Dr. Sharmeen Bhuiyan
Sylhet Medical University
The old adage declares that health is wealth, suggesting that wellbeing itself is the greatest asset a person can possess. In Bangladesh, the relationship inverts with brutal clarity: wealth is the prerequisite for health, and the absence of it is a slow sentence to inadequate treatment, delayed diagnosis, and preventable suffering.
The question is not merely rhetorical. It describes the operational logic of a healthcare system where the ability to pay determines the quality of care, where public provision collapses under neglect, and where a vacuum of insurance leaves families one medical emergency away from financial ruin. This article is intended to stimulate a more enhanced and effective discussion on the issue.
The Arithmetic of Private Healthcare Against Per Capita Income
Bangladesh’s per capita income stands at approximately $3,020, a figure that places the country in the lower middle-income threshold but masks an enormous internal disparity. Against this income, a single consultation with a specialist at a private hospital in Dhaka can cost between Tk 1,500 and Tk 3,000, a basic diagnostic workup including blood tests, imaging, and pathology can exceed Tk 10,000, and a routine surgical procedure at a private facility can easily surpass Tk 100,000.
For a household earning the median income, a single serious illness can consume months of total earnings. Out of pocket spending accounts for roughly 74 percent of total health expenditure in Bangladesh, one of the highest rates in the world. For every 100 taka spent on healthcare, 74 taka come directly from the pockets of citizens, compared to just 12 percent in Rwanda or 36 percent in countries with functional prepayment mechanisms. This is not a funding model; it is a punishment model, where the sick pay for being sick.
Income Inequality as a Health Determinant
The lowest income quintile in Bangladesh consumes roughly 0.22 times what the highest quintile consumes. Income inequality, measured by the Gini coefficient, has risen steeply over the past decade. This widening gap reproduces itself in health outcomes with mechanical precision. The wealthy access private clinics with intensivists, advanced imaging, and sterile operating theatres. The poor queue at overcrowded government hospitals where doctors are overworked, supplies are erratic, and diagnostic equipment is frequently nonfunctional.
District and upazila health complexes across the country face chronic shortages of physicians and nurses, with many specialist posts lying vacant for years. The system does not merely deliver unequal care; it delivers two entirely different medical realities separated by the thickness of a wallet.
The Quality Chasm Between Public and Private
Bangladesh ranks 88th in global healthcare quality indices, a position that reflects the median experience of a system characterised by unavailability of doctors, negative perceptions of public facility responsiveness, and pervasive distrust. Private hospitals are perceived as more responsive and better equipped, but they operate with minimal regulatory oversight and a pronounced profit orientation.
The commercialisation of private healthcare in Bangladesh is characterised by commission-based referral systems, unnecessary diagnostic tests, and inflated billing practices that exploit the information asymmetry between medical providers and patients. A patient arriving at a private facility with chest pain may undergo a battery of tests, many of them clinically redundant, because the facility profits from each investigation. The moral hazard is structural: when healthcare is a revenue centre rather than a public good, every patient becomes a profit unit, and every illness becomes a revenue opportunity.
The Insurance Vacuum
The near total absence of a health insurance market compounds every other failure. Bangladesh has no comprehensive national health insurance scheme and only a nascent and fragmented private insurance sector that covers a negligible fraction of the population. The result is predictable: households absorb health shocks through savings, asset sales, or debt, and when these prove insufficient, they simply go without treatment.
Catastrophic health expenditure, defined as out-of-pocket medical costs exceeding 10 percent of household consumption, pushes millions below the poverty line each year. The World Bank has documented that out-of-pocket health spending further impoverishes an already vulnerable population. No country has achieved universal health coverage without a prepayment and risk pooling mechanism. Bangladesh remains one of the few nations attempting to do so.
Regional Flight and the Geography of Wealth
The ultimate demonstration of wealth as health is medical tourism by Bangladesh’s affluent. An estimated 100,000 to 150,000 Bangladeshis travel abroad annually for medical treatment, spending hundreds of millions of dollars in hospitals in Kolkata, Chennai, Bangkok, and Singapore. A cardiac bypass at a Bangkok hospital costs substantially more than in Dhaka, but the assurance of quality, hygiene, and postoperative care makes the additional expense acceptable to those who can afford it.
Chennai’s Apollo and Fortis hospitals, Bumrungrad in Bangkok, and Mount Elizabeth in Singapore have built significant patient volumes from Bangladesh. This capital outflow represents the most damning indictment of domestic healthcare quality: when the wealthy of a country will not trust its hospitals, the system has failed not merely the poor but the very standard of care itself.
Public Health as the Only Remedy
The inversion of health and wealth in Bangladesh will persist until two structural corrections are made. First, public health provision must be rebuilt with adequate investment. The government currently allocates less than 1 percent of GDP to health, the lowest among all least developed countries and far below the 5 percent recommended by the World Health Organisation. This must rise to at least 3 percent within five years, with directed spending on district hospital capacity, diagnostic equipment, specialist recruitment, and essential medicine supply chains.
Second, the moral hazard of profit maximising private healthcare must be constrained through enforceable regulation: standardised pricing frameworks, prohibition of commission-based referrals, mandatory clinical audit of diagnostic appropriateness, and transparent billing requirements.
A social health insurance scheme, even if initially limited to formal sector workers and gradually expanded, must be legislated and implemented to introduce risk pooling as a structural feature of the system. Until public provision becomes credible and private predation becomes costly, the answer to the question will remain unchanged: in Bangladesh, wealth is health, and health without wealth is a gamble that most cannot afford to lose.
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