Johir Rayhan was still COVID-positive and with lingering liver problems when his doctors at a Dhaka private hospital discharged him. Although his family waited until the worst of his infection seemed to be over, they told his doctors to let him go home after only eight days because they could no longer afford to keep him there.
But the 29-year-old’s hospital bill and other costs such as continued medication, transport, and his wife’s stay at the hospital still added up to BDT 300,000 (around US$3,500) — equivalent to about 10 months of his salary. It was not the kind of money the young middle-class couple would have at the ready. According to Rayhan’s wife Chandni, they were able to pay the bill with money Rayhan’s father had on hand from a loan he had taken out to complete a flat he was building.
A hospital bill is something for which most Bangladeshi households have to tap into savings, sell assets, or have to borrow heavily for — particularly for treatment for the elderly and for common chronic diseases such as diabetes, cancer, and heart disease. The country has one of the highest out-of-pocket expenditures on health care in Asia, and was at 74% in 2018, according to the global health expenditure database of the World Health Organization (WHO). (Out-of-pocket spending ranges from medicine, consultation, and diagnosis to food, transportation, and the attendant’s costs.) In comparison, public expenditure was only 16.98% of total healthcare expenditure during the same year, and has witnessed a steady decline from 21% in 2010.
This situation has been highlighted all the more in the current pandemic that has already seen at least 1.2 million COVID-19 cases in Bangladesh and where it has claimed more than 21,000 lives. As desperate coronavirus-infected Bangladeshis seek treatment, the sheer inefficiencies of the country’s health system are being laid bare, along with the lack of affordable health care.
Treatment costs that hurt the pocket
In May, the health ministry’s Health Economics Unit (HEU) published a study of public and private hospital costs for COVID-19 treatment. It found that the government spent on average BDT 128,000 (US$1,500) for a general bed patient and BDT 408,000 (US$4,800) for an ICU bed patient in public hospitals. In comparison, average treatment costs in private hospitals for the same patient categories were BDT 242,000 (US$2,850) and BDT 509,000 (US$6,000) respectively — and paid for entirely by patients.
A mother watches over her child at the International Centre for Diarrhoeal Disease Research in Dhaka. Public hospitals provide free medical care, but when certain services are not available, many patients are forced to sell property and spend their life savings to avail of the procedures and treatments they need. Bangladesh has one of the highest out-of-pocket health care expenditures in Asia. (“Mother and Child at Disease Research Centre in Dhaka” by United Nations Photo is licensed under CC BY-NC-ND 2.0)
The research noted in particular that medication at private hospitals — roughly 30% of total treatment costs — had prices that were twice that in public hospitals; diagnosis, which is around 17% of total treatment costs, had fees that were seven times higher than those in public hospitals.
The runaway costs of medicines are evident in patients’ bills. Rayhan, for example, needed multiple injections of the antiviral drug Remdesivir, which costs BDT 4,500 (over US$50) per jab. Medicine prices in the country are largely unregulated and expensive.
Despite repeated statements that the government would soon regulate prices of private healthcare services, no such implementation has been seen yet, including that of the national treatment protocol for COVID-19.
The study also showed, though, that expenses at government hospitals need as much scrutiny as private hospitals because of the costs that patients are being made to shoulder. While treatment and medicines are technically free at state hospitals, patients have ended up having to spend BDT 6,400 ($75) and BDT 33,000 ($390) respectively out-of-pocket on general and ICU beds to cover diagnostic fees and medicine expenses, despite state subsidies. There are also fees for admission and meals, which are not subsidized as well.
“Public facilities don’t charge, but if they don’t have the service, patients are forced to buy what they need elsewhere with (their own) money,” Dr. Mahbub E Elahi Chowdhury, a scientist at the research institute International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), points out.
“On paper, health care is free in our country,” he adds. “But in practice, it is not.”
For sure, even though middle-income and well-off patients have struggled to access treatment during the pandemic, they can still get the best treatment available — albeit with a hefty bill. The poor, however, have always been worse off due to high health care costs and the lack of social safety nets. They lose the most in a health emergency, are forced to sell off assets, or go into debt to afford proper treatment, which is often available only at a far distance from their homes.
Yet what is telling is that even the poorest of the poor flock to private healthcare options because of the lack of necessary services at public facilities, many of which are also located far from rural communities. They also have a shortage of specialist doctors and medicines, which translates into delay in care; that is, if any is given at all.
“While the health infrastructure is in place,” said Dr. Rashid-E-Mahbub, a public health expert and chairman of the National Committee on Health Rights Movement, “the government has not yet been able to ensure service delivery.”
And so the poor either forego treatment altogether or go into debt that they may never be able to repay just so they can avail of services at a private hospital.
A joint 2019 report by the WHO and the World Bank found seven percent of Bangladeshi households were pushed into poverty (under the international US$1.90-a-day poverty line) because of out-of-pocket spending on healthcare. This figure was based on data from the last national Household Income and Expenditure Survey in 2016.
A study published earlier this year, also based on the same dataset, estimated around one-quarter of households faced catastrophic health expenditure (CHE) and were concentrated among the poor. CHE is when out-of-pocket payments on healthcare exceed 10% of a household’s total annual consumption.
Pilot scheme for the poor
In 2016, the government had introduced a pilot health-financing scheme in three upazilas (sub-districts) of Tangail District in central Bangladesh. Households below the poverty line would receive free in-patient healthcare services in their own areas unless referred to the Tangail district hospital for specialized care. The scheme would cover the major out-of-pocket costs associated with treatment and supposedly free in public facilities — physician’s fees, drugs, and diagnosis.
Remote villages in Bangladesh often lack decent health facilities. Residents sometimes need to travel as far as 40km from home, a trip which includes a precarious ferry boat ride like this, to get to the nearest town or city with a slightly better-equipped medical facility.
The scheme is in line with the government’s plan to provide universal health insurance coverage by 2032, starting with those living below the poverty line, according to the “Health Care Finance Strategy (HCFS) 2012-2032.” But with the pilot phase only just completed in a limited area within one district (out of the country’s 64) and with limited scope, universal health coverage is a distant dream, let alone uniform health services across the country.
In charge of monitoring and evaluation of the scheme, icddr,b in its evaluation last year of the pilot phase found that households covered under it experienced significantly less financial hardship than those out of coverage. This is according to Dr. Chowdhury, acting lead of icddr,b’s Universal Health Coverage program.
But even the assurance of premium in-patient care at public facilities was apparently not enough to lure the poor. Nearly half of the participants requiring in-patient care still opted for health care services elsewhere, including private facilities, according to a summary of the evaluation (the full evaluation of the pilot is yet to be released).
Take the case of Banu, who wasn’t one of the participants in the pilot phase of the scheme but mirrors much of their personal profiles. Unsure of her age but looks to be in her 40s, Banu is from a remote village in the northern border district of Lalmonirhat, which lacks any decent health facilities. According to Banu, if she is ever in need of treatment, she would have to consult a doctor in Lalmonirhat town, who she describes as “not good,” or cross the Teesta river to Rangpur City, a major center in the region.
Last year, when her married daughter had a miscarriage, Banu had to come up with BDT 60,000 (around US$700) on short notice to cover all the costs for her care at a private hospital in Rangpur, a journey of around 40km from Lalmonirhat.
The family survives on the bare minimum Banu and the male members of the family earn during periodic domestic and cleaning work in Dhaka and as agricultural laborers back home the rest of the year. Banu paid the doctor right after the operation with some hard-earned savings and money borrowed from relatives. But she still came up BDT 20,000 (US$235) short. This she eventually got from selling a cow her daughter and son-in-law had bought recently. Banu says that she considered herself lucky that the doctor allowed her three days to come up with the rest of the money.
Banu had also taken her daughter to the same hospital years earlier for appendicitis. Asked why she didn’t consider the public hospitals in her district or in Rangpur, she retorts, “They don’t let you in without money. What’s the point in going?” ●
Maliha Khan is a journalist based in Dhaka, Bangladesh.
