1. Health Financing Initiatives and Challenges in Bangladesh Health Economics Unit Ministry of Health and Family Welfare

2. Objectives and expectations ❶ Sharing of different government initiatives in the area of health financing ❸ Garner support for implementation of the initiatives included in the HCF Strategy and its spirit of access, equity and efficiency ❹ Identify possible roles of different stakeholders in implementation 2

3. increased significantly from 2008 to 2011- 93% of DHs and 48% of UHCs reported collecting some user fees(BHFS 2012) Health financing Mechanisms in Bangladesh Targeted towards low income urban/rural Unsustainable High drop-out rates Public Health Facilities provide free care to all population DSF Scheme- Maternal Health Vouchers, P4P Urban Health Unaffordable by majority Risk-Adjusted Premiums Inequitable Covers less than 1% of the population Private Health Insurance User Fees Govt. Funded Health Care/NGOs Micro Health Insurance

4. The Health Care Financing Strategy 2012-2032 www.heu.gov.bd Expanding Social Protection for Health: Towards Universal Health Care Coverage Health Care Financing Strategy 2012-2032 4

5. Health Care Financing Strategy (2012-2032) ❶ The Health Care Financing Strategy provides a framework for developing and advancing health financing in Bangladesh. ❷ The framework and its direction are aimed at: ① Increasing the level of funding for health ② Improving equity in health financing ③ Improving access to essential health services ④ Reducing the incidence of impoverishment due to catastrophic health care expenditures ⑤ Improving quality and efficiency of service delivery.

6. Population coverage plan in HCFS 6

7. 7 Civil Servant Scheme Ready Made Garment Scheme Formal Sector 18.8 M (12.3%) Micro-insurance / CBHI Private Insurance Tax Funded public health services Informa l Above Poverty Line (APL) 85.7 M (56.2%) SSK Scheme Tax Funded public health services Below Poverty Line 48 M (31.5%) Evaluation and Fine- Tuning Unified SHI Scheme 1. COVERAGE – Progressive Approach during System- Building Phase following common guiding principles and design elements Initial Phase (2014- 2017) Assessment & Fine-Tuning (2018) Scale-Up (2019- 2020) Nationwide Implementa tion (2021 onwards) Enactment of SHI Law

8. 8 2. IMPLEMENTATION PLATFORMS Policies and Frameworks (Legal, Regulatory, and Financial) Draft SHI Law, Approval process and IRR User fee retention; provider autonomy Organization HCFS Advisory Council and HCFS Coordination Team New autonomous body and its office Communication Key Stakeholders- political, internal, CS and public Marketing Plan Capacity Development Individual, organizational capacities (outsourcing of studies and researches) financial management, contracting, statistical analysis, marketing, SHI management Health System Efficiencies Quality assurance and accreditation system, IT system, expansion of DSF Procurement of drugs, adequate and motivated HR, needs-based resource allocation Monitoring and Evaluation Regular reporting and monitoring; registration and monitoring of micro insurance; evaluation of schemes and fine-tuning Impact monitoring by independent body Initial Phase (2014- 2017) Assessment & Fine- Tuning (2018) Scale- Up (2019- 2020) Nationwide Implementation (2021 onwards)

10. Objectives of the scheme ❶ Improve access of the poor to hospital inpatient care by reducing financial barriers ❷ Protect poor people from catastrophic payment for treatment ❸ Increase the authority at hospital level for functional improvement as a part of Local Level Planning (LLP) and development. ❹ Introduce performance based financing models. 10

11. Overview of SSK ❶ Innovative health protection scheme to be Piloted in 3 upazilas ❷ Targeted to Below Poverty Line (BPL) households initially ❸ Fully subsidized (govt. will pay the premium) ❹ Later, APL households will be included in the scheme as paying members for sustainability, risk pooling and cross- subsidization ❺ Initial stage Tk. 1000 per household per year as premium ❻ Household can get treatment benefit up to Tk 50,000 per year ❼ Support from KfW 11

12. Service Delivery  Health card (paper based / smart card) per household  A benefit package of treatment for 50 diseases including drugs and diagnosis according to defined treatment guidelines  Initially Public Health Facilities (Upazila Health Complexes and District Hospital) will provide the services  Gradually includes private facilities under an accreditation plan  UHC as the focal point of service delivery with a SSK booth at the hospital  Structured referral to DH (UHC as the gate keeper)

13. Service delivery 13 U H C O P D Consultation SSK Booth Household D H A Benefit package of 50 diseases including diagnosis and drugs as per defined treatment guidelines Transport cost

14. Management of the Scheme ❶ SSK Cell at centre and coordinators at field ❷ Engagement of Scheme Operator as management agency ❸ Grievance procedure ❹ Introduce modern IT (in claims processing, accounting, controlling, and electronic patient records) for increased efficiency and transparency ❺ Supervision and guidance from Inter-ministerial Steering Committee led by Hon’ble Health Minister and Working Committee headed by Secretary MOHFW 14

15. Financial management of the Scheme ❶ SSK Cell will receive the premium from the Government (DP) ❷ It will allocate an amount to the Scheme Operator (SO) ❸ Hospital will treat the SSK patients according to the standard guidelines ❹ It will claim reimbursement to the SO based on the designated price of the benefit package ❺ SO will review the claim and disburse the money to the hospital ❻ SO will get fix management fees 15

16. BPL HH SSK Cell S O U H C D H GoB/DP Financial management of the Scheme Premium for BPL HH Allocate fund Issue Health Card Treat patients as per guide lines Design Benefit Package Structured referrals Claim forms Reimbursed Feed back Management fees 16

17. Identification & Registration of BPL Population ❶ BPL identification & registration will be started soon ❷ Eligible poor for SSK scheme would be those satisfying any 2 of the 3 criteria which includes: ① main earning person or head of family is a casual day labourer ② landless household owning homestead only and no other land ③ household have no permanent/regular income source ❸ Organize sensitization campaign at pilot sites, and ❹ Decide the process of identification & registration consulting with local administration 17

18. Grievance Mechanism ❶ An independent grievance mechanism to be established through an executive order of GoB ❷ SSK members/beneficiaries will have right to complain ① poor quality of services ② lack of drugs ③ unofficial payments ④ Other related issues Grievance authority ① accessible for SSK members at local level (UHC) ② will have the power to initiate inspection and sanctions 18

20. SSK, Formal &Informal sector coverage Single fund Efficiency Solidarity Risk-adjusted resource allocations Pooling Effectiveness Allocation Contribution Resource collection Formal sector Income related payments EmployerEmployee Subsidy Taxes Int. buyer Govt employees Private formal sector, RMG,BRAC Membership according to profession MHINGO Union … Competition Informal sector Income related payment Employee (sliding scale) National grants Financed through remittance levy (0.5 %) SSK Below poverty line National grants Financed through (general / earmarked) taxation

21. Guiding Principles Uniform base benefit Obligation to contract Family membership Portability of benefits Choice of providers

22. Legislation on Social Health Protection ❶ Legal base for implementing social health insurance/ protection schemes ❸ Provide institutional framework for financial and service delivery issues 22

23. Thanks