Challenges

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

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:

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:

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.