Very Significant Topic

1. Stepping Towards Achieving Universal
Health Coverage(UHC) by Promoting Special
Health Care System in Rural Bangladesh: A
Study on Shasthya Surokhsha
Karmasuchi(SSK)
Fahmida Mridha- 214i414i
Graduate School of International
Cooperation Studies(GSICS)
Kobe University
1

2. BACKGROUND
According to (W.H.O)- Universal Health Coverage promotes quality health service to all without financial hardship. It
includes full range of essential health service including health promotion, prevention, treatment, rehabilitation and
palliative care.
Ensuring universal health coverage is a big challenge for Bangladesh. However, government targets a successful
implementation of SDG goal-3 “Health For All” and its 13 targets including UHC by 2030.
The direct payment by oneself for health expenditure in Bangladesh is about 67% of total health expenditure(Mustafa
et al., 2018) and it is having an upward trend. Around 17% of the households face catastrophic health expenditure due
to direct payment for health which push around 5 million Bangladeshis into poverty every year (khan et.al, 2017).
Such expanding health expenditure leading to financial impoverishment results to an economic burden in the path of
development. But if we can reduce these health expenditure for the vulnerable people who are below poverty line, we
can maintain the stream of our current economic growth. At the same time successful implementation of SDG 1 (No
poverty), 2 (Zero hunger), 4 (Quality education) will also be easier.
2

3. BACKGROUND
As an initial step, special health care project (SSK) is inaugurated to ensure a better health service without financial
hardship for vulnerable people of 3 subdistricts of Tangail district. Each household is provided with an electric health
card providing US$ 620 coverage/year against a government premium of US $12. SSK ensures cost-free inpatient
treatment for various non-communicable diseases (78 types) with a free transportation cost for referral facility in
District Hospital. It also provides with free drug and diagnostic facility. Hospital bed and food is also at free cost.
People also has access to a grievance authority for complaining on the quality of the services.
Key Actors for service assurance:
1. SSK Cell (Management body). It performs administrative task, finance management, benefit package
management, grievance process, monitoring and evolution.
2. Supporting Body: Green Delta Insurance. It select the people below poverty line for providing card, facilitate
the subdistrict hospital in claim reimbursement process.
3. District Hospital and 3 Sub-district hospitals. 3

4. BACKGROUND
There has been some study done on this government project. Since it’s a pilot project it requires more research work
in terms of evaluation of ensuring UHC. The study aims at assessing whether this special health care service can
cover all the dimensions of UHC or not. Additionally, this study will try to identify the problems and challenges for
further scale up in other sub-districts.
Research Question
1. To what extent is SSK capable of meeting the service coverage requirements to the card holders ?
2. To what extent is SSK capable of reducing direct payment for health expenditure (OOP) to ensure financial
protection to the beneficiaries?
3. What are the challenges in implementation of SSK? What are the challenges in ensuring better Services under
SSK?
4

5. Literature Review
Gotsadze et al. (2015)- An impact evaluation of medical insurance for poor in Georgia: preliminary result and policy
implications
Ensuring equity in health sector is a big challenge and many countries have started health insurance scheme
to ensure easy access to health care. However, channeling state premium for the poor through private insurance
company to ensure special health care or special health insurance scheme is a new phenomenon to the target of
ensuring UHC.
To evaluate the impact of MIP this paper used 3 sets of outcome variables in regression model:
 Service utilization
 Direct health expenditure (OOP) and
 Odds of receiving free benefits without copayments.
(self reported due to the limitation noted in literature review)
Cont
…5

6. Literature Review
Service utilization:
 Utilizing any services (self treatment/ preventive /or curative/out-patient care) due to illness during the 30 days
period of interview.
 Utilization of inpatient service for last 1 year.
Direct health expenditure (OOP)
 Average cost per out-patient visit
 Average cost per inpatient stay
 Monthly cost for self treatment/chronic disease management
 All health care related expenditure faced by individual for 1 month
Odds of receiving free benefits without copayments
 Socio-demographic variables (age, Gender, education, marital status, household size, consumption level)
Cont…
6

7. Literature Review
Using descriptive statistics of this socio-demographic variables the impact of MIP on different groups were explored.
This paper concluded that MIP had an important role in improving equity among citizen by reducing out of pocket
expenditure (direct payment) and thus providing financial benefits to the poorest. However, MIP could not have
significant role in service utilization to the poor. It suggested that the urban poor people had better access to service
coverage compared to rural poor. Causes detected are-
 Service supply
 Public awareness of MIP and its benefits
 Providers responsiveness
 Private insurer behavior.
7

8. Literature Review
Siddiqui et al. (2019)- Role of Social Health Protection in Universal Health Coverage: A case study of Rawalpindi,
Islamabad
This study is based on cross-sectional data which is collected through questionnaire. Researcher used Socio-
economic conditions, food and non-food expenditure, health care expenditure, health service coverage, financial
protection indicators and demographic condition as variable.
To assess the performance of Social Health Protection for UHC; guideline was taken from “Tracking UHC: Global
monitoring report”. Service coverage :3 preventive and 3 treatment indicators were selected from this guideline.
Financial protection Catastrophic expenditure
Impoverish health expenditure
8

9. Literature Review
Financial protection
Somanathan et al., (2013)- Integrating the Poor into Universal Health Coverage in Vietnam
Health coverage for poor people under Social Health Insurance (SHI) was not successful. It could neither
lower direct payment nor improve financial protection. Rather it led to a case of impoverishment for the poor who
had a minimum income and assets.
The cause behind this was including of government subsidy along with main insurance system. Moreover,
there was a fragmentation of funding across different groups.
Nakazawa & Moji (2018)- What is needed to realize universal “health” coverage? The meaning of health revisited
Financial support are not sufficient for ensuring UHC and also requires organized and well-equipped hospital
facilities.
9

10. Literature Review
Financial Protection
Devadasan et al., (2013)- Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima
Yojana (RSBY) in Gujarat, India
Analyzed the extent to which RSBY contributes to Universal health coverage by protecting households from
OOP payments and suggested that it could provide partial financial protection only.
Details of OOP expenditure was measured under Direct health expenditure for buying medicine, diagnosis,
consultation fees, Hospital charges; and Indirect health expenditure for food, travel, informal fees. Payment for
buying medicine and diagnosis were the main causes detected for poor financial protection.
10

11. Literature Review
Challenges
Lahariya (2018)- ‘Ayushman Bharat’ Program and Universal Health Coverage in India
Ayushman Bharat (AB) Program gave emphasis on successful use of human resources of health sector.
Challenges detected are- Recruitment of health service providers.
Proper identification and enrolment of health beneficiaries to avoid fraud.
Proper assessment of the service provided.
Well functioning IT platform and trained staff.
11

12. Literature Review
Ahmed et al., (2018)- Evaluating the implementation related challenges of Shasthyo Suroksha Karmsuchi
(health protection scheme) of the government of Bangladesh: a study protocol
Implementation related challenges-
Problems in selection process of BPL
Availability of necessary equipment, drugs, logistics for providing service
Scarcity of human resources
Referrals problem
Fund management difficulties
Barrier in claim management
12

13. Financial Factors
Contextual Factors
Financial Protection
Service Coverage &
Challenges
UHC
Adopted and modified from
 WHO cubic model for UHC
 Devadasan et al., (2013)
 Gotsadze et al. (2015)
 Ahmed et al., (2018)
Conceptual Framework

14. Variables for Financial Factors: (Will be taken by INTERVIEW from 20 patients selected by PURPOSIVE SAMPLING who have
taken health care service under SSK.)
1.Expenditure during Hospitalization
Direct expenditure during hospitalization
 Direct payment for medicine
 Direct payment for diagnosis/ Lab. Test
 Direct payment for hospital bed/ Accommodation
 Direct payment for food
Indirect expenditure
 Informal Fees
2.Source of health expenditure
SSK/ Own/ SSK& Own/ Borrow/Sold asset
Cont….. Adopted and modified from Gotsadze et al. (2015) and Devadasan et al., (2013)
14

15. Variables for Financial Factors
3.Monthly income of card beneficiary.
4.Total health care expenditure per year.(per month)
Adopted and modified from Gotsadze et al. (2015) and Devadasan et al., (2013)
Variables for Contextual Factors: UHFPO(1), Doctors(3),Nurses(2), UNO, Chairperson (elected by people) will be interview = 8 people by KII
1.Medicine Availability
2.Diagnosis/Laboratory Facility
3.Transportation Facility during referral to district hospital
4.Problems related to Fund Management
5.Manpower/Human resources
6. Limited Types of inpatient treatments
7.Limited number of beds
8. Poor Infrastructure of hospital
9. Poor coordination 15

16. Methodology
•Method: Qualitative (Exploratory)
•Study area: Kalihati (Subdistrict of Tangail District) where SSK project is running.
•Study population : Patients who have received inpatient care after being enrolled as card beneficiary
•Sampling: Purposive
•Data collection: Interview
•Respondents:
I. Twenty SSK card beneficiaries who received inpatient care after being enrolled.
II. Three Doctors currently providing service.
III. Two Nurses currently providing service.
IV. Upazilla/ Sub-district Health and Family Planning Officer (UHFPO).
V. Upazilla/Sub-district Executive Officer (UNO).
VI. Upazilla/ Sub-district Chairperson ( People’s Representative)
16

17. Capability of SSK in reducing direct payment for health expenditure (OOP) to ensure financial protection to the
beneficiaries?
17
Expenditure during hospitalization
None of the admitted patient had to pay any direct or indirect money for availing health service.
Usual willingness to seek health consultation
Seven of Twenty patient Usually seek help for health care consultation from SSK.
Another Seven seek help from both SSK and Private.
Rest of them seek help to private hospital or other sources.
A large portion of respondents who seek health care facility other than SSK opined that they also preferred other sources since they needed
to buy medicine unless a case of admission.
Major Source of health expenditure
Only for two patient SSK is the only major source of health expenditure.
For Ten patient major source of health expenditure is both SSK and Own. There are also incidence of borrowing and selling asset.
A considerable number of the respondents said that consultation from SSK was free. However, medicine is not provided at free cost unless
admitted. Moreover, those drugs are not provided from general outdoor service of sub-district hospitals. So, they needed to buy.
Health Care Expenditure
Some respondents have annual health expenditure which is above 50,000TK and majority of them seek consultation from both SSK or
SSK and private.
Considerable number of respondents have monthly health expenditure which is half of their monthly income or even more than
that.

18. Summary of Findings
Capability of SSK to meet the service coverage requirements to the card holders.
18
Contextual Factors
Drugs and diagnosis facilities
As a primary health care center drugs and diagnosis facilities provided for the listed inpatient care is sufficient. However,
the number of listed treatments is not sufficient. List should add more services including outpatient care to meet the
actual demand of BPL. ( 3 Doctors)
One of the doctors mentioned that update of the operating principle including financial management is needed for better
assurance of the services to the targeted population.
Sufficient availability of drugs, laboratory facilities. (2 Nurses)
Ensure drugs and diagnosis for limited inpatient care only. To ensure the actual goals of financial protection for the
BPL, outpatient service should be included along with increase of the list for inpatient care. (UHFPO)

19. What are the challenges in ensuring better Services under SSK?
Contextual Factors
Limited Types of inpatient
treatments
• Doctors opined that convincing patient about the limited inpatient service delivery is a big
challenge. Sometimes they also demand for outpatient service. (3 Doctors)
• As a peoples’ representative feel the need to add outpatient service.(UHFPO)
Limited number of beds • Sometimes overload of admitted patient create pressure on ensuring bed for SSK patient.
(Doctor 3 & Nurses)
Ensure Transportation for
referral cases
• Written in provision but practically does not exist (UHFPO)
Scarcity of Human
Resources
• All the doctors demanded for increase of human resources.
• Two of them informed that Doctors recruited under SSK is posted somewhere else and is
absent for a long time. So, all the extra official writings in the admission form needs to be
written by the doctors recruited under Bangladesh Civil Service (BCS). They added that
this painful situation interferes their regular routine work. However, this over task could
also be minimized by use of ICT based consultation system.
• UHFPO assured to the scarcity of cleaning staffs.
• Inadequate supply of cleaning staffs delay service delivery. (Nurse 1)
19

20. What are the challenges in ensuring better Services under SSK?
Contextual Factors
Fund Management Sometimes delayed but does not have any noticeable interference with the service
delivery. (Chairperson and UHFPO)
Poor Infrastructure of hospital It is essential to improve overall infrastructure of the sub-district health complex to
ensure quality health service by reducing out of pocket payment for BPL(UHFPO).
Poor coordination Reservation of information (UNO)
Poor response from Headquarter and insufficient coordination meetings ( Peoples
representative- Chairperson).
20

21. Findings on Financial Protection
There is no doubt that SSK is beneficiary to BPL. Its success lies in reduction of out pocket expenditure during
hospitalization. However, there are instances of borrowing or selling asset among the respondents which indicates this
targeted population need more support with health care service to meet the actual target of UHC.
There are also instances where a large portion of their monthly income goes for treatment of their family members. A
considerable number of family have annual health expenditure above 50000 BDT.
SSK has limited number of inpatient care which needs to be expanded to ensure more beneficiaries to receive the
service only from SSK. Moreover, addition of outpatient service can attract more receiver (BPL) to rely on the service
from SSK only.
Findings of Service coverage and challenges in ensuring better health care service
Drugs and diagnosis facilities are sufficient to meet the demand of the admitted patient under the limited list of
inpatient care. However, infrastructural development of the hospital along with bed and transportation facilities need to
be ensured. Human resources are another essential elements which need to be increased for a better health service
delivery. ICT based consultation system can minimize the over task load of Doctors.
Due to the covid situation coordination meetings were not regular. However, this could be overcome by use of ICT.
21

22. BIBLIOGRAPHY
Ahmed, S., Hasan, Z., Ahmed, M. W., Dorin, F., Sultana, M., Islam, Z., Mirelman, A.J., Rehnberg, C., Khan, J.A.M., Chowdhury, M. E. (2018).
Evaluating the implementation related challenges of Shasthyo Suroksha Karmasuchi (health protection scheme) of the government of
Bangladesh: a study protocol. BMC Health Services Research, 18: 552.
Devadasan, N., Seshadri, T., Trivedi, M., & Criel, B. (2013). Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima Yojana
(RSBY) in Gujarat, India. Health Research Policy and Systems, 11(1), 1-8.
Gotsadze, G., Zoidze, A., Rukhadze, N., Shengelia, N., & Chkhaidze, N. (2015). An impact evaluation of medical insurance for poor in Georgia:
preliminary results and policy implications. Health policy and planning, 30: i2-i13.
Khan, J. A., Ahmed, S., & Evans, T. G. (2017). Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in
Bangladesh an estimation of financial risk protection of universal health coverage. Health policy and planning, 32(8), 1102-1110.
Lahariya, C. (2018). ‘Ayushman Bharat’program and universal health coverage in India. Indian pediatrics, 55(6), 495-506. Retrieved from
https://link.springer.com/content/pdf/10.1007/s13312-018-1341-1.pdf
Mustafa, A., Rahman, A., Hossain, N., Begum, T. (2018). Bangladesh National Health Accounts 1997-2015 (BNHA-V).
file:///C:/Users/Dell/Downloads/BNHA1997-2015%20(2).pdf
Nakazawa, M., & Moji, K. (2018). What is needed to realize universal “health” coverage? The meaning of health revisited. Journal of Global Health
Reports, 2, e2018021.
Siddiqui, M. H., Khattak, F. H., Khan, M.I. (2019). Role of Social Health Protection in Universal Health Coverage: A Case Study of
Rawalpindi, Islamabad. Health Economics Working Paper No 1. Retrieved From
https://pide.org.pk/pdf/HealthEconomics/WorkingPaper-Hira.pdf
Somanathan, A., Dao, H. L., & Tien, T. V. (2013). Integrating the poor into universal health coverage in Vietnam. Retrieved From
https://openknowledge.worldbank.org/bitstream/handle/10986/13315/74945.pdf?sequence=1&isAllowed=y
22