Monday, January 21, 2019

Universal Health Coverage: An unachievable target for Bangladesh!

  • Nurul Islam Hasib,
    Published: 2018-04-08 00:21:07 BdST

When the last health facility survey was released in 2015, it raised many eyebrows as it revealed a pathetic picture on the availability of basic amenities and equipment in both government and private facilities at the districts and levels below.

Only around 25 percent of such facilities had all the six basic equipment - stethoscope, thermometer, blood pressure apparatus, adult weighing scale, child or infant scale, and a light source - a list WHO and USAID propose for basic health services.

Experts instantly questioned the quality of care.

Money was not the problem to buy those as Bangladesh buys health equipment worth millions of dollars. The fact is that those who are responsible are not paying attention.

The question of accountability and quality comes again as the World Health Day celebrated on Saturday was themed on ‘Universal health coverage or UHC for everyone, everywhere’ - calling upon the countries to provide quality healthcare services to all when and where they are needed.

Bangladesh sets the target to reach the UHC goal by 2032.

“It’s an ambitious goal,” Dr Ishtiaque Mannan, a Bangladeshi public health expert and deputy country director of Save the Children, told, referring to the weak regulations, lack of accountability as well as governance in the health sector.

“It’s all interlinked,” he said. “If we cannot ensure accountability, we cannot ensure quality. And without quality, there is no universal health coverage.”

UHC is a way of preventing people from falling into poverty due to heavy out-of-pocket expenditure during medical treatment. The concept is that people should have access to quality healthcare without getting into financial trouble.

In Bangladesh, people spend over 65 percent of their entire health expenditure on their own, which estimates suggest pushes 5 percent of them into poverty every year.

UHC – two misunderstandings

The British medical journal, The Lancet editor-in-chief Richard Horton, on the world health day, warned when contemplating how to achieve “health for all” through UHC, “two dangerous misunderstandings must be addressed.”

“UHC is neither a destination to be reached nor a panacea for delivering better health, even in its broadest definition.”

He said as every country that can claim to have reached UHC will surely testify—from the UK to Japan, Canada to Australia—the notion of a destination is “illusory”.

“No country ever completely reaches all of its people with all health services. Disparities are endemic. And even for those people who are covered, sustaining that coverage throughout their lives is a permanent technical, financial, and political struggle.

“The social contract on which government and people establish UHC is under continuous attack—from other equally deserving social causes, constantly expanding expectations of a demanding population, and increasingly expensive health technologies.”

Presenting UHC as a panacea for achieving health is an even more treacherous misunderstanding, he said.

“A viable, high-quality health system is necessary but not sufficient to achieve health for all,” he wrote.  Instead, governments must assess the most critical threats to the health of their populations and target their actions accordingly.

UHC alone did not defeat what were once common infectious diseases. It took broad political programmes that included better living standards, upgraded housing, improved nutrition, and safer water and sanitation.

For example, tackling cardiovascular disease required tobacco control. Stalling the current epidemic of diabetes will demand policies to attack rising rates of overweight and obesity. Strong vertical programmes, not UHC, have been responsible for turning the tide against AIDS, malaria, and child mortality.

“Make no mistake. It is not a choice between universality and verticality. It is the judicious combination of both,” he said.

Set priorities

Dr Mannan suggested Bangladesh prioritise its own issue. “We have to take one step at a time. We cannot do everything at a time,” he said, adding that regulatory aspect should be prioritised and have to be enforced.

“It is just 12 years before the SDGs ended. One of the weaknesses of the SDGs is that there is no significant financial commitment. So it is difficult for the countries like Bangladesh to mobilise internal resources for holistic development within this short period because we don’t have that required governance, order and regulatory system.

“Universal health coverage is ultimate care to reach all the people. So its too ambitious and too early to call,” he said, suggesting prioritisation of works.

“If we cannot set the priorities, then the journey can be lost.”

Prof Syed Abdul Hamid, director of the Dhaka University’s Health Economics Unit, also agreed to strengthen health system.

“Lack of good governance is the number one problem, no doubt. But can you address that overnight? No. So what to do? The government knows that. Everything is on paper. But there is no implementation,” he said, adding that the ongoing five-year programme of the health sector detailed the way of strengthening health sector.

For achieving UHC, he said, in Bangladesh perspective, the first focus should be on making government facilities at Upazilla and the level below useful with adequate workforce and equipment so that people take services there.

“The out of pocket spending is very high as people are going to the private facilities.

"In many remote places, the government services are not functional.

"There is no quality of care. If we can bring them to the government facilities, then their cost of treatment will be reduced,” he added.