost21,	22.		People	have	to	borrow	money	or	sell	
assets	to	pay	for	health	care.	It	has		also	been	found	
that	 20	 percent	 of	 the	 poorest	 spend	 16.5	 percent	
of	their	household	consumption	for	health	reasons,	
while	20	percent	of	the	richest	spend	9.2	percent	21.
Inadequate	 and	 inefficient	 public	 healthcare	 and	
profiteering	in	the	private	healthcare	sector	are	two	
major	 factors	 behind	 such	 private	 spending.	As	 a	
result	the	gap	between	those	who	can	access	needed	
health	services	without	fear	of	financial	hardship	and	
those	who	cannot	is	widening23.	So,	despite	the	rising	
health care costs in the country, the declining trend 
of health care allocation is against GOB target to 
plummet	the	OPP	down	from	64%	to	32%	by	203224. 
In	fact,	the	OPP	will	increase	further	if	the	allocation	
is not increased in the budget. 
Another	 important	 issue	 can	 be	 considered	 as	 the	
budgetary	 allocation	 between	 development	 and	
non-development	sectors	of	medical	and	health	care	
division.	For	healthcare	sector,	development	budget	
meant allocation for construction and infrastructural 
development	 of	 hospitals	 and	 medical	 care	 units,	
enrichment	 of	 modern	 medical	 equipments	 and	
diagnostic	tools,	improvement	of	treatment	systems	

From the table 3, it can be said that the allocation 
for	the	development	sector	is	lower	in	comparison	to	
the	allocation	for	non-development	sector.		Although	
the	table	shows	an	increasing	trend	of	development	
budget	 from	 FY	 2013-14	 to	 the	 running	 period	 of	
time,	still	it	is	much	lower	than	50	percent.	Even	then	
a	significant	portion	of	development	budget	remains	
unspent	every	year.	Over	the	past	seven	years	it	has	
been observed that the health ministry can utilize only 
76%	percent	of	its	annual	development	budget	25.
Despite	suffering	from	acute	shortage	of	resources,	
government	hospitals	only	utilize	a	little	more	than	
half	of	their	annual	budget,	forcing	patients	to	seek	
treatment	in	the	private	sector.	Government	hospitals	
in rural areas receive their budget near the end of the 
fiscal	year	due	to	bureaucratic	tangles	and	thus	do	
not	have	much	time	to	spend	the	money.	In	addition,	
there	is	a	core	system	weakness	and	knowledge	gap.	
Typically	at	the	ground	level,	government	has	made	
big investment for buying an ambulance but does 
not	have	the	system	for	small	investment	to	repair	
puncture.	 A	 2012	 World	 Bank	 survey	 identified,	
about	10%	of	installed	medical	equipments	in	public	
health	 facilities	 had	 been	 unused	 and	 another	 20	
percent	had	never	been	installed	 26.	This	is	clearly	
inefficient	 use	 of	 resources	 and	 reflects	 lack	 of	
transparency	and	good	governance.	TIB	repeatedly	
reported	 that	 the	 sector	 has	 been	 plagued	 with	
corruption	and	corruption	has	been	institutionalized	
in	all	bodies	within	the	sector	which	is,	one	of	the	
prime	 reasons,	 for	 under	 utilization	 of	 allocated	
fund27.	Another	 problem	 is	 unequal	 distribution	 of	
funds	 and	 resources.	 Figure	 3	 shows	 the	 unequal	
distribution of budget allocation in seven different 
divisions,	where	Dhaka	got	almost	half.	But	Sylhet	
and	Barisal	division	jointly	received	fund	less	than	
one-fourth	of	Dhaka	 28 and second largest amount 
received	by	Chittagong	division	which	is	18%.



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Healthcare	Financing	in	Bangladesh:	Challenges	and	Recommendations

Figure	3:	Distribution	of	Division-wise	Total	Health	
Expenditure	(THE)
Challenges and Recommendations:
Bangladesh	has	a	massive	shortage	of	skilled	health	
work	 force.	 The	 country	 has	 only	 0·5	 doctors	
and	 0·2	 nurses	 per	 1000	 people,	 far	 less	 than	 the	
minimum	standard	of	2·28	per	1000	recommended	
by	WHO29.	Trained	and	skilled	workforce	is	a	key	
to	ensure	quality	health	care	for	people.	Bangladesh	
has an extensive health infrastructure, but due to 
shortage	of	health	care	workers	and	logistics,	most	
public	health	facilities	cannot	perform	optimally30. A 
workforce	plan	for	the	short,	medium	and	long	term	
is	necessary	with	a	clear	strategy	to	achieve	targets	
within	a	specified	time,	addressing	both	the	public	
and	the	private	sectors.	The	plan	should	also	address	
the	needs	and	motivations	of	 the	workers,	as	well	
as	 their	responsibilities	and	accountability	 towards	
patients.
In	 Bangladesh,	 rates	 of	 antenatal	 care	 use,	 skilled	
birth attendance, and facility-based deliveries are 
lower	than	those	are	for	neighboring	countries.	Still	
home	 delivery	 is	 63%	 and	 delivery	 with	 no	 skill	
birth	attendant	is	58%.	Delivery	at	facility	among	the	
poorest	quintal	is	only	15%	and	delivery	with	skill	
birth	attendant	is	only	18%.	We	need	to	reach	this	
quintal	of	the	population	and	special	fund	for	mother	
would	help	to	improve	maternal	health	indicators	9.  
In	this	year	Budget,	GoB	took	an	initiative	for	the	
mothers	named	‘Maternal	Health	Voucher	Scheme’	
15.		It	is	a	good	initiative	and	effective	plan	to	expand	
this	program	would	bring	positive	changes	in	case	of	
maternal health and achieving MDG 5.  
We	 are	 having	 an	 epidemiological	 shift	 in	 disease	
burden	where	infectious	diseases	are	taking	a	back	seat	
and	non	communicable	diseases	(NCDs)	are	coming	
up31. Our health system is not ready for this transition 
and	healthcare	is	likely	to	be	more	costly.	NCDs	like	
heart	diseases,	hypertension,	diabetes	and	cancer	are	
emerging	as	major	health	threats	and	are	responsible	
for	52	percent	of	the	total	deaths	in	Bangladesh32. It is 

high	time	to	plan	ahead	and	allocate	enough	funds	to	
fight	the	upcoming	NCD	epidemic.	Moreover,	with	
the	increase	in	life	expectancy,	aged	people	would	
constitute	 a	 major	 part	 of	 our	 population	 in	 near	
future	and	consequently	geriatric	diseases	would	go	
up.	We	should	have	a	plan	to	improve	the	medical	
care for senior citizen.
Government	 of	 Bangladesh	 plan	 to	 provide	
13,861	mini	 laptops	 to	community	clinics	 15,  But 
a	 recent	 study	 by	 World	 Vision	 identified	 several	
potential	barriers	to	delivering	expected	healthcare	
services from community health clinics including 
infrastructural	weakness,	irregular	medicine	supply,	
a	 lack	 of	 monitoring	 and	 negligence	 in	 duties	 of	
caregivers. None of the community clinics surveyed 
has electricity connections and in most of those, 
tube	 wells	 do	 not	 work	 and	 the	 toilet	 facility	 is	
not	 available.	About	 34	 percent	 of	 the	 clinics	 did	
not receive medicines on a regular basis. Besides, 
inadequate	 training	 for	 service	 providers	 and	 their	
limited	capacity	to	deal	with	things	during	emergency	
situation and critical diseases are hindering the 
optimal	services33.	Therefore,	what	is	needed	first	is	
to	remove	the	barriers	to	improve	their	performance	
and	strengthen	their	functional	capacity.	Due	to	their	
proximity	to	people,	we	also	propose	that	in	addition	
to	 the	 primary	 health	 care,	 the	 community	 clinics	
can	 serve	 as	 a	 potential	 platform	 for	 preventive	
service	 package.	Also,	 we	 recommend	 reinforcing	
the	Upazilla	Health	Complexes	and	district	hospitals	
to	enable	them	to	function	as	the	principal	service	
hospitals	for	general	population.
The	provision	for	free	health	care	services	should	be	
expanded.	We	strongly	recommend	for	 free	health	
services	for	the	vulnerable	population	including	ultra	
poor,	 pregnant	 women,	 under-five	 children,	 urban	
slum	dwellers,	garments	workers,	labors	and	people	
in hard to reach areas. Under an initiative launched 
by the United Nations called COIA (Commission on 
Information	 and	 Accountability)	 for	 maternal	 and	
child health, the MIS started to electronically register 
and	track	every	pregnant	woman	and	under-five	child,	
using 11 core indicators and this registry can be used 
for	providing	free	service	to	these	groups.	For	others,	
free	 health	 cards	 can	 be	 issued.	We	 also	 advocate	
to	 provide	 free	 primary	 and	 emergency	 health	
services	to	the	migrant	workers	to	acknowledge	their	
substantial	 contribution	 to	 national	 economy	 with	
remittance and because most of them cannot afford 
health care overseas. 
Recent	 Ebola	 outbreak	 in	 Africa	 highlighted	 how	



509

Hassan	MZ,	Fahim	SM,	Zafr	AHA,	Islam	MS	,	Alam	S

vulnerable our health care system is in terms of a 
pandemic	 or	 epidemic	 threat	 and	 it	 reminds	 us	 of	
the	desperate	need	to	strengthen	health	systems	for	
everyone,	 everywhere.	 We	 recommend	 investing	
for	strong,	equitable	health	systems	to	be	prepared	
to	 fight	 against	 emerging	 threats	 and	 increasingly	
severe natural disasters.
Conclusion:
Bangladesh has achieved many of the Millennium 
Development	 Goals	 (MDGs),	 but	 a	 stronger	
commitment is needed to achieve the Universal 
Health	Coverage	(UHC)	 34.	UHC	is	right	to	health	
that	 means	 every	 person	 everywhere	 should	 have	
access	 to	 quality	 healthcare	 without	 suffering	
financial	 hardship	 35, 36. It says about reducing the 
out	of	pocket	expenditure	through	the	cost	sharing	
or	 pre-payment	 mechanism.	 Inadequate	 funding,	

inequity	in	financing	and	its	inefficient	use	are	some	
of the crucial challenges that should be resolved to 
ensure	quality	health	for	all	and	establish	universal	
health coverage 37. 
Healthcare	is	not	a	charity,	but	a	basic	human	right	
enshrined in article 15a, 16 and 18 of Bangladesh’s 
constitution38. It is recognized by the UN declaration. 
Bangladesh is also committed to ensure health for 
all as a signee of Alma Ata Declaration39.	Therefore	
to	uphold	people’s	right	 to	health	GoB	should	put	
health	 as	 a	 national	 priority,	 allocate	 sufficient	
budget for the sector and ensure the utilization of the 
allocated	 fund	 rationally,	 and	 these	 initiatives	 will	
help	Bangladesh	to	step	forward	towards	post-MDG	
goals and achieving universal health coverage.
Conflict of interest: 
None	of	the	authors	declared	any	conflict	of	interest.	

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