National professor AK Azad Khan, president of the Bangladesh Diabetic Society, who headed the health sector reform commission, tells Sadiqur Rahman about the state of the health sector, issues of budget priorities, primary health care as a constitutional right, governance reforms, decentralisation, research culture and the imperative to reduce the out-of-pocket medical expenses in an interview with New Age
New Age: What is your long-term vision for the health sector?
AK Azad Khan: The aspiration is straightforward. Everyone should enjoy good health. There must be an effective system of disease prevention and when people fall ill, they must receive proper treatment. Health care is a fundamental right. A modern state must guarantee this right to its citizens.
New Age: Based on your observation of the health systems in developed countries, what level of service should Bangladesh realistically aim for?
AK Azad Khan: At the very least, every citizen should have access to prevention and treatment for common diseases. With the current level of medical knowledge, infrastructure and socio-economic capacity, this is achievable. We are not discussing unattainable ideals. We are discussing realistic standards that comparable countries have already achieved.
New Age: Why is not that happening?
AK Azad Khan: That can’t be answered in one sentence. The health system needs improvement. The budget needs to increase and that is not happening. Elections are approaching. No matter what we say or how much we criticise, we want politicians to run the state. We elect them in polls. So, we should ask them: if they are elected, how will they improve the health system? What will their party do for health sector reforms if they go to power? What is their plan?
Unfortunately, this discussion isn’t taking place in the current election because the health system has not truly been recognised as a fundamental right. The health budget is less than 1 per cent of the gross domestic product. The health sector reform commission has recommended an increase to 5 per cent of the gross domestic product. Before the report submission, the commission met political parties. They said that if they went to power, they would try to implement the recommendations. Journalists should ask these questions to the candidates who are contesting the elections. That will also create public awareness.
New Age: The commission report outlines what the interim government can do during its tenure and what the next elected government can do in the next two years. The interim government is nearing the end of its tenure.
AK Azad Khan: The commission recommended amending the constitution to recognise primary health care as a fundamental right so that the government is obliged to provide basic health care free. We said that primary health care, as defined by the World Health Organisation, should become a government responsibility and a citizen’s right. If that happens, about 95 per cent of the healthcare needs will be met. We also suggested that if this can’t be financed by the budget, a health levy could be introduced. A specific allocation for primary health care could be ensured through a health tax.
New Age: Such an important issue was not discussed in the national consensus commission nor was it included in the July national charter.
AK Azad Khan: I can’t say why that happened. As far as I know, health sector reform was not on the agenda of the national consensus commission. The health sector reform commission was not formed by the health ministry. It was formed directly by the Chief Adviser’s Office. We worked hard on the report and submitted it to him. He appreciated it and said that it was very practical. He instructed the health ministry to take steps for its early implementation. The health adviser and the health secretary were present at that time.
New Age: The report was submitted a long time ago. Have you seen the implementation in line with expectations?
AK Azad Khan: We haven’t been informed of what is happening internally. We have only been told that work on the report is under way. Such reforms can’t be completed in a single day. The government has to adopt the recommendations first and implementation will then follow. That is the essence of it.
New Age: What are the major recommendations of the health sector reform commission?
AK Azad Khan: Our central recommendation is the constitutional recognition of primary health care as a fundamental right. The government should be legally obliged to provide essential healthcare services free. We also proposed that the government should introduce a health levy or earmarked tax to finance primary healthcare services if the budgetary allocation is insufficient. This would ensure stable funding and reduce dependence on out-of-pocket payments.
New Age: Why is this recommendation particularly important?
AK Azad Khan: Because the out-of-pocket expenditure is extremely high. When people become seriously ill, they are often forced to sell land, livestock or other assets to pay for treatment. This pushes families into long-term poverty. In systems with universal or publicly funded health care, the risk is shared across society. Besides, the burden falls disproportionately on the poor and the lower-middle class. Recognising primary health care as a right would change the dynamics.
New Age: The commission also proposed major changes in the governance and management of the health sector. Would you explain?
AK Azad Khan: The current system is overly centralised and inefficient. The management authority is concentrated in Dhaka although Bangladesh has a population of more than 180 million. The health sector urgently needs decentralisation. We recommended decentralising healthcare management to the divisional level and large cities, with strong regional authorities responsible for recruitment and service delivery. We also proposed replacing the fragmented structure of ministry-directorate overlap with an independent health commission. Policy, regulation, recruitment and long-term planning should be handled by professional bodies rather than conventional administrative cadres. In addition, the recruitment for the health sector should be conducted through a dedicated health service commission to ensure transparency, merit-based selection and political impartiality.
Decentralisation allows resources to be allocated where they are most needed and improves the management of human resources. Physicians and medical college professors are now transferred frequently, often without regard to institutional continuity. This weakens hospitals and medical colleges. Bangladesh produces many physicians, but very few full-time academic researchers. Teaching, research and clinical service are poorly integrated. We recommended creating stable, full-time academic positions in medical colleges and universities, with competitive compensation and distinct career paths.
Countries with strong research institutions develop better clinical protocols, train better specialists and improve patient outcomes. Without this foundation, healthcare services become stagnant. Unfortunately, research is not considered important here. Almost everyone who completes postgraduate studies now wants to become a professor. However, completing a postgraduate degree does not automatically make one eligible to be a teacher or a professor. Medical service and medical science education should be treated as separate tracks, with distinct career paths. What does the term ‘professor’ mean? Philosophically, the concept refers to people who possess such depth of knowledge that they can profess for the future. Academic institutions must be able to attract talented and capable minds. We must recognise that advanced healthcare today depends not only on hospitals but also on continuous scientific work.
Globally, health care is moving towards prevention, early diagnosis and shorter hospital stays. Many procedures that once required weeks of hospitalisation are now done on a day-care basis. Bangladesh should adapt to this trend. We don’t need many tertiary-level hospitals in every district. Instead, we need fewer but high-quality referral hospitals, supported by strong primary and secondary care networks. Better transport and digital technology also mean that physical distance is less of a barrier than before.
Telemedicine and digital health are often mentioned as solutions for rural areas. One of the greatest challenges is to make qualified physicians stay in remote regions. Technology can help to bridge this gap. Telemedicine allows specialists to support local health workers, review cases and guide treatment without being physically present. Bangladesh must invest in this infrastructure. Ignoring technological changes would make our system obsolete within a decade.
New Age: Many patients still travel abroad for treatment. Why?
AK Azad Khan: There are two reasons: limited capacity in certain specialised fields and lack of public confidence. Treatment of some types, particularly of rare or highly complex diseases, is extremely expensive and not feasible to provide domestically at the highest global standard. That is understandable. But for many routine procedures, people still choose to go abroad because they don’t trust the quality of care at home. This reflects systemic weaknesses in regulation, accountability and service standards. Strengthening domestic healthcare services would reduce this outflow significantly.
New Age: The commission also proposed a structured referral system.
AK Azad Khan: A referral system cannot function in isolation. It must be part of a comprehensive primary healthcare package. If citizens are guaranteed basic services at local facilities and referred upward only when necessary, free, within the public system, tertiary hospitals can then focus on complex cases. Without universal primary care coverage, referral systems become meaningless.
New Age: What role should the interim government and the next elected government play?
AK Azad Khan: The interim government could have begun the legal and institutional groundwork, drafting constitutional amendments, designing financing mechanisms and initiating decentralisation pilots.
The elected government must adopt the full reform package, increase the allocation and implement changes in a gradual yet decisive manner. This requires will. Health reform can’t be achieved through administrative circulars alone. Citizens must demand health care as a right. Political parties should clearly state how much they will allocate to health and what reforms they will implement. Journalists also have a responsibility to keep this issue at the centre of public debates. It would have been good if the interim government had at least initiated preliminary steps for health sector reforms.
