Although Bangladesh has achieved remarkable progress in reducing neonatal and maternal mortality, overarching issues and opportunities for improvement remain. Bangladesh has demonstrated a willingness and ability to overcome previous challenges, and adjustments to address these obstacles will be the next crucial steps in advancing neonatal and maternal health in the country.

Out-of-pocket spending

Compared with other countries, the health system in Bangladesh is notable for how little it has spent on health care, and how much of that spending is from private sources. Total health expenditure in Bangladesh in 2015 was only 2.9% of the gross domestic product—one of the lowest allocations in the world. Health spending as a percentage of the gross domestic product lags that of Bangladesh’s regional neighbors (3.8%), low-income nations worldwide (5.4%), and lower-middle-income countries worldwide (4.3%).1 Revenue for health care is primarily derived from private sources, especially user fees and other out-of-pocket payments.

In 2009, an estimated 4% of all households in Bangladesh were impoverished due to high out-of-pocket costs.2 By 2019, out-of-pocket spending represented 72.7% of total health expenditure in Bangladesh—one of the highest proportions in the world.3 A recent study showed high financial hardship due to out-of-pocket payments in Bangladesh, with the incidence of catastrophic health expenditure at 24%.4 Aside from some employer-operated private insurance plans, few prepayment mechanisms exist for Bangladeshis, in part explaining why out-of-pocket spending constitutes 92.9% of the nation’s private health expenditures.5,6

Figure 36: Sources of Health Expenditure in Bangladesh from 2000 to 2020

World Health Organization (2019)

Excessive cesarean section rates

As highlighted previously, cesarean section (C-section) rates particularly among the wealthiest women delivering predominantly in private facilities are several times higher than levels the World Health Organization would usually consider essential.7 In 2017-2018, the C-section rate among mothers in the wealthiest quintile was 61.5% and the majority of C-sections were elective as opposed to emergency.8 C-section has been one of the most instrumental interventions in saving the lives of mothers and children, but overuse in unnecessary circumstances poses undue medical risks. In 2010, the average medical care expenditure for a C-section delivery in Bangladesh was US$276, compared with US$45 for a vaginal delivery.9 Health expenditures related to C-sections accounted for the majority of delivery-related expenditures, and 6.9% of total health expenditure in Bangladesh in 2010.9 Interviewees often spoke to the need to address this issue, with one expert noting:

On the one hand, a cesarean is a life-saving procedure related to morbidity. On the other hand, it would be an injustice to the public if we don’t work according to the indications. So, with due respect to the cesarean sections, I would say that it must be an optimization of cesarean sections.

- Obstetrician

Addressing overuse of C-section has direct implications for impacted women and the overall health system of Bangladesh that is burdened by the cost of this increasingly utilized procedure.

Lingering inequalities

Key indicators such as antenatal care coverage, in-facility delivery coverage, C-section rates, and postnatal care have been influential in reducing neonatal and maternal mortality in Bangladesh, but disparities in coverage remain. In general, much of the progress Bangladesh has made in recent decades has been driven by advancements among wealthier communities able to afford private care. Although programs such as the Maternal Health Voucher Scheme have proven capable at improving care utilization in key districts, overall, improvements among the poor have not kept pace with advancements among the wealthy. As one interviewee noted:

The elite class majorly seek care from those hospitals, so we are not much concerned for them. But the mother who belongs to a hand-to-mouth family needs support from us; this type of mother is huge in number.

- Government Official

Highlighted earlier in the integrated maternal, neonatal, and stillbirth mortality transition framework, reducing inequalities is expected to be a key next step for Bangladesh as the country continues to advance along the usual trajectory of progress.

  1. 1
    World Bank. Current health expenditure (% of GDP) [data set]. Accessed November 28, 2022. https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS
  2. 2
    Islam Ashadul, Akhter S, Islam M. Health financing in Bangladesh: why changes in public financial management rules will be important. Health Syst Reform. 2018;4(2):65-68. https://doi.org/10.1080/23288604.2018.1442650
  3. 3
    World Bank. Out-of-pocket expenditure (% of current health expenditure) [data set]. Accessed November 28, 2022. https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS
  4. 4
    Ahmed S, Ahmed MW, Hasan MZ, et al. Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016. Int Health. 2022;14(1):84-96. https://doi.org/10.1093/inthealth/ihab015
  5. 5
    World Health Organization (WHO) Regional Office for the Western Pacific. Bangladesh Health System Review. Health Systems in Transition series; Vol. 5, No. 3. Geneva: WHO; 2015. Accessed November 28, 2022. https://apps.who.int/iris/handle/10665/208214
  6. 6
    Molla AA, Chi C. Who pays for health care in Bangladesh? An analysis of progressivity in health systems financing. Int J Equity Health. 2017;16(1):167. https://doi.org/10.1186/s12939-017-0654-3
  7. 7
    Betrán AP, Torloni MR, Zhang JJ, Gülmezoglu AM; WHO Working Group on Caesarean Section. WHO statement on caesarean section rates. BJOG. 2016;123(5):667-670. https://doi.org/10.1111/1471-0528.13526
  8. 8
    US Agency for International Development. The DHS Program STATcompiler. Accessed November 17, 2022. http://www.statcompiler.com
  9. 9
    Haider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM. Ever-increasing Caesarean section and its economic burden in Bangladesh. PloS One. 2018;13(12):e0208623. https://doi.org/10.1371/journal.pone.0208623

Context