A brief presentation on Health System of Bangladesh

1. HEALTH SYSTEM IN BANGLADESH
Dr Zulfiquer Ahmed Amin
Dept of Hospital Administration
AIIMS, Delhi

11. A health Care System consists of all organizations;
structural and non-structural resources, people and their
coherent actions that promote, restore or maintain health.

15. 4 Types of Health System Goals

16. The health system in Bangladesh is pluralistic.

18. Guiding Principles of Health System in Bangladesh (BD)
Constitution :
-Article 15(a) : Ensure basic necessities of life (Including medical
care) to its citizens.
-Article 18(1) : Raise the level of nutritional status and improve
public health.
SDGs:
SDG-3: Ensure healthy lives and promote wellbeing for all at all ages
by 2030 (13 Targets and 28 Indicators)
MDGs: Achieve by 2015
-MDG 4: Reduce Child Mortality
-MDG 5: Improve Maternal Health.
-MDG 6: Combat HIV/AIDS, Malaria and other Diseases

19. Health Population and Nutrition Program (1998-2021) :
Sustainable improvement in health, nutrition and family welfare.
National Health Policy (NHP)-2011:
15 Principles. Ensure quality health, nutrition and family welfare
services which is affordable, attainable and acceptable to its citizens.
Bangladesh National Population Policy-2012:
Lower the Total Fertility Rate (TFR) to 2.1, achieve NRR = 1 to achieve
stable population by 2060.
National Drug Policy-2014
Vision 2021:
Digital Bangladesh and improving Human Development Index.

20. • National Nutrition Policy 2015
• Healthcare Financing Strategy 2012-2032: Expanding Social
Protection for Health Towards Universal Coverage
• Bangladesh Health Workforce Strategy 2016–2021
Agreement on International declarations:
• The Alma Ata Declaration (1978)
• The World Summit for Children (1990)
• International Conference on Population and Development (1994)
• Beijing Women’s Conference (1995)

26. A soft reminder that Bangladesh is 22 times smaller in area-size,
and 7.5 times smaller in population-size than India

37. Concept of Community Clinics (CC):
Public-Private Partnership
Till Date: 13,861. Govt has plan to increase upto 18,000

38. (Within Half-an-hr of walking Distance)

40. Village Level
Community Clinic 1 for each 6000 population
CHCP/HA/FWA
13,861 (18,500 planned)
Union Level
Health
Rural Health Center
(10 Bedded)
MO (2), Nurse (2), Nursing Attendant (4),
Lab Tech (1), Pharmacist (1)
(13). Provides both IPD
and OPD service
Rural Health Center
(20 Bedded)
RMO (1), MO (4), Nurse (4), Lab Tech (2),
Pharmacist (2)
Provides both IPD and
OPD service
Rural Dispensary/USC 1,362
MO, MA, Pharmacist Provides OPD service
Family Planning
Health & Family Welfare
Center
4,300
MO 250
Sub-Asst Community Med Officer, FWV,
Pharmacist
Provides OPD service
Maternal & Child Welfare
Center
55
Health Service Facilities

41. Upazila Level
Health
Upazila Health
Complex
50 Bedded: 268
31 Bedded: 146
10 Bedded: 10
31 Bed: 4 x Consultant (Med, Surg,
Gynae, Anaes), 9 x Doctor (UHFPO,
RMO, DS), 2 x MO,(Implications of
HPNSDP)
50 Bed: 10 x Consultant (In addition,
Eye, ENT, Cardiology, Paed, Ortho,
Derma)
424
Provides IPD, OPD
and emergency
service
Hospitals in Upazila
level, other than UHC
31 Bedded: 5
30 Bedded: 1
20 Bed Trauma
Centre: 5
11
Family Planning
Maternal & Child
Health Unit
MO (MCH-FP) Not in all Upazila

42. District Level
District Hospital 59
General Hospital (100/150/200/250/278/300 Beds).
Narayanganj & Narsindi have 2 hospitals.
Dhaka, Mymensing, Dinajpur have no hospital
21
Supplementary Health
Facilities
School Health Clinics 23
Chest Clinics 43
Chest Hospitals (20/60/100/150/250 Beds) 12
Leprosy Hospital (20/30/80 Beds) 3
Infectious Disease
Hospitals
(20/100 Beds) 3
Family Planning
MCWC (MO-Clinic), MO-MCH-FP).
At District Level OPD, IPD, Emg Service
60

43. Health Service facilities in Bangladesh

45. Organogram of Civil Surgeon
Office

46. Organogram of District Hospital

50. Health Workforce
(Source: Bangladesh Health Bulletin, 2017)
Professional Trades Total
Field Based Domiciliary workers
(DGHS)
26,538
Health Assistant (HA) 1 for each 5-600 rural
population
20,881
Assistant Health Inspector (AHI) 1 for 5 HA 4,202
Health Inspector (HI) 1 for 3 AHI 1,399
Sanitary Inspector (SI) 1 per Upazila 493
Field Based Domiciliary workers
(DGFP)
28,000
Family Welfare Assistant 1 FWA for 6000 population 23,500
Family Planning Inspector 1 in each union 4,500
Family Welfare Visitor

51. Professional Trades Total
DGHS DGFP DGNM
Doctors 24,990 1,118
FPO - 485
Nurses 33,239
Medical Technician 7817
MO (Traditional Medicine) 1,911
Dental Tech 541
EPI 496
Laboratory Tech 2167
Pharmacy Tech 2899
Physiotherapist 296
Radiotherapist 80
Sanitary Inspector 498
Sub Asst Community MO 5368
CHCP 12,959
Total 1,15,802 29,603 33,239
Grand Total 1,78,644

52. Healthcare Workforce Distribution
Bangladesh is characterized by:
-“shortage, inappropriate skill mix and inequitable distribution” of its
health workforce.
-Health workforce is skewed towards doctors with a ratio of doctors
to nurses to technologists of 1:0.4:0.24, in stark contrast to the WHO
recommended ratio of 1:3:5.
-Estimated 58% of the medical doctors working in the private sector
(2017).
-Formal health workforce (doctors, dentists, nurses) is mostly
concentrated in the urban areas.
-There are only 1.1 doctors per 10 000 population in rural areas,
compared to 18.2 per 10 000 in urban areas.
-Less than 20% of health workers serve over 70% people living in
rural areas.

56. SWAp
(Sector-Wide Approach Programs)
National Health Policy of Bangladesh came into being in 2011. While
the policy documents provided broad directions for action, the
practical programmatic operations in the health sector have been
guided by National 5 Years Plan from 1971 to 1997.
The Fifth Five Year Plan(1997-2002) introduced for the first time a
sector-wide approach (SWAp) to health sector programming,
marked the decision to move away from a project-based modality to
a SWAp.

58. A number of reforms with far-reaching consequences were
envisaged in Sector Wide Programs:
• Transition from a vertically integrated but horizontally segregated
project- based approach towards a sector-wide approach.
• Unification of the health and family planning wings of the Ministry
of Health and Family Welfare (MOHFW) so as to avoid duplication of
efforts.
• Introduction of an Essential Service Package (ESP)—containing five
basic maternal, child and public health services—to be delivered
from one single service point in the spirit of “one-stop shopping.”
• Construction of a Community Clinic for every 6,000 people, taking a
wide range of healthcare services closer to the people.

62. MDG and Bangladesh

63. SDG and Bangladesh

66. Source: UN, ESCAP, 2018

67. Under 5 Mortality
Neonate Mortality

68. Source: WHO/SVRS, 2017

69. Source: WHO/SVRS, 2017

76. Communicable Disease Control
Programs
• Malaria Elimination Program
• Aedes Transmitted Disease Control Program. Three diseases have
been included under Aedes transmitted disease control program.
These are: Dengue, Chikungunya and Zika.
• Filaria Elimination Program. MDA has been stopped in all the 19
eligible endemic regions.
• Soil Transmitted Helminths (STH) Control Program. The ‘Little
Doctor’ program (involving school students) is an initiative under
STH Control Program.
• Antimicrobial Resistance Containment (ARC)
• Prevent and control viral hepatitis by 2030

77. • National Kalazar Elimination Program (NKEP). Goal to reduce
the annual incidence of kala-azar to less than 1 patient per
10,000 population.
• National TB Control Program
• Leprosy Elimination Program
• 4th National Strategic Plan for HIV and AIDS Response 2018-
2022. Overall HIV prevalence has remained at <1%
• Tobacco Control Program:
• Food and waterborne diseases control

78. • National Rabies Elimination Program. Shifted the target from
control to elimination of rabies by 2022
• National Newborn Health Program (NNHP)
• The ‘Little Doctor’ program (involving school students) is an
initiative under STH Control Program.
• Disease Surveillance
-National Influenza Surveillance, Bangladesh (NISB)
-Dengue Surveillance
-Anthrax Surveillance
-Food Borne Illness Surveillance
-Cholera Surveillance
• Program for IHR-2005
• Health Interventions For FDMNs (Including Immunization)

81. Family Planning Program
The rate of population growth declined from over 2.50 per cent in
1971 to 1.20 per cent in 2013.
Targets for the 7th FYP (2016-2020):
-To reduce the fertility rate to 2.0 by the end of the plan
implementation period.
-Increase Contraceptive Prevalence Rate from 62.4% to 75%.
- Reduce unmet demand of eligible couples for FP supplies from 12%
to 10%.
- Reduce discontinuation rate of contraceptive rate from 30% to
20%.

83. Health Financing Mechanisms in BD

84. • Bangladesh health systems financing is characterized by high out-of-
pocket payments (63.3%)
• The second largest financing agent is government, making up 26.0% of
THE.
• The private firms’ share has remained at around 1.0% over the years.
• The share of non-government organizations (NGOs) from their own
sources has ranged between 1% and 2.0% of the THE.
• Expenditure through NGOs varied from 5% to 9%
• Bangladesh currently spends US$ 32.00 per person on health per year.
• Impoverishment: 3.4% people are being pushed into poverty because
of out-of-pocket health spending.
• At the 10%-threshold level, total 14.2% of households faced CHE
(Source: Global health expenditure database . Geneva : World Health Organization; 2016)
CHARACTERISTICS OF HSF IN BD

86. Health financing in BD
Source: Health Planning and Management, 2018
5,231.90 Bn

91. According to an estimate, US $ 54 per capita is required to attain a
fully functioning health system by 2015. Bangladesh currently spends
$32 per capita in health. When compared to other South Asian
countries, this figure is quite low.
The health spending in Bangladesh in 2018 accounted for 3.4% of
gross domestic product (GDP), which is lower than the average (3.8%)
in South East Asia (SEA) region, below the average of low-income
countries (5.4%), lower-middle income countries (4.3%), and far
below the world (8.5%).
In response to NHP-2011, government undertook Health Care
Financing Strategy 2012 to 2032 with the aim of allocating more funds
in health and reducing out‐of‐pocket (OOP) payments to 32% by 2032.

93. Current Initiative
• People Below the Poverty Line healthcare services free of cost
for 50 types of diseases.
• Non-contributory health insurance scheme for the below
poverty line (BPL). Medical costs up to 50,000/- Tk per
household per year.
• To be implemented over the period of 2012-2032
• The scheme pays for services delivered, using predefined
Diagnosis Related Groups (DRGs).
Pilot project
“Shasthya Suraksha Kormosuchi” (SSK) (Health Protection Program)

97. Demand-side Financing (DSF):
Maternal Health Voucher Scheme
• Introduced in 2007, an innovative ‘Maternal Health Voucher
Scheme’, a demand-side financing (DSF) initiative.
• These interventions vary in design but have typically been used to
increase health service utilization by offsetting some financial costs
for users, or increasing household income and incentivizing ‘healthy
behaviours’.
• All the voucher holders received health services free of charge
(ANC, PNC, Safe delivery and treatment of complications, including
cesarean section, transportation cost, and laboratory test).
• If the voucher holder mother has her delivery in Health facility or by
SBA at home, she will get cash incentive for nutritious food.

98. • Public Health Insurance
• Community-Based Health Insurance: For RMG sector
• Social insurance or payroll-based systems: For formal employees
• Private health insurance: Existing only in some pocket areas run
by NGOs
• Health micro-insurance: Cashpor micro credit, Gonoshashtho
Kendro (People’s Health-care, GSK), Grameen Kalyan (Rural
welfare, GK), Sajida Foundation, Shakti, Dhaka Community
Hospital, Nari Uddug Kendra, Dushtha Shasthya Kendra,
Integrated Development Foundation and Society for Social
Services, and BRAC.
Health Insurance in Bangladesh

101. • Plan to screen and link factory workers to quality health-care
services for common non-communicable diseases (NCDs).
For every BDT 100 (about USD 1.25) spent, the worker earns 1
APON point. With 200 points, the worker gains access to
APON’s zero-cash health coverage, allowing them to get free
medical diagnoses and prescriptions from a doctor.
HAEFA: Health Education for All
UPHCSDP: The Urban Primary Health-care Service Delivery Program
APON: Alor Pothe Nobojatray Foundation
SNV Netherlands Inclusive Business Pilot
The price of the female workers health insurance is 500 Bangladeshi Taka (USD 6)

102. Private Healthcare in Bangladesh
Since 1976, to compensate for the government’s limited capacity to
provide basic health services, the private sector and NGOs have
established a network of facilities to provide health and family
planning services.
As of June 2016, the number of registered private hospitals and
clinics is 5,054, and that of registered private diagnostic centers is
9,529. The total number of beds in these registered private hospitals
and clinics is 90,587.
Bangladesh is known worldwide for having one of the most dynamic
NGO sectors, with 2,471 NGOs registered with NGO Affairs Bureau.

103. Regulatory Institutions
To regulate private practice and the functioning of the private clinics
and private laboratories, the ‘Medical Practice, Private Clinics and
Laboratories Ordinance-1982’ was promulgated.
There are two main regulatory institutions. The Directorate General of
Health Services (DGHS) oversees most of the activities related to
private sector regulation. The Ministry of Health has been
empowered as the final appeal authority if any person is aggrieved by
an order of the Directorate.

104. Domestic pharmaceutical sector
Bangladesh has made significant progress in the development of its
domestic pharmaceutical sector, with the introduction of the
National Drug Policy (NDP)-1982.
The pharmaceutical industry in Bangladesh is one of the most
developed technology sectors within Bangladesh. Manufacturers
produce insulin, hormones, and cancer drugs. This sector provides
97% of the total medicinal requirement of the local market.

106. ● Medicines are being exported to more than 100
countries
● Medicine price in Bangladesh is currently among the
lowest in the world

107. (In million $)

108. Regulation and governance of pharmaceuticals
DGDA regulates all activities related to import and export of raw
materials, packaging materials, production, sale, pricing, licensing,
registration of all kinds of medicine including those of Ayurvedic,
Unani, herbal and homeopathic systems.
The Pharmacy Council of Bangladesh(PCB) was established under the
Pharmacy Ordinance Act in 1976. to control the pharmacy practice in
Bangladesh.
Government fixed the maximum retail prices of 117 listed essential
drugs.

109. HMIS in Bangladesh
In 2009, Honourable Prime Minister Shaikh Hasina expressed her
vision towards achieving “Digital Bangladesh” by 2021.
The DHIS2 (District Health Information System, version 2), is used for
gathering data on preventive and public health services, OpenMRS
(Open Medical Record System), has been chosen for hospital
automation. The HRM (Human Resource Management) System is
used for processing human resource information. OpenELIS (a
software and business-process framework for public health
laboratories) and dcm4chee (an application for the management
and archiving of clinical images).

110. Electronic shared health records (SHR) system 2015 (MIS has already
collected electronic records of 98 million citizens).
Mobile phone health service (The mobile phone health service
received the ICT4 Development Award in 2010 and special mention at
the Manthan India Award in 2011.
Telemedicine
Attendance monitoring from central point by fingerprint machines.
Under the initiative called COIA (Commission on Information and
Accountability) for maternal and child health, the MIS electronically
register and track every pregnant woman and under-five child.
Multiple stakeholders sharing the same health data platform.
mHealth service called MAMA (Mobile Alliance for Maternal Action).
Provides to pregnant and new mothers, lifesaving information and
advice for newborn babies and children through SMS
E-Health
GIS in Health Service
Bio Medical Technology (BMT)
MIS- Practical Applications

113. Achievements of BD
Bangladesh is often cited as a ‘success story’ with good progress
against many of the Millennium Development Goals (MDG) and
related indicators as demonstrated in continuous reduction in child
(31.52 deaths per thousand live births, 2018) and maternal mortality
ratio (176 deaths/100,000 live births; 2015 est) as well as fertility
rates (TFR=2.1; 2018).
In 2010, the United Nations recognized the country for its exemplary
progress towards MDG 4 in child mortality.

114. Source: WHO/UNICEF. Maternal Mortality-1990 to 2013

115. System factors to reduce MMR
Maternal mortality ratio per 100,000 live births was 288 in 2007 and
reduced to 228 in 2011 and further reduced to 176 in 2016.
The decline is achieved due to:
-Reduced total fertility rate (from 5 births per woman in 1990, to 2 in
2011)
-Increased skilled delivery attendance (from 5% in 1991 to 32% in
2011).
-Programs such as the ‘Maternal Health Voucher Scheme’ and
‘Emergency Obstetrical Care Services’ (EmOCs), P4P and the
-Rapid development of the private sector, mostly the NGOs
-Women empowerment

119. Infant mortality rate per 1,000 live births was 45.8 in 2007, reduced
to 37.0 in 2011 and became 28.2 in 2016. Below 5 (years of age)
mortality rate per 1,000 live births reduced from 59.3 in 2007 to 46.5
in 2011 and 34.2 in 2016.
IMR declines have been achieved due to:
-Improved coverage of effective interventions to prevent or treat the
most important causes of child mortality and with
-Improvements in socioeconomic conditions.
-Programs to ensure high coverage of vaccine preventable diseases,
-Treatment of diarrhoea and ARIs,
-Implementation of IMCI
System factors to reduce Under 5 Mortality

120. Comparative Health Indicators

129. SWOT Analysis
OOP
Equity issue
Mal-distribution
of HC Workforce
Unorganized
Hospital Admin
Training
Treatment abroad

130. Paradoxes
• Despite immense weakness and threats in Health
System in Bangladesh, every year BD is showing
significant improvement in Health Indices.
• BD showed significant ability to achieve important
parameters of MDG and will reach the key goals of SDG.
• Despite weak family planning activities, TFR has come
down to 2.17 (2017)

131. Take Away Home Message
Bangladesh is the 8th most populous country of the world, while it is
the 94th largest by area, with almost 2.2% of the world's population
living in 0.2% of global land.
Still, we are thriving.

132. Bangladesh Annual GDP Growth Rate

133. Source: WB, 2016

138. Thank You Sir

139. World’s Longest Sea-Beach, Cox’s Bazar

140. World’s Largest Mangrove Forest,
Sunderban

141. Royal Bengal Tiger