Lecture 11 - Privatisation and Politics: The Case of Healthcare in Bangladesh

Small ‘d’ development

development of capitalism as a geographically uneven, contradictory set of historical processes (Gillian Hart)

How should health be delivered? (3)

• state-based entitlements: rights-based

• charitable goods, based on need, NGO model

• market commodities, free-market, neoliberal-capitalist

Introduction of biomedicine in West Bengal

• surgeons arrived in first fleets, East India Company

  • aim to support colonists, men

• then female sex workers, still to protect men

• pregnant and childbearing women

  • support colonists, later to support workforce

• entry-point for Christian missionaries

• infrastructure abandoned post-independence

Health services in East vs West Pakistan

• 1959-1966, beds in public hospitals grew by 55% in West Pakistan and 15% in East Pakistan

• resources stayed in West Pakistan

• people did not look to the state for healthcare

1971: Liberation and Early Nation Building

• right to medical care included in constitution

  • socialism one of 4 constitutional pillars

• market-oriented transitions in Development

  • ‘free-market’ taken as best way to spur social and economic development

  • spear-headed by World Bank and IMF

  • SAPs to reduce state involvement

• went from health as a Human Right to health as an area of investment

• went from health care as social goods to health care as commodities

• donor recipient health care systems

  • acceptance of aid moved to market-centric

  • private health insurance schemes

  • state shifts from ‘provider’ to ‘regulator’

• in Bangladesh

  • one of the first to sign on for Structural Adjustment Programs

General Ershad

• 1980s

• removed subsidies, privatisation, etc.

• less impact in healthcare

  • already poorly invested in

  • little direct investment in private health care service delivery

  • weak regulatory frameworks

  • insurance schemes remained small

  • expansion of NGOs, partly as a way to delegitimise leftists

USAID Smiling Sun Project (7)

• introduced 2007

• assumes that the end goal of healthcare is profit -> not entirely state supported

• state completely absent from picture

• trying to draw people from public health system

• 2013 -> giving up on franchise model and cost recovery

• simultaneous growth of independent private health 

• today, 2x registered hospital beds in private sector compared to public sector 

Health Markets in Bangladesh

• influx of investment and resources in 1990s and 2000s

• transition towards commodities outside state/development

• little government investment, coordination, oversight

• superficial and outdated 1982 regulatory framework

• diverse (large corporate hospitals to ‘start-ups’)

Maternal Health in Bangladesh

• 2005 -> <10% of births in institutions

• 2010 -> 20% of births in institutions, more private

• 2017 -> 50% of births in institutions, >30% private, >30% c-sections

• 2022 -> >60% of births in institutions, >40% private, >40% c-sections

• stalling in maternal mortality 2010-2015

• almost all private facility births are via c-section

  • why? to maximise profit, portrayed as ‘women’s choice’

Ethicisation of privatisation

• an outgrowth of hegemonic neoliberal forces

• private maternal health services

  • largely supported by c-sections

Bhorosh Apa

• not waiting for the state

• public health services perceived as fragmented, unpredictable, failing to deliver care, ‘for the poor’

• dhormo: doing good via helping the poor

  • investing in private health as a good deed

• market logics no amoral or immoral -> integral and complex as service-oriented business