The paradox of less financing and low use is not merely a technical issue, it is a political and governance failure that compromises the health and dignity of millions. The time for marginal fixes is over, writes听 Md Mohsin Ali
PUBLIC health system stands at a crossroads. For a country that has made significant strides in maternal and child health and lowered infectious disease burdens, a deep contradiction now threatens to jeopardise further progress: the paradox of low public financing coupled with low budget utilisation. In plain terms, not only is Bangladesh spending too little on health, but it is also failing to fully spend what it does allocate. This dual crisis is silently corroding the healthcare system, increasing inequality and jeopardising national health goals, including Universal Health Coverage by 2030.
At the heart of this crisis lies a chronically underfunded health sector. Despite growing demands and evolving health challenges, Bangladesh allocates just 5 to 6 per cent of its national budget to health. This figure is far below the World Health Organisation鈥檚 recommended 15 per cent and even lower than what many neighbouring countries invest. When measured as a share of the gross domestic product, public health spending remains under 1 per cent, which places Bangladesh among the lowest spenders globally.
Because public financing is so limited, the financial burden of healthcare has been shifted onto individuals and families. Out-of-pocket expenditures now account for nearly 70 per cent of total health spending in the country 鈥� more than twice the global average. This disproportionate burden is driving millions into poverty every year through catastrophic expenditure. Access to care becomes a matter of affordability, and those with the fewest means often delay treatment, rely on informal care, or avoid seeking help altogether. As a result, a system that should provide protection instead perpetuates financial vulnerability and social inequity.
More troubling is that even the limited public health funds available are not fully used. Over recent years, health budget utilisation has consistently hovered below 75 per cent, well below the World Health Organisation鈥檚 suggested minimum of 90 per cent. While it may seem a paradox, the reality is that millions of funds earmarked for improving healthcare remain unspent each year.
Several interlinked issues explain this underutilisation. The budgeting process itself is overly rigid and centralised. Funds are allocated through an incremental, line-item approach based largely on past expenditures rather than actual need. This system offers little room for local adaptation, delays procurement and ties the hands of facility managers who cannot reallocate resources even in emergencies. Bureaucratic hurdles further complicate spending. Financial decisions require multiple layers of approval, causing delays in hiring, infrastructure upgrades and equipment maintenance.
At the facility level, many managers lack the training to navigate public financial rules. Medical professionals, despite their clinical expertise, are often not equipped with the financial literacy needed to plan and execute complex budgets. Add to this is the fear of audit scrutiny or political interference, leading to managers hesitance to spend allocated funds, even on essential services.
The consequences of this spending paralysis are obvious. Many public hospitals and clinics across Bangladesh continue to operate with poor infrastructure, unserviceable equipment and severe shortages of human resources including doctors, nurses and technicians. Even where staff and equipment are available, public perception of quality remains low. As a result, many people turn to expensive private care, reinforcing the cycle of high out-of-pocket spending and deepening the trust deficit in the public health system.
This paradox has far-reaching effects. Health inequality is worsening, as the poor are hit hardest by high costs and limited access. Essential services, including those for non-communicable diseases, mental health and emergency care, are often missing or underfunded. The most vulnerable 鈥� rural populations, the urban poor, women and children 鈥� bear the brunt of this dysfunction.
To break this cycle, Bangladesh must act decisively. Increasing health financing is the first and most obvious step. The government must raise the health budget to at least 10 per cent of total national spending in the short term and move toward the global recommendation over time. However, more money alone will not fix the system. Budget processes need urgent reform. Rather than the current one-size-fits-all model, resource allocation should reflect population needs, disease burdens and regional context. Local health authorities must be empowered with financial decision-making autonomy so they can respond quickly to changing circumstances.
Equally important is the need to strengthen the capacity of health managers. Training in financial planning, budgeting and execution must become a core part of public health governance. Systems for accountability and transparency must be strengthened to ensure that funds are spent efficiently and ethically.
Bangladesh must also invest in its health workforce and infrastructure. Without enough trained professionals and functioning facilities, increased funding will have little effect on service delivery. Improving the quality of care in public institutions is essential not only for health outcomes but also for rebuilding public trust.
The paradox of less financing and low use is not merely a technical issue, it is a political and governance failure that compromises the health and dignity of millions. If Bangladesh is serious about achieving UHC and ensuring that no citizen is left behind, it must confront this paradox head-on. The time for marginal fixes is over. A comprehensive, integrated reform agenda is the only way forward.
By aligning funding with need and ensuring every allocated taka works for the people, Bangladesh can build a health system that is equitable, efficient and resilient.
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Dr Md Mohsin Ali,听 a public health and nutrition specialist, is a former government and UNICEF official.
