UNIVERSAL health coverage aims to provide everyone with essential healthcare services without financial strain. However, despite global pledges to achieve universal health coverage by 2030, more than half of the world鈥檚 population still lacks access to basic health services. The Health Care Financing Strategy 2012鈥�32 of Bangladesh aimed to reduce out-of-pocket expenditure from 64 per cent to 32 per cent by 2032.
The reality is even more alarming 鈥� WHO鈥檚 estimation of 2022 shows Bangladeshis bear 72.5 per cent of their total healthcare expenses out of their pockets, which pushed 61 lakh people, or 3.7 per cent of the population, into poverty in 2022.
In 2021, in terms of overall health expenditure, Bangladesh鈥檚 per capita health expenditure stood at just $58 鈥� one of the lowest in the region, second only to Pakistan鈥檚 $43. The path to universal health coverage has been riddled with challenges, underscoring the urgent need for a thorough assessment of our healthcare system and well-planned reforms.
Recognising the critical state of the healthcare system and to make healthcare more people-centric, accessible and universal, the interim government formed a 12-member health sector reform commission as part of broader reforms. This commission aims to address systemic issues, including healthcare governance, financing and workforce development, to pave the way towards achieving universal health coverage.
Bangladesh鈥檚 commitment to healthcare development dates back to its First Five-Year Plan (1973鈥�78), which prioritised rural health infrastructure. Until 1980, the private healthcare sector remained underdeveloped. However, the subsequent decade witnessed increased commercialisation across various industries, including healthcare.
The private sector gravitated towards more profitable secondary and tertiary care, overshadowing primary healthcare. Consequently, the private sector now controls nearly 70 per cent of the market share, while the public health sector鈥檚 share has declined from 36 per cent to 23 per cent over the past two decades.
Moreover, the allocation of resources to healthcare remains insufficient. The World Health Organisation recommends that countries allocate 14鈥�15 per cent of their GDP to healthcare to ensure universal health coverage and a robust health system. In contrast, Bangladesh allocates only 5 per cent, leading to significant disparities. Mismanagement in healthcare governance and financing has further contributed to the sector鈥檚 current state, with forward-thinking reforms often obstructed at the policy level.
A critical impediment to achieving universal health coverage in Bangladesh is the shortage of medical personnel. The World Health Organisation recommends a doctor-to-population ratio of 44.5 doctors per 10,000 people, along with three nurses and five trained assistants per doctor.
While there has been a recent increase in the number of nurses, the number of auxiliary healthcare personnel has declined. This shortage undermines the goals of state institutions, making healthcare less accessible and overburdening existing medical staff.
At the upazila level, doctors face an overwhelming patient load, resulting in inefficiencies. Patients often struggle to convey their concerns due to not having a welcoming environment, limiting their mobility within the system.
Additionally, the lack of a well-functioning referral system has led to an over-reliance on specialists, often bypassing primary care providers. Financial incentives have been prioritised over patient care, and within urban settings, primary healthcare remains highly disorganised.
The rapid urbanisation in Bangladesh presents additional challenges. In the 1980s, urbanisation accelerated, with the urban population rising to around 15 per cent by 1985, driven by industrialisation, rural-to-urban migration, and city expansions.
As of 2025, approximately 42.6 per cent of the population resides in urban areas. This demographic shift has placed significant strain on urban healthcare infrastructure, which was not adequately planned to accommodate such growth.
Shortcomings in urban planning serve as a stark reminder of our present realities. Moving forward, there needs to be a shift in awareness 鈥� one that does not place sole blame on medical practitioners but instead addresses systemic issues such as the absence of a well-structured referral system.
The pharmaceutical sector in Bangladesh has also encountered significant challenges. Medicine prices have surged, with studies indicating a 300 per cent increase due to promotional costs rather than production expenses.
The transition from multinational to local dominance has not significantly benefited the general public, as drug prices remain high. Additionally, there is growing concern over excessive prescriptions, driven by industrial interests rather than medical necessity.
Medical education is at the heart of shaping the future healthcare sector, influenced by both public and private institutions, economic and political forces, and various interest groups. In Bangladesh, the training of medical professionals, including doctors and nurses, often appears unstructured.
Many institutions actively promote themselves as prestigious despite significant gaps in faculty expertise, infrastructure and manpower. The issue does not lie with students but with the need for comprehensive development 鈥� strengthening medical education, ensuring quality accreditation across all institutions and addressing workforce shortages.
To accelerate progress towards universal health coverage, Bangladesh must adopt a multifaceted approach:
Align healthcare expenditure with WHO recommendations by allocating 14鈥�15 per cent of GDP to the health sector while ensuring the proper use of healthcare financing. This investment is crucial for building a resilient healthcare system capable of providing comprehensive services to all citizens.
A key reform would be establishing a standardised electronic medical record system linked to the national ID. This would ensure that every citizen has a consistent medical record accessible across all healthcare facilities, improving efficiency and continuity of care.
Revitalise the public health sector by enhancing infrastructure and strengthening primary healthcare services, especially in rural areas, to reduce reliance on private providers and ensure equitable access to care.
Address the shortage of skilled medical personnel by implementing structured training programmes, improving working conditions, and offering competitive salaries to foster growth, development, and retention of talent within the country.
Develop an efficient system to streamline patient care and reduce unnecessary specialist consultations, as well as monitor and control drug pricing to make essential medicines affordable.
Achieving Universal Health Coverage in Bangladesh is essential for building a resilient and equitable society. Persistent gaps in healthcare financing, infrastructure, and workforce development call for urgent reforms.
With the Health Sector Reform Commission, there is an opportunity to tackle these challenges through investment, policy coherence, and strengthened public healthcare. Ensuring accessible and affordable healthcare for all requires a collective commitment from policymakers, healthcare professionals, and civil society. But how long must we wait? The time for action is now.
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Molla Mehedi Hasan is a public health researcher currently working as a research assistant on a project funded by the Research and Innovation Centre of Khulna University.