Health Financing in Bangladesh
Dr. Mohammad Khairul Hasan
Deputy Chief , Planning Wing
MOHFW
Date: 18.02.2014
Introduction
• Government of Bangladesh (GOB)
has constitutional obligation
to ensure public health to all citizens.
• GOB is committed to achieve health related
MDGs, vision 2021 goals, etc.
• Health, population and nutrition are among the
most urgent development agenda of the
Government of Bangladesh (GOB).
2
SALARY
GOB
OTHER
RECURRENT
NON -DEV
32
OPS
HPNSDP
22
PROJECT
DEVELOPMENT
Source
EXPENDITURE
DP
MOF
ALLOCATION TO
MOHFW
MTBF
ADP
PC
Health Expenditure & Financing Features
• Per capita health expenditure
US$16 (2007), $27 (2011).
• Total health expenditure (THE) as % of GDP
3.4%
Health Expenditure & Financing
Features
10%
26%
Public Health
Expenditure
Out of Pocket
Expenditure
64%
Direct External
Funding , Private,
NGOs & Others
Trend of MOHFW Budget
(5 years)
Budget
Year
NonDevelopment
(Taka in Crore)
Development
Total
2009-10
3925.36
3075.00
7000.36
2010-11
4676.00
3472.92
8148.92
2011-12
5327.00
3561.75
8888.75
2012-13
5529.62
3825.39
9355.01
2013-14
58,93.00
3602.00
9495.00
10000
8888.75
9000
8148.92
8000
7000.36
7000
4000
5529.62
5327.00
6000
5000
9495.00
9355.01
5893.00
4676.00
3925.36
3075.00
3472.92
3561.75
3825.39
3602.00
3000
2000
1000
0
2009-10
2010-11
Non Development
2011-12
2012-13
2013-14
Development
Total
MOHFW Budget Compared to National Budget
(Five years)
Year
National Budget
(Taka in Corer)
MOHFW Budget
(Taka in Crore)
(%)
2009-10
1,13,819
7000.36
6.17%
2010-11
1,32,170
8148.92
6.17%
2011-12
1,63,589
8888.75
5.43%
2012-13
1,91,738
9355.01
4.88%
2013-14
2,22,491
9495.00
4.27%
Trend of GOB Health Budget Allocation
• Share of MOHFW budget as percentage of GDP
decreased gradually from 1.01% in FY 2009-10 to
0.91% in FY 2012-13. Whereas it was 0.7% in
Pakistan, 1.2% in India and 2.1% in Nepal as per
2011.
• In absolute term MOHFW budget increased to
9495.00 crore in 2013-14 from 7000.00 crore in 200910, an increase of about 36% over 4 years.
• Over the last 4 years national budget increased
from 1,13,819 crore to 2,22,491 core about 95%
• Compared to national budget , share of
MOHFW budget decreased to 4.27% from 6.17%
for the same period.
• WHO suggests that health budget should be at
least 15% of the national budget for developing
countries.
Comparison National and MOHFW Budget
(%)
250000
222491
7.00%
191738
200000
6.00%
163589
150000
5.00%
132170
113819
3.00%
2.00%
50000
8148.92
8888.75
9355.01
9495
0
1.00%
0.00%
2009-10
5.43%
4.88%
4.27%
4.00%
100000
7000.36
6.17% 6.17%
2010-11
National Budget
2011-12
2012-13
2013-14
MOHFW Budget
(%)
Current Health Budget Expenditure
Pattern
• MTBF is the budget projection instrument for
financing both non-development and
development budget.
• Almost 90% MOHFW’s non-development
budget is spent for the salary of personnel
(60%), MSR and recurrent expenditure.
Current Health Budget Expenditure Pattern
• Development budget is use to fund MOHFW’s
development related activities for accelerated
achievement in health related MDGs by 2015,
6th Five Year Plan and vision 2021 targets.
• MOHFW is implementing 3rd SWAp called
Health, Population and
Nutrition Sector
Development Program (HPNSDP) for 2011-16
along with some parallel projects (now 22)
included in the ADP.
Source of Health Budget
– Major portion of the health budget (Non-development and
Development together) being provided by GOB .
– Total estimated cost of HPNSDP (2011-16) is Tk. 56,993.00
crore (about US$ 7.7 billion). Of this GOB contribution is Tk.
43,420.00 crore (76%) and DP contribution is Tk. 13,573.00
crore (24%).
– Development budget requirement of HPNSDP estimated
through 32 OPs is Tk. 22,177.00 crore ( 39% of total cost of
HPNSDP)
24%
76%
GOB
DP
Development Budget gap of HPNSDP
(Taka in crore)
Financial
Year
Estimated PIP
budget of
HPNSDP
Allocation
given by the
MTBF budget
for HPNSDP
Funding
gap/Difference
2011-12
2012-13
2013-14
2014-15
3786.00
5007.00
5140.00
4000.00
3040.55
2832.28
2877.61
3378.00
-745.45
-2174.72
-2262.39
-622.00
2015-16
4243.00
-527.20
Total
22176.00
3715.80
(provisional)
15844.24
-6331.76 (29%)
25000
20000
15000
10000
5000
0
2011-12
2012-13
2013-14
2014-15
2015-16
Total
-5000
-6331.76
-10000
Estimated PIP budget of HPNSDP
Allocation given by the MTBF budget for HPNSDP
Funding gap/Difference
RFW of HPNSDP & Current Status
BASELINE
UPDATE
2013
TARGET
2016
Infant mortality rate (IMR)
52
BDHS 2007
43
BDHS 2011
31
Challenges
Under 5 mortality rate
65
BDHS 2007
53
BDHS 2011
48
On track
Neonatal mortality rate
37
BDHS 2007
32
BDHS 2011
21
Challenges
Maternal mortality ratio
194
BMMS 2010
194
BMMS 2010
≤143
Challenges
Total fertility rate (TFR)
2.7
BDHS 2007
2.3
BDHS 2011
2.00
Challenges
Prevalence of stunting among
children under 5 years of age
43.2%
BDHS 2007
38.7%
UESD 2013
38%
On track
Prevalence of underweight among
children under 5 years of age
41.0%
BDHS 2007
35.1%
UESD 2013
33%
On track
<1%
SS 2007
<1%
SS 2011
<1%
On track
INDICATOR
Prevalence of HIV in MARP
Challenges of Health Sector Funding
• Per capita health spending ($27 ) is very low
compared to most South Asian countries (India$59, Sri Lanka-$97, Nepal-$33) while WHO
recommends for $54 per capita spending for a
fully functioning health system-Inadequacy
/Accessibility concern.
• Out of pocket expenditure is very high (64%),
against the global status of 32%.-Equity concern.
• HPNSDP has already faced a financing gap of
Tk. 5’182.56 crore in the last 3 years of
implementation. Trend shows there will
remain about Tk. 6,332.00 crore at the end of
the program in 2016.
• Budget deficit will make it difficult to achieve
some RFW Indicators of HPNSDP- Low level of
public spending.
Additional Resources Mobilization Prospect
• GOB Mid Term Budgetary Framework (MTBF) based on
revenue income (tax, non-tax and other sources) of GOBmoderate prospect
- Increase user fees and its retention by MOHFW
- Increase sin tax, e.g., tax on cigarettes and narcotics and
allocate MOHFW
- Competition with other Ministries for increased allocation
in the context of differential priorities of GOB (e.g., for
infrastructure, electricity, education, etc)
- Efficiency in budget utilization by MOHFW and it’s
Directorates.
Additional Resources mobilization
• Donor financing- low prospect of substantial
increase :
- Integrating DP parallel funded program into MOHFW
planning and budgeting process.
-`Potential window of Global Fund (GAVI, GFATM,
etc.).
• Public Private Partnership (PPP)-low prospect
- Since introduction of PPP Policy MOHFW has been
able to process only one project (Kidney dialysis).
- Encourage multi and national companies to support
health sector as part of Corporate Social
Responsibilities
Additional Resources mobilization Prospect (cont.)
• Social health insurance-moderate prospect
- Premium based pre-paid health insurance
scheme can be introduced gradually beginning
with formal sector. Then go for informal sector
and others.
• Local Govt. institutions/Municipalities/Upazila
Parishad etc.
- Can provide health budget through LLP & other
mechanism.
Issues of concern before introducing health
insurance for UHC
Before introducing social insurance widely following are the
essential elements to make the health system ready:
• Regulate volatile private health sector in terms of
quality and pricing of services.
• Develop service standardization model and
introduce fixed fee schedule of services across the
health facilities ( both public & private).
• Both public and private health facilities
should have same quality of services and
fixed pricing schedule of services with
accreditation and monitoring mechanism.
• Adjustment of MTBF budget allocation
between
non-development
and
development parts to make some room for
the copayment
of health insurance
premium for the poor and
to make
efficient use of resources.
Way forward
• For achieving universal health coverage in the long run
both accelerated HPN service delivery through SWAp
(mainly for primary HPN care) and financing through
social health insurance scheme (for curative and
specialized care except EOC) may work together.
• SWAp/HPNSDP is the instrument to provide primary
HPN services and continue uninterrupted services at all
public health and FP facilities (esp. outpatient services
regarded as pro-poor) in order to achieve MDG and
other national goals.
• Continuation of health Safety net programs like Demand
side financing (DSF) Maternal health voucher scheme,
Community Clinic approach, Nutrition services etc.
Thank You