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Paradigm of insurance companies in Bangladesh : myths & depths Ins

People assume insurance works like a financial portfolio, with a return
The industry has been promoting how insurance is a protection

Insurance is the protection of adverse risk. Risk is one of its most challenging and constant aspects of the human experience.

The insurance industry is not only central to the creation of a stable business environment for a country’s economic growth but also critical for the reduction of the financial burden on the government during natural and economic crises.

In the past, we have seen a strong track record of Bangladesh’s growth and development, even in times of global uncertainty during the Covid-19 crisis.

A strong recovery from the COVID-19 pandemic continued in 2022-23, although a recent surge in commodity prices, scarcity of dollar reserves prompting a new financial market crisis have presented new challenges for the government and the economy of Bangladesh.

The insurance industry of Bangladesh also had a good start in the beginning of 2023.

However, due to the uncertainty of the financial sector, especially compared to the banking and capital market, the insurance market was in a standstill situation among the financial portfolios at the end of the year.

Lack of confidence among the people regarding the financial sector and the spillover effect was faced by the insurance industry.

Over the last few years in the insurance industry, Insurance companies are trying to make the public aware of the benefits of insurance and protection.

Most people assume insurance to work like other financial portfolios, where they get a profitable return. Hence, the industry as a whole has been working towards creating awareness on how insurance works as a protection and not just any financial securities with return.

Subsequently, a few changes have been evident across the industry. The regulatory body is also trying to promote and encourage the companies to pay off 100% of the claims and insurance settlements.

In our economy if any part of the financial ecosystem is in crisis, the insurance sector is likely to be in a crunch as well.

We often find that insurance is at the bottom of everyone’s priority. It is almost a push to sell products and most of the people of our country do not willingly buy insurance policies.

We have even witnessed financially-sound individuals and business houses prefer to save in FDR, bonds, and real estate investments or even stock markets to get a speedy return, but never insurance.

To create awareness, we could mandate insurance to some extent at least. When comparing to other countries, for instance, applying for a visa in Europe or Australia everyone requires travel insurance.

Furthermore, people can decide the premium depending on the level of protection they want.

Recently, the government has implemented a few insurance policies. For instance, Bangladeshi immigrants abroad that are earning remittance, are mandated to take insurance.

Another insurance policy has been implemented in primary schools. However, if we look at the 4.2 million RMG workers that help us to earn foreign currency through export, they still do not have any kind of insurance protection.

Similarly, we can focus on promising real estates, the agricultural sector, high value crops and valuable personal assets.

In a study report of LightCastle Analytics Wing has described that despite a booming economy and the expected middle-income country status by 2024, the insurance industry of Bangladesh can only be described as underdeveloped. A major reason for this is that most consumers in Bangladesh are unaware and uneducated about how insurance works, due to a lack of information dissemination.

Around 7% of households in the country have to finance healthcare payments by selling their assets.

Insurance would relieve them of this burden by providing protection against the risk of unaffordable treatments. To protect consumers, regulatory bodies need to impede the sale of unfair or exploitative contracts, which is often caused by complicated policy language and unjust pricing.

Regulation to limit insolvency risks will also ensure that customers get paid when they need to collect claims, which is often considered a major peril of insurance contracts.

Moreover, the poor performance and outlook of the financial sector are not promising either.

Regulatory reform must focus on protecting consumers from complex and potentially deceptive contracts, and the increasing availability of insurance products to members of all stakes of the economy.

The Insurance Core Principles (ICPs) developed by the International Association of Insurance Supervisors (IAIS) provide a globally accepted framework of principles that the government can adopt for Idra.

Despite the dismal image portrayed by the current situation and numbers, Bangladesh’s insurance sector has significant potential as the average income and GDP continue to rise.

Moreover, as the middle and affluent class in cities throughout the country increases in size, the desirability of insurance also increases.

Recent statistics showed that the total market value of the Bangladesh insurance industry in 2023 was over Tk17,000 crore, where the contribution of life insurance was about over Tk12,500 crore and the remaining Tk4,500 crore came from the non-life insurance sector.

In 2023, the total premium earnings was about Tk17,000 crore with about 10% growth showing a positive trend.

In 2022, we have also witnessed a new trend whereby more people are being aware about protection and insurance policies; this has also continued to 2023 and onwards.

Then the impact of the insurance industry can be easily illustrated by the impact of a 1% increase in insurance penetration with some pragmatic initiatives by the policymakers, investors, practitioners and positive acceptance by the consumers.

The author is CEO (Admin) of Chartered Life Insurance Company Ltd

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Home ›› 01 Feb 2022 ›› Opinion

Problems and prospects of insurance sector in Bangladesh

In Bangladesh during the 1970s, the government owned Jiban Bima Corporation (JBC) and Sadharan Bima Corporation (SBC) were the only providers of life and general insurance coverage for individuals and business properties. At that time, the industry did not take innovative measures for product development. In Bangladesh, the first private insurance company was set up in 1985. At present there are 79 insurance companies operating in the country of which there are 33 life and 46 non-life companies. In a developing country like Bangladesh insurance companies can play a very important role in the economy. Though insurance industry has very good prospect in the economy, for some reasons it has failed to achieve its goals. If we know the real reasons then we can take the necessary steps to remove them. There are 79 insurance companies operating in Bangladesh.

The population of the country is about 170 million and only 10 million people have life insurance policies. In non-life sector 79,754 small and medium enterprises are in operation out of which 93.6 per cent are small and 6.4 per cent are medium. According to the Bangladesh Road Transport Authority (BRTA) statistics, at this moment there are 50,00,000 vehicles which are registered. Only a few of these have first party insurance. More than 5,000 garments industries are doing business in our country and those have group insurance. Thousands of launches are plying in the waterways everyday in our country and they need insurance for passengers. Bus and railway passengers also need insurance. In addition to this, all fixed assets like building and factory need insurance coverage.

Insurance penetration rate is measured as the ratio of premium underwritten in a particular year to the GDP. Insurance penetration in Bangladesh is very low at only 0.59 per cent. This rate is the lowest in the South Asia. Low insurance penetration and high protection gap indicate a significant deficiency across the entire insurance ecosystem in Bangladesh.

Insurance density is used as an indicator for the development of insurance within a country and is calculated by the ratio of total insurance premium to whole population of a given country. Insurance density in Bangladesh is only $8.75 where as in India this rate is more than $80.

A vast majority of the people, especially in rural areas are left outside the insurance coverage. This mainly results from the awareness level among people. A large number of the people do not have the minimum idea about insurance. In other words, the negative attitude from the people is preventing them from opting for insurance coverage.

Most of the insurance companies in our country are located in urban areas and there are only a few branches in rural areas. They apparently do not consider the fact that the majority of our population reside in rural areas. So this centralization policy acts as an obstruction for the growth of insurance business in our country.

Lack of financial literacy adversely affects the marketing of insurance. About 70 per cent of the population is floating in the sea of ignorance, when it comes to insurance. Lack of financial literacy leads one to think that insurance is some sort of deception, it is of no value in life and they do not know what is insurance and what its importance is as security for future.

Many insurance agents are not skilled enough. These agents cannot perform their jobs properly to make the people aware of the benefits of life insurance.

The insurance companies are facing higher cost of business nowadays. They say that government tax, house rent, utility bills, commission fees, stationeries costs are growing day by day. But their business is not growing at that rate. Most of the insurance companies of our country are facing financial problems. Recently, the government is trying to take initiatives to close some of the insurance companies because they are not maintaining the minimum standard. For poor financial condition the insurance companies are also unable to increase the number of their branches which is a barrier for the growth of insurance business in Bangladesh. Many people of Bangladesh have a very small saving potentiality and have little or no disposable income. Their income may not deem to be sufficient for the payment of premium. So this factor discourages them to buy life insurance policies.

Lack of surveillance from relevant government ministries encourages many insurance companies to adopt unethical practices like harassing policy holders and tampering with the financial statements. Sometimes, the government imposes some conflicting rules and regulations without discussing with insurance companies’ regulating body. It creates conflict between insurance companies and the government and this in one of the main hindrances regarding boosting insurance business.

To take an insurance policy there are a great number of rules and regulations which must be adhered to by the insured person. This rules and regulations are full of complexities. So the people are often discouraged to take an insurance policy.

Almost all the insurers and policy holders have reservations about the licensing system for insurance companies. They identified it as a major hurdle faced by new insurance businesses. The government does not evaluate their documents of application with due consideration and unnecessary delays of approval.

Bangladesh is one of the fastest growing economies in South Asia with an ever expanding GDP. However insurance penetration (0.59) has not grown in line with GDP growth and it is one of the lowest in global emerging economies. In line with the government’s vision of driving insurance penetration in the country, the insurance regulator IDRA (Insurance Development and Regulatory Authority) of Bangladesh aims to develop the insurance market in Bangladesh by addressing root level issues. As well as the problems mentioned above, there are many good signs for the insurance business in Bangladesh. The GDP of our country is resulting in increase of per capita income. So this growing GDP and income holds bright prospects for insurance companies.

There are so many new businesses starting every day and the manufacturing sector is booming with global demand. There is a big opportunity lying ahead for the insurance companies as the population of our country is increasing day by day. This growth of population opens greater scope for every kind of insurance business. And that results in growing prospect for insurance companies.

Micro insurance can be a great prospective area for the insurance business in our country. Most of the people in our country are unable to have costly and long term insurance policies. Micro insurance can be provided to individuals small business owners against low insurance premiums with easy terms and conditions.

Nowadays, along with traditional insurance services companies can offer various non-traditional insurance services to their customer. Target market of insurance company may expand and they can offer different types of non- traditional insurance services such as health insurance, personal accident insurance, travel insurance, burglary insurance and pension schemes.

Insurance companies can usually make profit from investment activities than from their regular insurance business. The private insurance companies are realising this fact and planning their future role in the financial market. They are making large investments in government bonds, ICB projects and in private sector business.

Insurance is not just a tool of risk coverage. It is also an attractive way of savings. The mixture of risk coverage with savings gives the opportunity for innovative product designing which means service diversification. In a dynamic insurance market one can expect to see new products being promoted at regular intervals.

Sadharan Bima Corporation (SBC) has long been the sole reinsurer in Bangladesh and private insurance companies were legally obliged to place 100 per cent of their reinsurance business with SBC. In 1990 the government amended the relevant provisions of the Insurance Act allowing 50 per cent of all reinsurance of general insurance business to be placed compulsorily with SBC and the rest to private locally companies. About 70 per cent of premium income from general insurance business in Bangladesh in retention reinsurance and the rest 30 per cent goes in to reinsurers abroad. Permissions to private insurance companies to act as reinsures will open up new opportunities to them.

The economy of Bangladesh is predominantly an agrarian one, with a huge number of people engaged in farming and fishing. The uncertainty of agriculture due to crop failure caused by climate variation, drought, cyclone and flood affects farmers’ income as well as government revenue. Various agriculture insurance services are becoming common these days. Demand for insurance protection against crop loans, livestock loans, fisheries loans and equipment loans are also increasing day by day.

Nowadays in Bangladesh the SME sector plays an important role in economic development. But they are deprived from taking large amount of loans from banks. If insurance business focuses on this sector in Bangladesh they are able to contribute more to the economy. Thus insurance business has a bright prospect in business sector in a developing country like Bangladesh.

Insurance is very important to the business sector and also for individual citizens. Most of the companies provide more or less the same services. For this reasons competition is increasing day by day between the insurance companies. At present a company cannot be established properly without developing a high-tech information technology infrastructure. People search their desired requirement through the internet. So, insurance companies need to develop internet visibility to increase both foreign and local investors.

Recently IDRA (Insurance development and Regulatory Authority) circulated some rules and regulations to ensure the transparency, accountability, accuracy and compliance of all government and private sector insurance companies. It is hoped that these measures will bring positive changes in the sector.

The writer is Director, Insurance Development and Regulatory Authority of Bangladesh.

He can be contacted at [email protected]

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Poblems and prospects of insurance business in bangldesh

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Bangladesh’s insurance industry outlook for 2021

Ala ahmad general manager metlife bangladesh.

As a whole, 2020 was characterized by uncertainty and challenges. However, every organization did not react in the same way to survive in the rapidly changed circumstances. While some industries experienced an unfavorable impact, others found new avenues of growth. The pandemic gave communities and businesses an impetus to innovate and rethink on how they operate. Across the world and in Bangladesh, companies have found new ways to deliver for customers by upgrading their infrastructure and operations, and by offering new services and ways to connect.

Bangladesh is rising against all the obstacles like it did many times in the past. The economy is beginning to show signs of recovery. The Government is taking active steps in all sectors including health, infrastructure and finance to sustain our previous growth momentum.

The pandemic has brought greater focus on people's health, the need for financial protection and the tools that enable this - including insurance. Bangladesh's life insurance penetration stands at only 0.5 percent, well behind the average of 3.3 percent of the emerging markets. This means that most of the Bangladeshis are living uninsured. The situation warrants insurers to take active steps to close the gap and help people access the financial protection they need.

In recent years, both the regulator and the Government have been driving several encouraging initiatives to strengthen confidence and create awareness about insurance among the population. 2020 also marked the celebration of first-ever National Insurance Day which paved the way for all the insurance providers and the regulator to join in bringing more people under the protection of insurance.

As we celebrate Bangladesh's 50th anniversary of independence in 2021, I am sure we will see even more collaboration to realize the insurance industry's potential.

In addition to this, several factors will be crucial in sustaining the sector's growth opportunities in 2021:

Paying close attention to changing consumer behavior

Insurance industry's interaction with customers has long been characterized as transactional and sporadic. However, we must change this to become proactive in understanding customer emotions and the drivers which influence their financial decision making. Covid-19 has marked an era defined by uncertainty and lack of safety. But humanity has always survived with empathy, hope and optimism. These will persist as we navigate our lives in the new normal. Insurers need to understand how people's behaviors are impacted. They also need to predict how this will change in the future.

Contrary to the popular belief, it is hope and optimism – not fear – that often influence the purchase of insurance. Customers consider life insurance or financial protection from a place of hope. Highly positive consumers are more likely to consider purchasing new or additional insurance for themselves or their family members. That means that they also expect complete honesty and transparency from their financial service providers in mitigating uncertainty. Greater awareness about financial planning tools will help customers find the right financial product and service provider.

Focusing on health, safety and convenience

If there is a time when collectively everyone is thinking about safety and convenience, that time is now. As a result, safety concerns are taking precedence in customer decisions. This has also propelled faster adoption of digital technologies. Traditionally, insurance businesses relied on face-to-face interactions in selling insurance policies. However, both customers and insurers are quickly getting used to contactless, digital ways of purchasing and maintaining policies.

While Covid-19 has diminished face-to-face contact, the agent relationship is still critical to building confidence in our customers' purchasing decisions. Insurers need to keep working to identify areas where digitalization can better enable hassle-free interaction between customers and agents.

The ongoing pandemic is further reinforcing people's focus on their health and wellbeing. 2021 will likely see a rapid rise in digital health services. Insurers should incorporate value-added services into their offering that move them from being a reimbursement provider to a more holistic partner. We can see encouraging developments as organizations are utilizing digital healthcare services such as telemedicine and personal wellbeing management to create a unique value proposition for their customers.

Promoting insurance education for the young

One of the success factors for Bangladesh's tremendous economic growth is its young population. With the population median age being just 27.6 years, a large group of young people are ideally positioned to take advantage of financial protection tools like insurance as they take their lives in diverse directions.

At a young age, the premium may also be less compared to a more matured age, making it easier to buy and continue life insurance policies. Insurers need to understand the power of these young individuals and rethink how they can be made more aware of the financial alternatives including insurance for their financial planning.

Moving forward

There is no doubt that 2020 has been tough for everyone. It is easy to be discouraged at these times, but understanding the challenges is the first step to weathering them. Businesses that are open to changes and that turn ideas into action faster will stay relevant to the market.

This means insurers will need to be more customer-centric to understand and respond to the fast-changing needs of customers. They also need to initiate new dialogues with customers, employees, and their communities to address and react to wider issues. Looking ahead, some uncertainties in the global and local economy are likely to remain but we believe organizations including insurers who can turn these challenges into opportunities of reinvention and transform will thrive in the new normal.

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Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions

Taufique joarder.

1 Bangladesh Office, FHI 360, Dhaka 1213, Bangladesh

Tahrim Z. Chaudhury

2 Bangladesh Country Office, Save the Children, Dhaka 1212, Bangladesh

Ishtiaq Mannan

Associated data.

The qualitative data used to support the findings of this study are included within the article and the supplementary information file. The transcripts are available from the corresponding author upon request.

Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most of health indicators across social, economic, and demographic parameters. This study explores the existing health policy environment and current activities to further the progress towards Universal Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes: activities around UHC, implementation barriers, suggestions) was done using the manual coding technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health services for all, expansion of access to primary health care services (support by donors), and the piloting of health insurance which has been piloted in three sub districts. Political commitment for these areas is strong. However, there are barriers pertaining to the larger policy level which includes a rigid public financing structure dating from the colonial era. While others pertain to the health sector’s implementation shortfalls including issues of human resources, political interference, monitoring, and supervision, most key informants discussed demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of empowerment. To overcome these, several policies have been recommended, e.g., redesigning the public finance structure, improving governance and regulatory mechanism, specifying code of conduct for service providers, introducing health-financing reform, and collaborating with different sectors. To address the implementation barriers, recommendations include improving service quality, strengthening overall health systems, improving health service management, and improving monitoring and supervision. Addressing demand-side barriers, such as patient education and community empowerment, is also needed. Research and advocacy are required to address crosscutting barriers such as the lack of common understanding of UHC.

1. Introduction

Universal Health Coverage (UHC) implies that all people have access to quality health services they need, without financial hardship [ 1 ]UHC received a fresh momentum with the adoption of Sustainable Development Goals (SDG), the eighth target of the third goal of which states, “Achieve UHC, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all” [ 2 ].

The health system of Bangladesh is experiencing a double burden of diseases, low service coverage, and a lack of effective financial risk protection mechanism. Bangladesh has a pluralistic healthcare system, which is highly unregulated and consists mainly of four key actors: government, for-profit private sector, not-for-profit private sector (mainly the nongovernmental organizations [NGOs]), and the international development organizations [ 3 ]. Public healthcare is steered by the Ministry of Health and Family Welfare, through its different Directorate Generals: Health Services, Family Planning, Drug Administration, Nursing and Midwifery, Health Economics Unit, etc. [ 4 ]. Private healthcare encompasses for-profit private, not-for-profit private (mainly the NGOs), and informal providers (village doctors and other vast array of different unqualified providers). The public healthcare services are organized along four levels: community level healthcare (provided by the domiciliary health providers and community clinics), primary level healthcare (provided in Rural Health Centers, Union Subcenters, Union Family Welfare Centers, and Upazila Health Complexes), secondary level healthcare (provided in District Hospitals, General Hospitals, Chest Disease Clinics, Tuberculosis Clinics, and Leprosy Hospitals), and tertiary level healthcare (provided in Post Graduate Medical Institutes, Specialized Healthcare Centers, Medical College Hospitals, and Infectious Disease Hospitals). The private sector also has health facilities ranging from individual doctors’ offices to high-end tertiary level international standard hospitals [ 4 ]. Public healthcare is highly subsidized by the government, with nominal payments required from patients, especially for the outpatient care. Health insurance, both national and private, is practically nonexistent. Health financing is underfunded; only 2.64 percent of gross domestic product (GDP) is spent on health, which is the lowest in the south Asia region [ 5 ]. Health financial coverage is so sparse that nine percent households face catastrophic health payment, 5.6 percent face impoverishment, and seven percent face distress financing (borrowing or selling household assets to finance healthcare costs) [ 6 ].

Equity in health is one of the central pillars for promoting UHC 7 According to the International Society for Equity in Health, “Equity is the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically” [ 8 ]. Unfortunately, out of pocket (OOP) contributions to health expenditure, one of the most inequitable sources of healthcare financing, in Bangladesh, are among the highest in the world with 67% 9 Quality of care, another important dimension of UHC, is highly questionable in the public sector [ 10 ]. This encourages people to resort to private sector healthcare, which is more expensive. Health expenditure in private health facilities is almost exclusively from OOP payments (93%) 11

The review of Bangladesh’s Demographic and Health Survey 2014 reveals inequity in most of the health indicators in terms of economic status, level of education, gender, location (urban vs. rural), and geography (divisions) [ 12 ]. Among fertility and family planning indicators, for example, marital age of first marriage is only 15.3 years in the lowest income quintile versus 17.6 years in the highest (national average 16.1 years). Mean ideal number of children is 2.4 among women with no education versus 2.0 among those with secondary or higher level of education (national average 2.2). Contraceptive prevalence rate (any method) is only 47.8% in Sylhet Division versus 69.8% in Rangpur (national average 62.4%). Percentage of unmet needs for family planning is 17.7 in the Sylhet Division versus 6.7 in Rangpur (national average 12.0).

Similar trends of inequity are observed in maternal and child health and nutrition indicators as well. For example, infant mortality rate is 35 per 1000 live births among the people of lowest income quintile, compared to only 14 among the highest income group. Antenatal care (ANC) coverage rate is highly inequitable in terms of all types of stratifications; for example, there are 14.7, 25.7, 37.6, and 37.8 percentage point differences between urban vs. rural, Khulna division vs. Sylhet division, completing secondary or higher education vs. no education, and highest vs. lowest income quintiles, respectively 12

The Bangladeshi Constitution commits to address inequalities in access to health in rural areas, and the country joined the global community in committing to achieve UHC by 2030 under the SDGs 13 However, there is no single route or ‘magic bullet’ to achieve UHC. While each country must decide its own path towards UHC based on the individual country contexts, all should draw on existing evidence and shared experience. Currently available evidences from Bangladesh on UHC mostly include quantitative household surveys on out of pocket expenditure [ 14 , 15 ], financial risk protection 6 15 – 17 ] and equity analysis [ 6 , 16 – 18 ]. The policy environment around UHC issues has been analyzed by very few studies, which includes an assessment of a set of proposed indicators related to UHC [ 19 , 20 ], and generic policy papers without description of methodology [ 21 , 22 ]. None of these papers systematically analyzed the UHC policy using qualitative research methods, involving the stakeholders. Therefore, in this study, the aim was to understand the existing health policy environment and current activities to further the progress towards UHC and the barriers or challenges faced in these endeavors. Suggestions by different stakeholders were also explored for an in-depth understanding of UHC.

2. Materials and Methods

This qualitative study, conducted between May and June 2017, involved document reviews and key informant interviews (KII). In order to understand the existing policy environment around UHC, we adopted the UHC Cube framework for data generation and analysis [ 1 ]. We explored the activities of different stakeholders in light of population coverage, access to services and financial protection dimensions. Then, we explored the policy, intervention-, and demand-side barriers pertaining to the three UHC dimensions. Inductively, we explored some barriers, which cut across all three levels. Finally, we explored the stakeholders’ perspective on how they want to address the barriers that they had identified.

Document reviews included published reports, guidelines, strategic documents, and policy documents. An initial list was prepared first, which was later supplemented by the information and suggestions from the informants of the KIIs. Reference tracking of published articles, consulted during the literature review, also contributed to the list.

KIIs were conducted using semistructured guidelines, supplemented by qualitative probing techniques. A tentative list of potential key informants was developed with consultation among the research team (a health systems researcher with experience in UHC related academic activities in Bangladesh, personnel from an international Nongovernmental Organization NGO involved in UHC advocacy, and a senior leader of an international NGO involved in implementing public health programs and health systems strengthening). The list was supplemented by snowball recruitment techniques as the interviews progressed.

Key informants were sampled purposively, aiming for maximum variation [ 23 ] in terms of their sectoral alignment. In total, 15 respondents were interviewed from different sectors, broadly categorized as follows:

Public sector (central level): 1
Public sector (district level): 5
Multilateral organization/donor: 2
NGO/implementation organization: 4
Academia/research: 2
Civil society (health journalist): 1

Interviews were conducted in the interviewees’ office, by two public health experts (one male and one female). The key informants were assured of strict anonymity regarding the content of their interviews. All the interviews were digitally recorded; however, they were provided the option of speaking ‘off the record’, should this be preferred. Manual note taking was also employed for all interviews in order to prevent the risk of data loss due to technical issues.

Although a key informant guideline was used for data generation, adequate probing was used to clarify the views expressed by the respondents. Follow-up questions were asked to ensure maximum and in-depth information. Each interview lasted between 25 and 45 minutes. The interview tool included questions on activities carried out by the respondent’s institution in light of UHC across the three dimensions of UHC: population coverage, access to services, financial protection [ 1 ], perceived barriers towards carrying out those activities, and suggestions to overcome those barriers.

Verbatim transcriptions were done by professional transcribers once the interviews had been finished. The transcripts were subsequently read carefully and matched with the records, to determine missing information. The thematic analysis of texts was done using manual coding. Texts were organized across three main themes: (1) activities around UHC, (2) barriers to implement UHC, and (3) suggestions to progress towards UHC. Appropriate quotations were extracted to substantiate the thematic analysis. Member checking was done through a seminar presentation with the key informants to ensure that their views are correctly and adequately reflected. To increase validity, the first and the second authors independently coded the dataset. The third author was involved where a third opinion was warranted to reach consensus or resolve controversial issues.

3.1. Policy Scan

The document review, aiming at understanding the existing policy environment, included 22 documents and a renowned journal’s special series on UHC issues in Bangladesh. Among the 22 documents, majority (n = 16) were published by different entities of the Government of Bangladesh (GoB), especially Ministry of Health and Family Welfare (MoHFW). The remaining were published by multi-lateral international organizations, civil society consortiums, and private academic and research organizations (complete list and findings in supplementary information file 1).

In order to address inequities and foster UHC, the GoB has taken several policy initiatives. Besides, various multilateral organizations, civil society consortiums, and academic and research organizations based in Bangladesh developed documents with policy directives for UHC in Bangladesh. We classified the GoB policy documents as follows: (1) overarching documents, not specific to the health sector; (2) overarching documents specific to the health sector, but not specific to health financing; (3) documents specifically related to health financing; and (4) documents not directly related to, but with implications for UHC (supplementary information file 1).

The most important policy document, specifically focusing on UHC in Bangladesh, is the ‘Health Care Financing Strategy 2012-2032: Expanding Social Protection for Health towards Universal Coverage’, published by the Health Economics Unit (HEU) of MoHFW [ 24 ]. Aligned with other important policy documents (e.g., National Health Policy 2011 [ 25 ], Health Population and Nutrition Sector Development Program (HPNSDP) 2011-2016 26 etc.), this strategy document acknowledged the importance of bringing more funds to the health sector and pooling the resources effectively. It summarized challenges of health financing in Bangladesh as (1) inadequate health financing; (2) inequity in health financing and utilization; and (3) inefficient use of existing resources. Designed to address the health-financing issues for the next 20 years, this document also proposed ways to combine funds from tax-based budgets with proposed social health protection schemes (including for the poor and the formal sector), existing community based and other prepayment schemes and donor funding to ensure financial protection against health expenditures for all segments of the population, starting with the poorest. It recognized the importance of and proposed collaboration with the for-profit and not-for-profit private sector, development partners, and the community people, to resolve the health-financing challenges. It proposed a gradual process to achieve universal coverage, starting from the poor and the formal sector (public, for-profit private, and not-for-profit private), progressively to remaining segments of the population by 2032.

Apart from this crucial document, a few other important policy documents provided important policy directions for UHC in Bangladesh. For example, the ‘Seventh Five-Year Plan Fiscal Year 2016-2020: Accelerating Growth, Empowering Citizens’ 26 expressed commitment to ensure that poor and marginalized people are able to access and utilize health services. Acknowledging the existing deficiency in per capita health expenditure, share of the national budget for health, quality of care and high OOP, it proposed a health-financing reform to address these issues. In light of these proposals, the ‘National Social Security Strategy of Bangladesh’ [ 27 ] suggested some specific reforms and action plans and listed relevant ministries to collaborate with. It expressed the commitment of the GoB to introduce a national health insurance scheme. These reforms require budgetary allocation, the insufficiency of which has been recognized by the ‘National Health Policy’. It not only recommended increasing the allocation but also proposed ensuring equitable care for the disadvantaged, poor, marginalized, elderly, and the disabled population. In alignment with National Health Policy’s recommendations, the ‘Health Population and Nutrition Sector Strategic Plan 2011 – 2016’ [ 27 ] dedicated a chapter on ‘health sector financing’, where it proposed a health-financing framework, advocated demand-side financing, and proposed a resource allocation formula. The ‘Health Nutrition and Population Strategic Investment Plan 2016-2021’ [ 27 ] identified 10 driving forces, the final one of which suggested greater investment in health, ensuring a focus on managing demand, increasing efficiency, and developing the evidence base for future health funding. It also identified Essential Service Package (ESP) as the first milestone on the road to UHC. It proposed three guiding principles for attaining UHC: quality, equity, and efficiency across health services. Apart from these government documents, many nongovernment ones, such as ‘Bangladesh Health Watch Report 2011: Moving Towards Universal Health Coverage’ [ 28 ], and ‘The Path to Universal Health Care in Bangladesh: Bridging the Gap of Human Resources for Health’ [ 29 ], advocated for creating greater demand for UHC and quality primary health care (PHC) among the community through support from the civil society.

3.2. Current Activities towards UHC in Bangladesh

The information presented in this section has been obtained through both document reviews and the key informant interviews.

Public Sector. ESP has been identified as the basis for UHC activities in public sector of Bangladesh. ESP is currently in the process of implementation, even at the lowest unit of health service delivery facility, the Community Clinic (CC) level. A pilot health-financing scheme, Shasthyo Suroksha Karmasuchi (SSK), has been introduced by HEU in three upazilas (Kalihati, Ghatail, and Madhupur) of Tangail District [ 30 ]. Initially, the below-poverty population has been included in the scheme (includes treatment for 50+ disease conditions) with the government paying for their premium; the above-poverty population is also intended for gradual inclusion in the scheme.

At the district or implementation level, information and communication technologies (ICT) are used extensively to improve population coverage. Services are delivered through health centers as well as through household visits. Social and behavioral change communications (SBCC) and Expanded Program on Immunization (EPI) activities are carried out as preventive measures. Curative programs include Integrated Management of Childhood Illnesses (IMCI), maternal and neonatal health activities, demand-side financing programs (DSF) with vouchers, Emergency Obstetric Care (EOC), and indoor and outdoor services, in most areas, if not all. The family planning directorate of the MoHFW is also engaged in sexual and reproductive health care, in addition to their role in family planning. The government has started shifting focus from just quantity to the quality of services as well. Medicines are given free of cost from health centers, which reduces the financial burden of the patients to some extent.

NGO Sector. NGOs are mainly engaged in increasing service coverage and that with service quality. In terms of service coverage, their emphasis is on newborn health, maternal health, nutrition, health system strengthening, etc. at the PHC level. In terms of population coverage, their main focus is towards the hard-to-reach areas and the population therein. They are focusing on community engagement and SBCC activities, which may go a long way to demand generation among the population for UHC and also decrease the financial burden for curative caer. A respondent from an international NGO clarified this concept:

“If we strengthen the preventive care, if we strengthen the SBCC components, that actually is the best way to bring down the cost of treatment in future.”

They also advocate with the government for modifying policies, many of which directly or indirectly contribute to the UHC journey.

Multilaterals and Donors. Multilateral organizations, such as World Health Organization (WHO), are more into generating a common understanding on UHC among the stake-holders. They are also providing technical support to the government in implementing UHC. Generating information and strengthening the health system are their larger approach to contribute to UHC activities. Highlighting importance of multisectoral action for UHC, a representative of a multilateral organization remarked,

“It is a big area where our organization wants to work and make changes. We try to engage all the concerned ministries, often through dialogues.”

Donors supported the HEU in developing the Health Care Financing Strategy 2012-2032 and also its implementation [ 24 ]. Raising awareness and a common understanding on UHC has also been a main focus.

Academia and Research. Academia and research organizations’ role is to familiarize the concept of UHC to the relevant stakeholders. A professor of a school of public health remarked:

“We are trying to bring them (stakeholders) to the consensus, so that they are clear about what this (UHC) is, why is it necessary, what to do in order to achieve it, and how they all can contribute to this cause.”

They are organizing short courses to develop capacity, conduct research work on UHC related issues, and do policy advocacy through roundtable discussions, TV talk shows, etc. Research organizations are also involved in planning, monitoring, and evaluating GoB health programs relevant to UHC.

Media. The media is also involved, as expected, in awareness building about UHC, especially among the common mass. Media has been involved since the beginning of the UHC agenda in Bangladesh, starting from a grant from Rockefeller Foundation made to the quasigovernmental autonomous organization, Press Institute of Bangladesh (PIB). Journalists received training on UHC, are writing extensively on different aspects of UHC, and visited the SSK project. Some journalists even went to other countries (e.g., Thailand, Nepal, Bhutan, Philippines) on an exposure tour. A senior health journalist said:

“These exposure tours helped me develop an idea about what other countries are doing in terms of UHC. All I have been writing in newspapers, and what I am telling you now, are in light of these visits.”

PIB is regularly organizing training and orientation sessions for journalists, and TV talk shows on different aspects of the UHC agenda [ 31 ].

3.3. Barriers towards Achieving UHC in Bangladesh

The information presented in this section has been obtained through key informant interviews. The barriers to progress towards UHC can be felt at different levels. The barriers have been categorized across three levels, which are again crosscut by one important barrier, the lack of a shared understanding on UHC. The three levels are (1) larger policy-level barriers, often beyond the jurisdiction of health sector alone, (2) implementation barriers in health sector, and (3) demand-side barriers ( Figure 1 ).

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Barriers of implementing UHC in Bangladesh.

Larger Policy-Level Barriers (Health Sector and Beyond). Public financial management has been designed such that only health sector finance is very difficult to alter separately. Ministry of Finance needs to change all its mechanisms and rules of procedures for all other ministries, if it wants to do something for one particular ministry. Bangladesh has traditionally been practicing supply-side budgeting, whose changing is complicated, has crosscutting ramifications, and, therefore, demands much broader or revolutionary commitment for whole system change. An expert from an international NGO on health systems strengthening said

“This is the legacy of British colonial bureaucracy, which no one dares changing, despite how much they want.”

In tandem with the increase in economic activities in people’s lives, the size of the economy is increasing. Since the purchasing power of people is increasing, their health seeking behavior is changing consequently, culminating in higher healthcare cost. A government high official said

“People nowadays go quickly to the doctor, demands quick diagnostic tests, want to get cured soon. They are much more aware. Some of this is informed awareness, which is good. However, there are some ill-informed care-seeking, which are increasing the cost of care unduly.”

As a result of all of these, the overall healthcare expenditure is increasing, which requires more funding to address. Eventually, implementation of UHC is becoming progressively expensive. This is happening in the context of a country that chronically allocates least share of its national budget for health. On top of all these, health insurance, if we consider as a means to UHC, itself is resource intensive.

The regulatory mechanism is not adequately functioning to regulate the private sector. There is currently no such structure for functional mediatory mechanism, to resolve or mediate the complaints of the service seekers. Unqualified providers often continue harmful medical practices, capitalizing loopholes in the regulatory framework and its implementation.

In addition, there is deficiency in health systems governance and stewardship. Accountability and transparency are difficult to ensure in public sector, especially in the presence of a highly centralized system. One key informant from a multilateral organization said,

“With the very centralized system it is difficult for the managers to be able to act on the information or data they have. So, they don’t always make decisions for their community, for their catchment area– based on the local data.”

Implementation Barriers in Health Sector. Poor human resource management, including shortages, deficient training, low motivation, retention issues, skill-mix imbalance, and quality service provision is staggering. Recruitment mechanisms by Bangladesh Civil Service (BCS) are also criticized for taking too long to deploy physicians into vacant posts in time. Political interference is often adding insult to injury, as recruitment, retention, and disciplinary measures become difficult for managers to exercise. One local level government health official said

“There are some bad areas near Hobiganj, where I cannot retain any physician. As soon as I deploy someone, phones keep coming from the honorable minister, secretary, political leaders, Awami League (ruling party) secretary, petit leaders, so and-so, requesting not to keep his doctor there.”

The same bureaucrat also reflected on difficulties of disciplinary actions against his employees due to political interference:

“Yesterday, going to an Upazila Health Complex I discovered, the physician had not come to his duty on time. I asked him to show the causes of his absence. Since evening I had received at least 10 phone calls, vouching for him that he had genuine reasons to remain absent that day. If I tend to take disciplinary actions, they would say, ‘why are you making too much of it?”

Deficient monitoring mechanisms often exacerbate the shortage of human resources, as the existing service providers cannot be ensured to stay in their posted positions.

There is no agreed-upon protocol for treatment, referral, follow-up, and even general service management. As a result, uniform care with sufficient quality is difficult to provide. Lack of proper training of service providers results in lack of quality of care and responsiveness towards the service seekers. Since the service providers are trained in a certain way, convincing them to do it differently overnight is challenging. Implementers of SSK in three upazilas faced this problem, as reported by a key informant from the central level of the government:

“They (service providers in SSK facilities) are trained in a certain way. When we are giving direction to do something differently for the sake of the project, they are saying, ‘why should I do it like this?’ Now, no one is willing to go to those centers, despite those being close to Dhaka. Someone even told me, if he has to stay there, he would rather leave the job.”

Identifying and reaching the hard-to-reach areas and population is another challenge to achieve UHC. Bangladesh has several difficult geographical regions, e.g., char or newly emerged land-strip in the bank of rivers, coastal areas, hill tracts, tea garden, etc. There are minority population groups, in terms of religion, ethnicity, etc. Also, the socially excluded and economically marginalized population needs special attention. Due to persistent lack of flexible budgeting and local level planning, these population groups never get due attention. One key informant from an international NGO said

“Government’s system is that; they always do flat budgeting. They allocate the same budget for hilly tea gardens of Sylhet, as they do for flat areas of Rangpur.”

Apart from the above-mentioned barriers, some key informants pointed to the donor dependency and consequent compromise in autonomy of priority setting, lack of sufficient infrastructure, management shortfall, elusive collaboration and coordination mechanism, to name a few.

Demand-Side Barriers. There is a pervasive sociocultural barrier against insurance. Several key informants mentioned there is overall deficiency of trust in the society, due to historical and sociocultural reasons. According to one key informant from the government sector:

“Let alone trusting health insurance agency, we don’t even trust our relatives, when it comes to financial transactions.”

Due to the pervasive lack of societal trust, coupled with lack of historical precedence to insurance mechanisms, it is difficult to convince people to give their money to a pooled fund.

Another historically established perception among the people is that the government is solely responsible for health and that must be free of cost. People are not receptive to the idea of paying for government healthcare, be it in the form of prepayment or otherwise.

Lack of information on the available services is another demand-side barrier to UHC. Communities also lack awareness regarding their own entitlements. They are not empowered enough to hold the decision-makers and services providers responsible for providing UHC.

Crosscutting Barriers. A lack of common understanding among different stakeholders, both supply and demandside, has been identified by several key informants as an overarching barrier to UHC. According to key informants, different people perceive UHC differently; for example, some think UHC is just about insurance (including commercial health insurance), some think this is just a variant of the PHC movement, while some others consider any activity pertaining to health as UHC. One key informant from an academic institution said

“If you ask a government officer, he would say, ‘we already have UHC’; healthcare has been free in Upazila Health Complexes since ages. We provide all types of health service; we don’t need a new UHC.”

Key informants suggested that if stakeholders lack a shared understanding and are not sufficiently motivated as a result, it would be difficult to take the UHC movement forward.

3.4. Suggestions from the Stakeholders to Overcome the Barriers

The recommendations are drawn from respondents and have been aligned with the barriers to UHC, as mentioned before.

Suggestions to Address Larger Policy-Level Barriers (Health Sector and Beyond)

(1) Redesign the Public Financial Management. Bangladesh must invest in addressing inequalities in access to health services and reducing reliance on OOP payments if it is to achieve UHC by 2030. Bangladesh’s Heath Nutrition and Population Strategic Investment Plan 2016-2021 recognizes the importance of investing in a strong foundation for UHC through its commitment to delivering primary healthcare under the ESP as the first milestone on the road to universal coverage. However, in order to accommodate the flexibility in financing options, required for UHC, redesigning the traditional public financial management is recommended. It should be rearranged in a way to accommodate demand-side financing, projects like SSK, local level planning, and local authority for spending.

(2) Health Insurance and Health-Financing Reform. The government should consider introducing a national single payer system and increase coverage gradually to different population segments; starting with the formal sector as they are more informed and more empowered to reclaim their right. Bangladesh needs its own model for health financing, which warrants further research and experiments. Creation of a purchasing body and separation of providers from purchaser authority is needed. Innovative financing mechanisms, such as bringing corporate social responsibility (CSR) money, zakat money, and sin tax money into UHC should be considered. A senior health journalist suggested

“There is no such corporate house which doesn’t do CSR. They can give this fund for UHC; only government needs to take the initiative. Zakat is also similar to CSR. If the government makes a law that people should contribute their zakat fund to UHC, that’s enough. It’s easy to convince people that ‘you are rich, but someone among your poor neighbors is deprived of treatment and dying The government makes arrangement with the tobacco industry that, their money is going to different sectors; this must be earmarked for health sector only.”

(3) Improve Regulatory Framework and Mediatory Mechanisms . It should be done with the aim of decreasing cost of medicines and healthcare. Policy makers need not only develop protocols, but also ensure compliance to these. Private sector should be regulated for better management, improved quality, and reduced cost. Regulation and its implementation should ensure that there is no overcharging, exploitation of any form, unnecessary procedures and tests, and irrational use of antibiotics. There should be an oversight board, or a private sector coordination board, and/or a functioning mediatory body. Reflecting on the high cost of medicine, a key informant from the government said

“They (pharmaceuticals) justify their high cost by saying, ‘Show me which country is giving medicine in lower price? Even you go to neighboring India, the price is higher there too’. But they never say that we can give medicines with much less price.”

(4) Intersectoral Collaboration . Civil society needs to be consulted for optimization of UHC endeavor. A key informant from the leadership of an international NGO said

“There should be a civil society and government collaboration, where we (civil society) will monitor our (national) progress, keep a watch, engage in dialogues, and raise our voice from time to time. This is needed so that the government, or whoever is working (on UHC), stays on right track.”

There needs to be an institutional body or a coordinating body, involving all relevant ministries or sectors and developing a common pathway towards UHC. It is important to include nonstate actors in the UHC movement, in order to get their data and insights. NGOs should come forward to support the government with technical expertise they have. A key informant from an international NGO said

“Role of organizations like ours is to raise the technical voice for UHC, and give courage to the government, stay with the government. We are not here to make them (government) look bad, rather we are trying to make their achievements more sustainable.”

Professional associations of service providers and the media should also be collaborated with. Collaborations should be addressed in the policy explicitly. There should be a clear guideline regarding intersectoral collaboration.

(5) Political Commitment. Political commitment and a better buy-in on UHC are indispensable. This may be achieved by going to the political parties before election and convincing them to include UHC in their manifesto.

Suggestions to Address Implementation Barriers in Health Sector

(6) Health Systems Strengthening. Comprehensive improvement in all health systems building blocks, such as financing, governance, and human resources, should be planned and operationalized. With an aim of overall health systems strengthening, PHC services should be prioritized, and duplication of services (between public and private sector, health and family planning, etc.) must be avoided.

(7) Improve Health Service Management. Health service management, including human resource management, inventory management, facility management, financial management, needs to be further improved. Vacant positions need to be filled.

(8) Improve Monitoring and Supervision. In order to improve supervision, the managers should get more support from the government; e.g., they should get vehicles and communication cost, etc.

(9) Involve ICT. Government of Bangladesh has placed importance on the utilization of ICT in various sectors. Building on government’s commitment, health sector decision-makers also should use the ICT more to allow the hard-to-reach population to reach the services quickly and improve supervision and monitoring. Worth mentioning is the fact that the health sector has already achieved much success in this regard; however, further work is recommended.

(10) Improve Health Promotion and Disease Prevention. In regard to the importance of SBCC in achieving UHC, a key informant from a multilateral organization remarked:

“If we are able to provide good health promotion, prevention, and we are able to bring a change on the behavior of the people that could have a significant impact later on cost of the services so that we avoid expensive interventions.”

(11) Deciding on and Adhering to Quality Criteria. Strict criteria for quality of care should be set, and a directive should be passed that providers would receive payment only if they comply with an agreed treatment protocol and quality criteria. Functioning referral mechanism should be ensured, along with a defined referral protocol. These require improved capacity of service providers, which can be attained through proper training. The training should not be limited to technical aspect of care but rather should include training on responsiveness or patient-centered care and quality of care. An advisor to an international NGO said

“A physician should be psychologically prepared in medical colleges, where they stay for five years. Our curriculum lacks issues like what should be the appropriate attitude in the profession they (students) are going, what should be their behavior. . . .There should be a review of the medical curriculum to orient them about the environment where they would be working. These should be included in medical education, or if not possible, then at least in the orientation trainings.”

(12) Code of Conduct for Service Providers. There should be code of conduct for service providers, like physicians and nurses. These need to be developed in consultation with relevant stakeholders, including professional bodies of the respective professional groups, i.e., Bangladesh Medical Association (BMA), Bangladesh Diploma Nurses Association (BDNA), etc.

(13) Improve Efficiency. To best utilize the existing resources, technical and allocative efficiency should be ensured. Decision-makers should push for improved taxmanagement; managers should decide on priory expenditures. Costing analysis of all services is needed, which demands developing a costing unit under HEU.

(14) Special Attention to Hard-to-Reach Areas and Marginalized Populations. Special attention should be paid to hard to reach areas and the marginalized population. A key informant from the local level family planning directorate of the government said

“Ifa mother has five children, she tries to help out the weakest one. Similarly, we should identify the areas that are weak socioeconomically; and focus more from the policy perspective.”

(15) Decentralization. A policy reform for decentralization is needed. A key informant from an international NGO said

“Wherever we engaged local government, we were met with success. It is true for service utilization, reaching the hard to reach, inclusion of poor people – in all of these areas local government was very instrumental.”

Suggestions to Address Demand-Side Barriers

(16) Patient/Client Education. We need to inform people about UHC in order to generate demand for it. We need to improve health literacy of general population, which is not possible only by the health sector. Health literacy should be enhanced through the general education as well. Common people should know what services are available.

(17) Community Empowerment. Communities should know what they are entitled to and how to get the responsible persons accountable for their work.

Suggestions to Address Crosscutting Barriers

(18) Research. In order to improve our knowledge and under standing on UHC, particularly in the context of Bangladesh, further research is necessary. The research should address the current pattern of health care expenditure, equity status of health care, different models of healthcare financing, various other issues related to different aspects of health systems, relevant to UHC. A health systems practitioner from Sylhet said

“We need to identify why physicians are not going to the place where they are posted. If you give a physician posting to Sulla (a difficult place), why they don’t stay there? We need to understand that first. I have been there, I know, if you are posted there, you will feel like, you are not even in this country.”

(19) Advocacy. Based on research, policy best-practices, and multisectoral experiences, advocacy for UHC should continue.

4. Discussion

This study found that almost all relevant policy documents of GoB explicitly acknowledged the need for UHC and proposed some directives. Many policy directives have already been translated into actions, by the central and local level public sector, NGOs, multilateral organizations and donors, academic and research organizations, and the media, in alignment with the ESP. However, there are barriers towards achieving UHC. Some barriers pertain to larger policy level, often beyond the health sector, while others pertain to the health sector’s implementation underperformances. The issue of demand-side barriers has also been raised by most of the key informants. Some empirical suggestions have also been made by the real practitioners, to tackle the barriers towards UHC.

Rockefeller Foundation’s Transforming Health Systems funding program in 2010 was one of the first initiatives to jumpstart UHC activities in Bangladesh. This multipronged funding approach involved building capacity, generating evidence, improving health information system, involving the media, improving medical education, and raising awareness, which eventually contributed to the overall policy preparedness and buy-in by the government, as well as the relevant civil society [ 32 ]. This early momentum was supplemented by the Prime Minister Sheikh Hasina’s commitment to achieve UHC by 2032, which she declared in the 64 United Nations General Assembly in May 2011 [ 33 ]. These, supposedly, culminated into the policy level commitment of Bangladesh for UHC, as reflected in our study as well.

Despite commitment by the policy makers as well as its reflections in policy documents such as the Health Care Financing Strategy 2012-2032 and Communication Strategy for UHC 2014-2016, many barriers exist. The issue of rigid colonial-era public financial management structure has been mentioned as an important barrier to UHC. This issue has been relatively less discussed in the existing health policy literature of Bangladesh, except for a recent commentary by a high level health bureaucrat and colleagues [ 34 ]. Further research, especially garnering the views from the Ministry of Finance in this regard would be useful. The issues of governance shortfall are also under-researched, especially in the context of their role in UHC. The role of budgetary deficiency, which is 4.3% of the total budget in 2015-2016, has also been pointed out in other studies 6 Ahmed, Evans, Standing, and Mahmud [ 35 ] argued in favor of a strong regulatory and mediatory mechanism in Bangladesh, which is currently experiencing a rapid growth in private sector healthcare.

Implementation barriers, in relation to UHC, are relatively better represented in the health system literature from Bangladesh. Different aspects of health workforce crisis (e.g., absolute shortage, under performance, skill-mix imbalance, difficulty in rural retention, lack of responsiveness) have been widely documented by Ahmed, Hossain, Chowdhury, and Bhuiya [ 36 ], Rawal, Joarder, and Mahmud [ 37 ], and Joarder, George, Sarker, Ahmed, and Peters [ 38 ] among others. The World Bank commissioned a full-fledged study examining the human resources for health (HRH) issues related to UHC in Bangladesh, in which they identified the challenges, and proposed specific policy options 29 Lapse in monitoring and supervision, especially that in case of HRH, has been pointed out in other studies too [ 3 , 29 ]. Mehl and Labrique [ 39 ] suggested prioritizing integrated health strategies to improve the monitoring and evaluation, drawing upon examples from India and Bangladesh. The deficiency of quality of care in Bangladesh and the need for a guideline and commensurate training of the service providers have also been argued in many studies [ 40 – 44 ]. The need for flexible budgeting and local level planning too have been advocated in multiple policy documents and studies [ 3 , 28 , 34 ].

Studies on demand-side issues pertaining to UHC are available, but not abundant, like the ones pertaining to implementation issues mentioned above. Ahmed et al. [ 45 ] explored the willingness to pay for community based health insurance among informal workers in urban Bangladesh. 86.7% of the informal workers, such as the rickshaw pullers, restaurant workers, and shopkeepers expressed their willingness for such insurance. Joarder, Uddin, and Islam [ 46 ], in a mixed-methods study from rural Bangladesh, argued community empowerment to be a cornerstone of UHC and delineated the status of community empowerment in terms of access to information, inclusion and participation, ability to hold decision makers accountable, and local organizational capacity. They found 90% of the respondent had access to some sources of health information, but the other aspects of community empowerment were almost nonexistent. Trust in the health system has been argued to be an important factor to establish a prepayment based health-financing mechanism [ 47 ] and other aspects of service provision [ 48 – 51 ], which are essential for UHC. There is no research on historical mistrust and its relation to religiocultural disinclination of Bangladeshis towards prepayment-based health financing. Further research is needed to understand this phenomenon better.

In order to overcome these barriers, several policies and strategies have also been proposed. These include, but are not limited to, redesigning the public financial management structure, introducing health-financing reform, improving regulatory and mediatory mechanisms, embracing inter sectoral collaboration, and garnering political commitment for UHC. In order to address the implementation barriers, key informants proposed strengthening the overall health systems, improving the health service management, improving monitoring and supervision, adhering to service quality criteria, specifying code of conduct for service providers, etc. Patient education and community empowerment have been proposed to address the demand-side barriers. A need for research and advocacy has also been pronounced, to address the crosscutting barrier, i.e., lack of common understanding on UHC.

Despite sincere efforts from the researchers, the study had some limitations, such that the study could not achieve data saturation. We had to limit the number of respondents due to time and resource constraints. Due to the same reason, further variety in selection of stakeholder respondents could not be entertained. Of particular importance is the view of the Ministry of Finance (MoF), which is one of the most important stakeholders and decision makers in matters of financing for UHC. It is recommended that further research and advocacy involving the MoF stakeholders are undertaken. A detailed prospective policy analysis in favor of UHC is also highly recommended.

5. Conclusions

The policy environment in Bangladesh is primed for an all out progress towards UHC, especially owing to the commitment from the highest political level within the country. However, outdated public financial management structure, coupled with demand-side barriers (e.g., sociocultural disinclination, lack of citizen empowerment and demand) pose a serious threat to the timely realization of UHC goals and aspirations. Therefore, customized and context-specific policy adjustments need to be incorporated for progress towards UHC and subsequently achieving the pertinent SDGs. Having identified the challenges and potential solutions, it is believed that Bangladesh will accomplish its mission successfully towards equity and UHC.

Data Availability

The funders did not have any role in design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Supplementary Material

Acknowledgments.

We sincerely thank Md. Ashadul Islam, Honorable Secretary, Health Services Division, Ministry of Health and Family Welfare, for his outstanding leadership and support for the progress of Bangladesh towards Universal Health Coverage. Particular mention goes to the following Save the Children colleagues for their time, patience, advice, inputs, and logistical support: Shamim Jahan, Imteaz Mannan, Golam Mothabbir, Tara Brace-John, Gabrielle Szabo, and Taskin Rahman. Ayesha Afrin from International Center for Diarrheal Disease Research, Bangladesh (icddr,b) helped us with the data collection. We also acknowledge the respondents who spared their valuable time and shared their insights on Universal Health Coverage in Bangladesh. This research was completed as part of a Save the Children project to promote primary healthcare as a priority for achieving Universal Health Coverage, funded by the Bill and Melinda Gates Foundation.

Overall Insurance Company’s Problems and Prospects in Bangladesh.

Problem of Insurance Business in Bangladesh

In a developing country like Bangladesh, insurance companies are playing a very important role in the economy. Though insurance industry has very prospect in the economy but for some reasons it’s totally failed to achieve its goal. If we want to know the reasons behind this hen we should look forward the following according to Bangladesh General Insurance Company Ltd.In this report the major problems in performing insurance business has been classified into some major criteria which are social, economic, political, legal and other reasons.The actual problems are discussed in detail within these criterion’s

Social Problems

Less Public awareness

A vast majority of people especially in rural areas are left outside the insurance coverage. This mainly results from the unawareness among the people. Even a large portion of people don’t have the minimum idea of insurance. People are not aware of the benefits from the insurance policy and a great number of people believe that insurance business is nothing but cheating and assume that insurance policy is quite unnecessary. This negative attitude from the people is lessening the importance of absorbing insurance policy in a large extent.

Centralization

Most of the insurance companies in our country are located in urban areas and there are few branches in rural areas. They think that they might have better scope for performing their business as the economic condition of the urban is better than the rural areas. They don’t think that the large number of our population reside in rural areas and if branches are expanded in rural areas then the business can thrive if proper motivation policy is taken to aware the mass people of the rural areas. Thus this centralization policy acts as an obstruction for the growth of insurance business in our country.

Economic Problems

Poor economic conditions

Bangladesh is one of the poorest countries in the world and most of the people in this country live under extreme poverty level. All of these people fight hard to earn their livelihood and are marginal in relation to the expenditure with the income. It is quite impossible for them to save some money for future need. Therefore they are quite unable to give the amount to the insurer which is called as premium and regarded as safety or precautionary measures against any accident. The number of people who can bear the premium to the insurance company is very few in regard to those mentioned above. Therefore the overall poor economic condition is creating obstacle to flourish the insurance business in Bangladesh

Poor financial position of the insurance companies

Most of the insurance companies of our country are facing financial problems. Recently government is trying to take initiative to close some of the insurance companies because they are not maintaining the minimum standards. They are investing their money in poor securities and business which is vulnerable regarding getting back the money with profit. As a result most of the insurance companies are suffering from loss years after years and for poor financial condition the insurance companies are also unable to expand their branch which is a barrier for the growth of insurance business in Bangladesh.

Higher cost of business

Growing cost of business is another problem that insurance companies are facing now a day. They urge that government tax, house rent, utility, commission fee, stationeries are growing day by day. But their businesses are not growing so fast with that rate.Besides this the policy holders are not willing to pay too much premium with growing cost that is hampering the strategies of insurance companies. So they are facing difficulties in running their business efficiently.

Problems of economic bases and effective principle

Before independence insurance business was control by private company. But after independence maximum insurance company take over by the government. For that reason government changed the company management, policy and applies new rules and regulations which system was very tricky and uncomfortable for the mass people.

Political problems

Political instability

Political instability is a major problem in Bangladesh. For the instability in politics,many disruptive situations are often created which are bad for any businesses. The people who operate various businesses in our country often experience various types of inconvenience in running their business. Insurance business is not an exception of this. Political instability and inconsistency of political courses are a serious problem for the insurance business.

Lack of supervision from the government

Lack of surveillance from government ministry encourages many insurance companies to follow some unethical practices like make harassment to policy holder and showing less in the financial statement. This not only destroying the reputation of the well known insurance companies but also creates negative impact in the mind of the people about insurance. Besides this government sometimes impose some conflicting rules and regulation without discussing with insurance companies governing body. It creates conflict among insurance companies with government and act as one of the main hindrances of growing insurance business.

Problem of planning and administration

After the change of the government, the whole planning and administrative measures are changed which is the main constraint for long term plans. Without long term planning any permanent development or solution of existing problems are impossible

Legal Problems

Too much complexity

To take an insurance policy there are great number of rules and regulations which must be compelled by the insured person. And into those rules a vast number of complexities is present there. Therefore the people are discouraged to take insurance policy because they think that the complexities will create extra pressure on their mind which may hamper other jobs.

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COMMENTS

Insurance Industry in Bangladesh: Opportunities and Challenges
net premium of Bangladesh insurance companies was about Tk.24811.49 million. Of. this figure life insurance premiums constituted Tk.17685.12 million and general. insurance constituted Tk.7126.37 ...
(PDF) Insurance Industry in Bangladesh
insurance policy. The main constraint in the development of insurance industry. in Bangladesh is the lack of risk awareness, financial inability etc. In. Bangladesh, there is a greater degree of ...
PDF Financial Performance of General Insurance Companies in Bangladesh: A
From 2012 onwards, the industry's average net claim increased reaching a net worth of $ 3.3 million in 2018. The highest average growth rate of SBC was 107% in 2012. The average growth rate of the private insurance companies was, on average, higher till 2011.
present status of insurance sector in Bangladesh
A total of 60 insurance companies are operating in Bangladesh till date. Of these companies, 57 are private, two state-owned and one is foreign. Insurance Directorate, under the Ministry of Commerce, is the regulatory-body of the country's insurance sector. At present there are 44 general insurance companies running in Bangladesh.
Insurance in Bangladesh
Bangladesh Insurance Academy (BIA) established in 1973 in Dhaka by the government of Bangladesh to impart training to Insurance professionals and others taking up insurance as a career. It is an autonomous body attached to the ministry of commerce. The management of the academy is vested in a board of governors formed by the government.
PDF Potential for growth: Transforming Bangladesh's insurance sector
The region is set to represent a large share of overall life insurance premiums between 2016 and 2025, rising from 11.6% to 21.7% (see Figure 6).24. Bangladesh is poised to capture some of this growth. The country's economic growth has been on an upward trend, which bodes well for the insurance sector (see Figure 7).
A Brief Review of Crisis and Prospects in the Insurance Sector of
Abstract. In recent years, Bangladesh's insurance market has seen consistent expansion and interest. The industry has challenges besides that. This report reflects the insurance companies' views ...
Challenges, Prospects and Role of Insurance on Economic Growth in
Based on the secondary data, this research critically reviews the previous studies to find the contribution of insurance on economic growth and prospects as well as challenges of insurance sector in the context of Bangladesh. Insurance has significant contribution on economic growth of a country that facilitates to create a strong capital base ...
Assignmennt On Insurance in Bangladesh Work2
Assignmennt on insurance in bangladesh work2 - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. This document provides an overview of the insurance industry in Bangladesh. It discusses the characteristics of insurance, including risk sharing, cooperation, risk evaluation, contingency payments, and fortuitous losses.
Insurance Sector of Bangladesh Assignment
Insurance Sector of Bangladesh Assignment - Free download as PDF File (.pdf), Text File (.txt) or read online for free. This document described theInsurance Sector of Bangladesh
Insurance sector of bangladesh assignment
9 Before independence insurance. 10 Other problems Lack of. 11 Prospects of insurance. 12 Micro insurance Micro insurance. 13 Service diversification Insurance is. 14 better service to. 15 Claim Settlement: Claim. 16 References Ahmed, S.U. (1977): Insurance sector of bangladesh assignment - Download as a PDF or view online for free.
Insurance in Bangladesh assignment.docx
1 Introduction: This is the law of nature that people have to live and play with hazards and to some extent insurance policy can free people from those frustrations. Even if this is true, people of Bangladesh still don't prefer to insure themselves. One may think that the people of Bangladesh are risk lover; on the other hand other may contradict by saying that their low purchasing power ...
Paradigm of insurance companies in Bangladesh : myths & depths Ins
A strong recovery from the COVID-19 pandemic continued in 2022-23, although a recent surge in commodity prices, scarcity of dollar reserves prompting a new financial market crisis have presented new challenges for the government and the economy of Bangladesh. The insurance industry of Bangladesh also had a good start in the beginning of 2023.
Problems and prospects of insurance sector in Bangladesh
There are 79 insurance companies operating in Bangladesh. The population of the country is about 170 million and only 10 million people have life insurance policies. In non-life sector 79,754 small and medium enterprises are in operation out of which 93.6 per cent are small and 6.4 per cent are medium. According to the Bangladesh Road Transport ...
Challenges, Prospects and Role of Insurance on Economic Growth in
The present paper has attempted to critically describe the marketing of insurance in Bangladesh. For this study, 110 respondents have been interviewed which includes 10 insurers, 65 policy-holders ...
Poblems and prospects of insurance business in bangldesh
1.4 Scope of the Study There were huge scopes to work in the area of this Assignment. Considering the dead line, and exposure of the paper has been wide-ranging. ... Bangladesh Insurance Academy is providing training facilities and professional education to those engaged in insurance business in the country. The syllabus, curriculum and ...
Bangladesh's insurance industry outlook for 2021
The pandemic has brought greater focus on people's health, the need for financial protection and the tools that enable this - including insurance. Bangladesh's life insurance penetration stands at only 0.5 percent, well behind the average of 3.3 percent of the emerging markets. This means that most of the Bangladeshis are living uninsured.
Universal Health Coverage in Bangladesh: Activities, Challenges, and
We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health ...
Insurance in Bangladesh Assignment
Insurance in Bangladesh assignment - Free download as PDF File (.pdf), Text File (.txt) or read online for free.
PDF Challenges, Prospects and Role of Insurance on Economic Growth in
At present, 62 companies are operating in Bangladesh under Insurance Act 2010 and out of them 18 are life insurance companies including 1 foreign company and 1 are state-owned company and 44 ...
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Insurance Industry in Bangladesh. Assignment. The growth of insurance industry in Bangladesh has made a average progress in 2007. Per capita spending on insurance is still a lot less than $3 while insurance penetration, measured on premium as a percentage of GROSS DOMESTIC PRODUCT, also below 1%. The private market operators consolidated their ...
Problems and Prospects of General Insurance in Bangladesh
Prominent among them is the Bangladesh Insurance Association (formed on 25 May 1988) having 30 members. It aims at promoting, supporting and protecting the interests and welfare of the member companies. Another example is Bangladesh insurance academy. Surveyors and insurance agents occupy a prominent position in the insurance market of Bangladesh.
Overall Insurance Company's Problems and Prospects in Bangladesh
Higher GDP. The GDP of our country is increasing than the previous years which results in increase of per capital income. So this growing GDP and income holds bright prospects for insurance companies. The major problem is the incapability of our people to pay the premium charged by the insurance companies.