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1 April 11:50

Bangladesh stands at a critical juncture in its public health journey. While the country has made remarkable progress since independence, deep structural gaps, rising disease burdens, and growing inequities continue to undermine the health of millions. If we consider the existing healthcare system in Bangladesh, it becomes clear that we need many more hospitals to serve the urban population. Dhaka alone now has a population of nearly 36.6 million (UN Report 2025), yet the number of large public-sector hospitals has barely increased since independence. Apart from facilities such as Dhaka Medical College Hospital, Sir Salimullah Medical College Hospital, and Shaheed Suhrawardy Medical College Hospital, there have been very few major additions.

At the same time, there has been a mushroom growth on private clinics. However, they are largely unaffordable for people from lower socioeconomic backgrounds. For low-income urban residents, government hospitals remain the primary, and often the only, place to seek care. This makes it crucial to expand and strengthen hospital-based care for urban populations.

Decentralisation is equally important. When specialised hospitals are only concentrated in Dhaka, patients from districts such as Noakhali or Kurigram are forced to spend significant amounts of time, money, and effort to seek treatment in an unfamiliar city. This is neither appropriate nor sustainable. Medical colleges and medical college hospitals outside Dhaka must be well equipped and adequately staffed so that patients can receive quality care closer to home.

Of course, the country also needs a much stronger healthcare system for the rural population, which still outnumbers those living in cities. Bangladesh has an extensive primary healthcare infrastructure, including upazila health complexes, union sub-centres, and community clinics. Each community clinic caters to a population of around 10,000–12,000 people and is staffed by a community healthcare provider. However, the system as a whole needs revitalisation. Facilities must be functional, well-staffed, and properly equipped so that people can seek treatment for common and basic health problems. Strengthening primary healthcare at the grassroots level is essential to reducing pressure on higher-level facilities.

Another major concern is the rapid increase in non-communicable diseases such as diabetes, hypertension, and chronic respiratory illnesses. This trend is visible across both urban and rural populations. Surveys show that 6–10 percent of the population is living with diabetes, many without knowing it. The situation with high blood pressure is even more alarming: around 20–25 out of every 100 people are affected.

These individuals are at a much higher risk of complications and premature death. Strengthening primary healthcare services is therefore critical so that chronic diseases can be detected early and managed with simple, low-cost treatments that prevent complications.

Urban slums are another major public health hotspot. In Dhaka and other cities, an estimated one-third of the population lives in slum settlements under extremely poor conditions. These communities are deprived of many basic healthcare services.

While rural populations have access to community clinics and other primary healthcare platforms, similar fixed-site facilities are largely absent in urban slums. Establishing community clinic–type facilities near large slum settlements could dramatically improve access to care. Even basic services, such as checking blood pressure or blood glucose, can make a meaningful difference by enabling early detection and prevention of diseases and complications.

Out-of-pocket health expenditure in Bangladesh remains persistently high, exceeding 70 percent. For diagnostic tests, this share often climbs to 80–90 percent or even higher, placing a severe financial burden, particularly on people from lower socioeconomic backgrounds.

To address this, we must ensure the availability of basic diagnostic services such as blood tests and X-rays at public facilities. Although X-ray machines exist in many rural areas, they are often out of order or lack essential supplies. Why should a low-income patient be forced to seek a chest X-ray from a private facility? Community clinics should have basic equipment—such as blood pressure machines, blood glucose meters, and essential medicines—provided free of charge. Ensuring these services would significantly reduce out-of-pocket spending.

Around 25% of children under five still suffer from stunting, raising their risk of death three- to fourfold. Photo: Collected

Access to affordable surgical care is another critical issue. Procedures such as caesarean sections or appendicectomie remain expensive even in public hospitals due to the cost of medicines and other supplies. Suppose a rickshaw puller in Dhaka develops acute abdominal pain and is taken to a hospital, where he is diagnosed with appendicitis and advised to undergo an appendicectomie. Surgery is essential, but there are very few facilities that provide it free of charge. 

Even when surgery is offered at no cost, patients often face unforeseen expenses. To truly reduce out-of-pocket health expenditure, it is crucial to ensure that all necessary components—antibiotics, essential surgical supplies, and other critical elements—are readily available. Crushing financial burdens on patients can be eased only if basic medical needs are reliably met.

Reducing out-of-pocket expenditure also requires more rational prescribing practices. Too often, medicines are prescribed that are not strictly necessary, adding to patients’ financial burden. Pressure from pharmaceutical companies can further encourage the prescription of expensive drugs when cheaper, equally effective alternatives exist.

This problem is particularly evident in the management of non-communicable diseases such as diabetes and hypertension. While Bangladesh has made progress in antibiotic stewardship, enforcement remains weak. Higher-generation antibiotics such as ceftriaxone, ceftazidime, and meropenem should never be sold without a prescription. If restrictions can be enforced for sleeping pills, they can certainly be enforced for higher antibiotics. Ultimately, all antibiotics should be brought under prescription control. Educational institutions and pharmaceutical companies also have a responsibility to promote ethical practices that prioritise public health alongside profit.

Bangladesh does not suffer from a lack of policies or institutions in the health sector. What we lack is effective implementation. We already have a Ministry of Health and Family Welfare, along with the Directorate General of Health Services, the Directorate General of Family Planning, and offices overseeing community clinics and nursing education.

The real issue is ensuring that allocated funds are justifiably spent, which requires good governance. Although significant resources are allocated to health, weak planning and delayed execution often prevent effective utilisation. There are people assigned specific roles, and the key is to make sure they actually perform their duties. Effective governance is therefore essential. We must also improve budgeting processes, ensure timely planning, and establish strict monitoring throughout the year so that allocated funds are actually spent for their intended purpose.

When Bangladesh became independent in 1971, the country faced severe food insecurity. Today, despite a much larger population, we no longer face the same level of staple food shortages. However, nutritional inequity remains profound. Around 24–25 percent of children under five still suffer from stunting, placing them at three to four times higher risk of death and limiting their cognitive development. Childhood wasting is an even greater concern. Recent surveys show that wasting has increased from 8 percent to 13 percent nationally—dangerously close to the WHO emergency threshold.

Malnutrition often begins before birth. Poor nutritional status among adolescent girls and pregnant women leads to inadequate pregnancy weight gain, low birth weight, and persistent childhood undernutrition. Improving the nutrition of adolescent girls and women of reproductive age must therefore be a top priority.

Dietary diversity also remains inadequate. Although Bangladesh has made progress in producing fish, eggs, milk, and poultry, many households cannot afford these foods. Targeted social safety net programmes are essential to support vulnerable populations, particularly pregnant women and families in hard-to-reach areas.

Climate change poses serious long-term threats to health and food security. Rising salinity in southern Bangladesh is already linked to increased rates of hypertension and other chronic conditions. Ensuring access to safe drinking water with low salinity is critical. Bangladesh has developed strong disaster response systems, but routine healthcare services in climate-vulnerable areas remain inadequate. Community counselling, improved housing ventilation, and awareness of heat-related health risks are increasingly important as temperatures continue to rise.

Additionally, mental health is one of the most neglected areas of public health in Bangladesh. Nearly 19 percent of the population suffers from some form of mental illness, yet stigma and limited access to care prevent many from seeking treatment. Expanding community counselling services—alongside psychiatric care—is essential. Family members, class peers, teachers and work colleagues could be made aware to positively interact with the patients. 

Bangladesh’s public health challenges are deeply interconnected, spanning governance, nutrition, environment, and equity. Addressing them requires a holistic approach that strengthens preventative primary healthcare instead of hospital-based care, enforces existing policies, and prioritises the most vulnerable.

The foundations of a strong health system are already in place. What is needed now is decisive leadership, good governance, and a sustained commitment to implementation. If we can ensure these, Bangladesh can translate its investments into real and lasting health gains for all.

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