The Covid-19 pandemic has challenged the health systems in Bangladesh with inadequate structural and human resources. The Ministry of Health and Family Welfare (MOHFW) will require additional resources for combatting the existing situation. This year, given the Covid-19-related emergency, Bangladesh Health Watch (BHW) carried out a rapid review to assess the budgetary allocation in the health sector (including water and sanitation) in Covid-19 response by the government, private (for profit and not-for profit) organisations and development partners in terms of equity, transparency/corruption, efficiency and effectiveness. Data had been collected over the period of 16th April to 5th May, 2020 from three different sources: desk review, key informant interviews and collection of allocation statements from non-governmental organisations.
• Overall funding needs to implement the Covid-19 Country Preparedness and Response Plan of the MOHFW are currently estimated to be USD 378 million. However, this may increase with the gravity of the crisis in the coming days. In order to sufficiently equip and supply the health care system for the anticipated influx of severe and critical Covid-19 cases, nearly USD 300 million was requested in the first call for funds, under six urgent broad thematic areas. The proportion of estimated cost for each pillar is presented in the figure 1. This suggests that 91.8 per cent of the fund is estimated to be spent for logistics and procurement. Out of the total estimated cost for logistics and procurement (US$273 million), 41 per cent was estimated as 'immediate need'.
• During the current health and economic crisis, the total stimulus package declared is 3.6 per cent of Gross Domestic Product. It is not adequate with respect to the need, and particularly not at all sufficient for the health sector. During this Covid-19 crisis, the health sector still remained neglected as a national priority. The total stimulus package for health (BDT 850 crore or 8.50 billion) represents 0.08 per cent of the total stimulus package announced.
• MOHFW and many development partners have tried to mobilise unused funds from some other works and also from the contingency fund to help tacke the pandemic. However, Bangladesh was late in terms of taking action, and in many cases, Bangladesh acted like 'firefighting' and 'ad-hoc basis'. This led to a delay in resource use. Though the World Bank (WB) allocated USD 100 million within two weeks, the financial rules and procurement procedures of the Ministry of Health and Family Welfare (MOHFW) and the WB delayed the utilisation of resources.
• Government needs to mobilise resources to provide incentives to health professionals, as announced under the stimulus packages.
• Analysis of allocation of a number of NGOs suggest that around 30 per cent of the fund has been allocated for procuring PPE, and 12 per cent for awareness raising activities (Figure 2)
• Disruption to the supply chain caused an increased price of supplies and logistics at the initial stage. Countries started competing with the same supply sources resulting in increase in prices in addition to difficulty to secure supply.
• The current allocation for the health sector focuses mainly on equipment, infrastructure development, incentives and insurance for health workers. However, it does not have any allocation for cleanliness, hand washing, medicine, mask and gloves, for general people.
• Implementation of the budget is more important where ensuring transparency in the case of managing stimulus packages, and tracking the distributive aspects are crucial.
• An overall rethinking is required for repositioning and prioritising the health sector in our development agenda besides expanding the budgetary allocation for health. Health is not only a sectoral agenda, rather health needs to be considered as a strategic agenda intertwined with many other sectors such as Ministry of Local Government, Rural Development and Cooperatives, Ministry of Women and Children Affairs; Ministry of Religious Affairs; Ministry of Social Welfare.
• Public health needs to be prioritised many times more than the current level, not just in case of increasing the budgetary allocation. The health budget should always be prepared from public health point of view. Hence, waste management, hygiene and cleanliness need attention and additional investment. Government needs to stress the strategic plan about increasing the public awareness, and use a 'whole-society' approach to tackle the pandemic. Community engagement is required to make people aware about the risk and follow social distancing and other hygiene and cleanliness measures.
• The health system needs to be prepared to manage Covid-19 cases while the regular health care services need to be continued. In addition, an adequate budget may need to be allocated for the massive vaccination programme once it is available. Government needs to delay or cut down some infrastructure development projects and reallocate the money to the need of the health sector.
• Government needs to allocate resources for health research. If a vaccine becomes available in the next budget year, Bangladesh might also be involved in the trial to get the advantage of being part of its first phase. In addition, an important lesson would be "proper documentation of the situation and public dissemination".
• Budget allocation for the health sector should be 3.0 - 4.0 per cent of GDP. Given the absorptive capacity of the ministry, the government can allocate around 2.0 per cent of GDP for the health sector, and gradually increase the budget over five years to reach the expected level.
• Government needs to delay or cut down some infrastructure development projects and reallocate the money to the need of the health sector.
• Resource allocation should be based on a comprehensive need assessment and an execution plan. MOHFW needs to assess the need for staff, supply of medical equipment, and training needs at the district and sub-district levels to provide the Covid-19 care and regular health care.
• Budgetary allocation for training and capacity development of health care professionals is needed, including doctors, nurses, laboratory technicians and support staff. This should include basic training on the safety of health care providers, treatment protocol and also emergency planning and responsiveness.
• Investment for capacity development of Institute of Epidemiology, Disease Control and Research (IEDCR) is also important.
• Public health needs should be prioritised, and health budget should be prepared from the public health perspective. Waste management, hygiene and cleanliness need attention and additional investment.
• Handwashing facilities need to be provided in public places, such as bus/train stations, shopping places, markets, schools, colleges and universities, and in community clinics, and masks and gloves should be provided for general people.
• Community engagement is required to make people aware of the risk and follow social distancing and other hygiene and cleanliness measures.
• Under the social safety net, it is important to provide cash to marginalised people so that they can spend as per their need for medicine and soap.
• During the crisis, general service provision, such as TB treatment, immunization, family planning services have been hampered, which also needs special attention.
• Decentralised decision making, service delivery and financial autonomy is required for containing such a pandemic.
• Systems should be in place for improved transparency and accountability of the health systems to safeguard against corruption during emergency and for quality and equity of services delivered during such a pandemic.
[This article is based on the technical report titled "Financial Analysis of Covid 19 Response: May 2020" published by Bangladesh Health Watch (BHW).]
Dr. Rumana Huque is a Professor of the Department of Economics, University of Dhaka.
S M Abdullah is an Associate Professor of the Department of Economics, University of Dhaka.
Sushama Kanan is a Research Fellow at Ark Foundation.
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