Background
The Constitution of Bangladesh made an obligation for the Government of Bangladesh to ensure good health for all its citizens. However, its average expenditure on health is little more than 1% of its gross domestic product [
1]. As a signatory of the Alma Ata Declaration (1978) Bangladesh adopted primary health care approach to deliver universal health coverage to its people. The global community observes greater commitment and resources for global health over the last 30 years after Alma Ata; however, the global commitment did not necessarily result in sustainable health improvements for the poor [
2]. In the low and middle income countries, there is a renewed interest in primary health care because of inequalities in health, inadequate progress towards the Millennium Development Goal (MDG) targets, shortage of human resources, and weak and fragmented health systems [
3]. Without strengthening of primary health care services significantly, the health-related MDGs will not be achieved in the most low-income countries by 2015 [
4]. In Bangladesh, given the current maternal mortality ratio of 322 per 100,000 [
5] and under-5 mortality rate of 65 per 1000 [
6], the role of primary health care service delivery is critical to achieving the health-related MDG goals by 2015 and beyond. Analysis of 30 low-income countries showed that over the period of 1990-2006, Bangladesh was able to achieve on average 4.8% yearly reduction in under-5 child mortality with a position 16
th compared to the first position of Thailand with 8.5% average yearly reduction in the same indicator [
7]. Case studies on Pakistan and Uganda showed that primary health care could make a significant difference to maternal, newborn and child health (MNCH) and mortality outcomes. So, based on the observed evidence, countries should prioritize primary health care to strengthen MNCH services in order to reach MDG targets reducing maternal and child mortality [
8] since MNCH is at the center of primary health care [
9].
With a population of 150 million, Bangladesh is the 7
th most populous country in the world. Sixty percent of health care services occur in the private sector [
10], however, an expansive network of primary, secondary and tertiary government health facilities exists. As of March 2010, 2506 non-government organizations (NGOs) [
11] are present in Bangladesh and out of them 48% big and 60% small NGOs [
12] are providing health care services in the rural, urban and semi-urban areas where government's services are inadequate. NGOs and private providers are doing better than the public sector providers both in the delivery of maternal and child health services (antenatal care: 53% vs. 44%) and institutional delivery (8% vs. 7%) [
6]. In fact, the NGO health facilities are substantiating government's program throughout the country. Among the NGOs in health sector, the Building Resources Across Community (BRAC) is a reputed provider in community-based direct service delivery. Just nine months after the inception of BRAC in the post-liberation war of Bangladesh, it initiated its health interventions through health care facilities. Along with other development interventions like education and microfinance programs BRAC always had preventive, promotional, curative and rehabilitative grassroots health programs in its community-based development programs. Reflecting on past experiences, BRAC restructured its health interventions in order to cope with the demands of national priorities and policies. Based on the experiences of past success, BRAC health program has evolved and responded to emerging national health problems. As a continuous commitment of investing in human capital development, BRAC opened static health facilities called
Shushastha (good health) in 1995 in order to serve as a back up to BRAC's existing community-based MNCH, tuberculosis and other health interventions through providing curative health services.
The
Shushastha is based on the philosophy of primary health care approach though it offers curative health services [
13]. The justification behind such an intervention originated from growing community demand for quality clinical services at minimum costs. BRAC community health workers found that community members did not have access to affordable and good quality medical services leaving them with little or no options for seeking health care services [
14]. The objective of establishing the BRAC
Shushastha was to develop a financially and programmatically sustainable model that provides clinical services for complicated and referral cases identified in the community. It provides antenatal care, simple delivery with obstetric care for emergency cases, postnatal care, family planning both clinical and non-clinical and other reproductive health services, including treatment of reproductive tract infections through both outpatient and inpatient services. It also provides pathology laboratory services and medicines. In 1995, the
Shushastha system was supported by a five-year grant and in 2000, BRAC developed a financial sustainability focused strategy through cost recovery. Later, BRAC was compelled to close some of the
Shushasthas due to lack of sustainability and hence cost recovery is an issue which is yet to be achieved.
In the discourse of financial sustainability and reducing donor dependency on critical service provisions and appropriate set service prices cost recovery is a major concern for any health facility. Despite the availability of general revenue for spending in health care the governments of developing countries are increasingly focusing on the cost recovery of the health facilities in order to mobilize more resources, improve equity and increase the efficiency of health facilities which, in fact, generated a huge debate over health financing policy and the cost effective primary health care in developing countries [
15]. It is a common view of policy makers in the health sector that cost recovery is a necessary component in improving the quality and financial sustainability of health services [
16]. Experience from Mauritania in early nineties also showed that cost recovery led to an increase in the amount of financial resources available in health facilities; contributed in the improvement of the quality of health care and the efficiency of the health systems provided fair supply of essential drugs and motivated staff [
17]. Evaluation of Niger's experience in the Integrated Management of Childhood Illness also showed that a cost recovery system succeeded in increasing the availability of essential drugs [
18]. The targeted BRAC health facility in this study is a primary health care facility and cost recovery is of much concern for its sustainability in providing quality, efficient and equitable services for the poor and the under privileged communities. These are important grounds to care about whether the facility does recover its costs sufficiently or not.
There are currently 48 Shushasthas, of which seven are upgraded facilities providing emergency obstetric care (EmOC), in 18 rural districts of Bangladesh. In the course of years it was observed that some complicated pregnancies could not be managed at the Shushasthas. Therefore, an upgraded Shushastha was planned in each district to offer EmOC and interlinked with a network of other Shushasthas. The study focused on cost recovery of an upgraded Shushastha, located at Gazipur, the district town next to the capital city, Dhaka. In fact, it is a 17-bed mini maternal and child health hospital, which provides both inpatient and outpatient services, including medicine and pathology services. Among the inpatient services, it mainly provides EmOC and other minor surgeries excluding ear, nose and throat, eye and orthopedics. For outpatients, the health facility mainly provides consultation, medicine and pathological services. It works as a community referral center and the BRAC community health workers, known as Shasthya Shebikas, usually refer the patients to this facility from the community. During the period of July 2004 - June 2005, this upgraded health facility employed three doctors, seven family welfare visitors (FWVs), two laboratory technicians (LTs), five traditional birth attendants (TBAs), a ward boy (WB), two cooks, a night guard and an accountant. Their average working hours per day is 12 hours. For caesarean surgery, there is no permanent anesthetists and they are usually hired from outside, on call. It has no nurses and the FWVs provide the services of nurses. This BRAC health facility has its own classifications of charges for the patients in terms of their socioeconomic conditions. At community level, BRAC program has village organizations (VOs) and the health facility charges VO members half the cost than that of non-VO members. For example, for outpatient consultations, VO members pay only Bangladeshi Taka (BDT.) 25 (= US$ 0.43) whereas the Non-VO members have to pay BDT. 50 (= US$ 0.86).
Earlier, several studies [
19‐
21] were conducted at the different level of public health and NGO facilities in Bangladesh in order to estimate the outpatient and inpatient services. One of the main limitations was that these studies estimated only recurrent costs and underestimated the unit costs of the health care services. Also it did not include drug costs considering the complicacy of its estimation [
21]. In the last several years, a significant number of costing studies were conducted in developing and developed countries as well and most of the studies highlighted issues of efficiency [
22‐
26]. This study estimated the cost recovery of a BRAC upgraded health facility, outlining its outpatient and inpatient services and, therefore, tried to explain its financial sustainability. This costing exercise has significant methodological implications for estimating the cost recovery ratio of primary health care facilities in the government, private and NGO sectors which, will assist them to become truly financially sustainable by reducing donor dependency, rendering the better quality and equitable services for the people.
Discussion
The cost recovery of a primary health care facility is of great concern for its financial sustainability and for providing quality, efficient and equitable health services to the community. In terms of cost recovery, IPD services contributed more than OPD services. Nearly, three-quarters of the total revenue came from the IPD services of the facility. The cesarean section is the most important revenue generating service among the IPD services while other services like normal delivery, D&C, MR, and outpatient consultations also played a significant role in increasing the overall cost recovery of the facility.
Increasing the efficiency of the health facility through controlling existing costs and optimizing the use of available resources is important for improved cost recovery. Among the existing cost categories, personnel costs were the highest, which was about one-third of the total costs of the facility. Although personnel cost was a large component for IPD and OPD services, the link between staff productivity and unit cost was not explored. The study also did not address the issue of efficiency. In fact, analysis was not done to figure out whether the numbers of health care providers at the facility were appropriate for the service volume of the facility. Time motion data was not available to find the amount that health care providers spent on unoccupied or personal activities. The effective and efficient utilization of personnel would positively affect the utilization of the health facility. It was also found that efficient use of unutilized time of the providers would help to reduce the costs of providing services [
31]. However, it can be recommended for the health facility that more efficient and effective personnel management may reduce the operational cost of the health facility.
Drugs were the second major component of all costs categories. Drug companies directly supplied the required drugs to the BRAC facility through their sales representatives. Compared to the government drug procurement system for primary health care facilities like sub-district level Upazila Health Complex (UHC) and Union Family Welfare Center, BRAC's health facilities enjoyed much more direct, functional, transparent and a quicker drug supply system. The government system always involves lengthy and complicated procedures for drug procurement. In the BRAC health facility, clear records of drug usage in the registry were maintained separately for IPD and OPD services, and there were no anomalies found in the drug registers examined. However, given the higher percentage of drug costs compared to other costs, it was anticipated that misuse of drugs may be the reason for higher drug costs. Further studies are needed to explore the underlying reasons. A lower pathology cost of the facility also supports this assumption. In order to minimize the gap in cost recovery, there is a need for efficient use of all supplies and utilities, including drugs, to prevent wastages.
In other words, given the high magnitude of variable costs, there might be scope to control variable costs and to maximize the cost recovery of the health facility. Specifically, the allocation of resources (personnel, supplies and operational costs) could be reviewed to reduce the variable costs of the facility.
This study offers an opportunity to compare the unit costs of BRAC health services to available service costs of the same kind. The unit cost of normal delivery at Rural Service Delivery Partnership (RSDP) supported NGO facilities was US$ 2.37 [
32] while it was US$ 5.72 [
33] at the Urban Family Health Partnership (UFHP) supported NGO facilities. The unit cost of normal delivery was US$ 2.17 - US$ 4.70 at the government primary health care facilities and US$ 9.04-10.13 in other NGO facilities [
29]. The unit cost of normal delivery at the BRAC facility was US$ 14 which seems quite higher than other available estimates. The unit cost of c-section at the government sub-district level UHC was US$ 6.71 while in other NGO facilities it was US$ 79.59 [
29]. The unit cost of c-section at the BRAC health facility was US$ 108. Although drugs and supplies were provided free of cost at the government facilities, BRAC's c-section cost was still higher. Annual average cost per patient of US$ 9.83 in our study was much higher than the projected cost per patient for maternal health of US$ 3.6 as part of the essential service package (ESP) of the public sector of Bangladesh [
34].
The constraint of using this study is the generalizabilty of its findings because it was conducted at a single facility and heath facilities may not have homogeneous cost components. It is too small to generalize its findings to the country as a whole although this BRAC health facility is a close representation of the government and other NGO primary health care facilities. The findings of this study need to be verified in a larger costing study. There is always a certain level of approximation and arbitrariness in various allocation keys in this costing methodology - an intrinsic limitation. The differences found between the cost recovery ratios estimated by this study and BRAC might be due to variation in methodology or may be for the specific reference year. However, the reasons for such variation need to be explored through further studies. Stratifying costs only by IPD and OPD and not by subservice categories creates a missed opportunity to consider which major sub-service categories incur the greatest cost and which could also guide understanding of price setting and profit margins. However, this study should be considered a significant initiative for measuring financial sustainability of primary health care facilities in Bangladesh and other developing country contexts.
Conclusion
This study gives us with the insights into the financial sustainability of an NGO primary health care facility in a developing country setting, through examination of costs, revenue and cost recovery status. The information on factors that contributed to variation of costs per patient or variation in terms of contribution of IPD and OPD services in cost recovery are critical to the operations of such health facilities. The gap found between costs and the cost recovery of the health facility needs to be explained carefully. At the same time, pragmatic mechanisms need to be developed to minimize this gap for sustainable health services. More specifically, a strategy should be developed to improve the efficiency of the facility. Program managers may look into ways of increasing facility utilization, maximizing use of staff and encouraging more rational use of drugs. Special emphasis should be placed on increasing utilization of IPD services by arranging additional IPD services.
This study can contribute to formulating macro level policy and health sector reform strategies in light of cost analysis and cost recovery of primary health care facilities. The findings can have implications for program budgeting, reducing donor dependency and also for the improvement of services. Planners use cost data in designing new health care interventions and this study may contribute to designing similar kinds health facilities for BRAC in other parts of the country. In the light of current maternal and child mortality scenario of Bangladesh, and addressing the challenges to meet health-related MDG targets by 2015, financially sustainable primary health care facilities are critical and this current study is certainly an important initiative in an under-researched area by providing estimates of cost recovery of an NGO primary health care facility. Despite the constraints in making the findings generalizable, the study has significant methodological implications in estimating the cost recovery ratios for the primary health facilities both in government and private sector including NGOs. Finally, it offers basis for undertaking cost-effectiveness or cost-benefit analysis for similar primary health care facilities.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
KA designed the study, analyzed the data, and wrote the manuscript. SA guided KA throughout the design, analysis and preparing and editing the manuscript. Both authors have read and approved the final manuscript.