Three interrelated financing areas are critical for reaching universal health coverage. These are raising funds for health, reducing financial barriers to access through prepayment and subsequent pooling of funds in preference to direct out-of-pocket payments and allocating or using funds in a way that promotes efficiency and equity.
Developments in these fields will determine whether health services are available for everyone and whether people can afford to use health services when they need them. Universal coverage, or universal health coverage, is defined as ensuring that all people can use preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
In countries like Bangladesh, the challenge is to increase funding available for health so that they are able to provide and make accessible the needed set of health services of sufficient quality, namely treatment, prevention, promotion and rehabilitation. Gradually, Bangladesh is in a positive trend to cover health expenditure that has been defined as critical minimum for providing at least a minimal set of health services. While for richer countries, the challenge is to protect the current levels of health expenditure while responding to the challenge of ageing populations (with implications for both revenues and costs) and cost pressure from technological advances, the cost pressure from highly-priced medicines posing challenges for poorer countries as well.
Countries could raise additional domestic funds for health or diversify their funding sources if they wished to. Options include governments giving higher priority to health in their budget allocations, collecting taxes more efficiently including compulsory insurance contributions, and raising additional funds through various types of innovative funding mechanisms. Taxes on harmful products such as tobacco and alcohol are one such option. They reduce consumption thereby improving health and increase the resources governments can spend on health. A ministry of health cannot, on its own, implement measures to increase funding, but it has the responsibility to try and influence it. This calls for more and better dialogue between the health policymakers, the ministry of finance, wider private actors and local government institutions.
The necessity of health financing mechanism for common people and people with low income like industrial workers is immensely important. The Bangladesh economy is well supported by textile and garments industry where majority of workers are women. This presents a unique situation where approximately 10 per cent of female workers in 19-25 years age range, become pregnant. Any project aiming at extending healthcare financing through health insurance mechanism at micro-level in order to provide basic healthcare services including essential hospitalisation coverage for garment workers (male and female) through scalable premium based on income dimensions has been the need of the hour since long.
Rationally, health insurance is against the risk of individuals incurring medical expenses. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organisation such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as 'coverage that provides for payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.
An empirical study (Health Care Financing , Efficiency and Equity) by Sherry A. Glied examined the efficiency and equity implications of alternative health care system financing strategies. Using data across the Organisation for Economic Cooperation and Development (OECD), it was observed that almost all financing choices are compatible with efficiency in the delivery of health care, and that there has been no consistent and systematic relationship between financing and cost containment. Using data on expenditures and life expectancy by income quintile from the Canadian health care system, the study observed that universal, publicly-funded health insurance is modestly redistributive. Putting $1.0 of tax funds into the public health insurance system effectively channels between $0.23 and $0.26 toward the lowest income quintile people, and about $0.50 to the bottom two income quintiles. Finally, a review of the literature across the OECD suggests that the progressivity of financing of the health insurance system has limited implications for overall income inequality, particularly over time. The most appropriate generalisation of the financing of developed county health care systems is that they share no general characteristic. Few systems fall squarely into any single box and even systems that more-or-less do, have evolved in their financing over time.
In recent years, the Diabetic Association of Bangladesh (DAB) initiated a project for provision of insurance and health services including screening of 6,000-7,000 garment industry workers. Swiss Micro Insurance Consultancy Group (SMCG), in association with the Swiss Tropical and Public Health Institute (Swiss TPH), is providing consultancy services. DAB has entered into a memorandum of understanding (MoU) to coordinate primary, secondary, and tertiary level curative cares at institutions of DAB and provide health education, promotion, care services for employees and workers of BGMEA members
The overall objective of the 2-year 'Comprehensive Healthcare for Bangladesh Garments Workers through Micro Health Insurance Programme' is to increase comprehensive and universal health services coverage with improved disease prevention, immediate access to health information and services and efficient cost control through a structured healthcare financing plan by introducing and testing the economic viability of a (group) health micro insurance scheme for (garment) industry workers in Bangladesh. Salient features of the project are that DAB will provide comprehensive health coverage except following high ends:
n Congenital infirmity, alcoholism or narcotic addiction, cosmetic or plastic treatment, termination of pregnancy, radiotherapy, chemotherapy, prostheses, AIDS and HIV-related diseases, special procedures like transplantation, cardiac, neuro surgery, faco surgery and dialysis.
n To reduce health care cost, all insured will be provided health promotion and disease prevention education.
n To reduce cost, there will be an extensive use of telemedicine, a support through its mobile health infrastructure for electronic registration, medical call centre platform with electronic prescription and mobile health applications for patient management.
Expected outcomes (and outputs) of the project are:
n About 6,000-7,000 garment industry workers are having improved access to and make use of preventive and curative health services. The workers appreciated and understood both the health services offered and used and the insurance mechanism as a risk management tool of their households.
n A tested institutional model for health and insurance service providers United Insurance Company Limited (UIC), health service provider Nationwide Health Network (NHN) , an enterprise of the Bangladesh Diabetic Association, the Telemedicine Reference Centre Pvt. Ltd. (TRCL) and four garment factories under the New Asia Group took an informed decision on the parameters, continuation and expansion of the scheme.
n A key constraint for development of a health insurance system in Bangladesh is the almost total lack of relevant data for a poor clientele. Key outputs during the planned duration of the project are documentation, analytical reports, studies, articles (in Bangladesh and international journals) and a national learning platform to share the experiences and lessons of the project.
n Replications among the members of the Bangladesh Garment Manufacturers and Exporters Association (BGMEA) and policy changes are now being considered.
The writer, a former Secretary and Chairman, NBR, is Chief Coordinator, Diabetic Association of Bangladesh.