The government led by Prime Minister Tarique Rahman has, in recent months, rolled out a series of social protection instruments – from family cards to farmers’ cards – prompting some critics to label it a ‘government of cards.’ The phrase may resonate in political discourse, but it risks obscuring a far more substantive policy development: the proposed nationwide digital e-health card system. This initiative has the potential to become one of the most significant public health reforms in Bangladesh’s recent history. It could move the country closer to a long-standing aspiration – an equitable, accountable, and modern healthcare system capable of delivering services to all citizens, regardless of income or geography.
The need for such reform is undeniable. Bangladesh’s health sector continues to face deep structural challenges. Access to healthcare remains highly unequal, with stark disparities between urban and rural populations, as well as between income groups. Public spending on health, as a share of GDP, remains among the lowest in Asia. Most concerningly, out-of-pocket expenditure accounts for nearly 75 percent of total health spending – one of the highest rates globally. For millions of households, a serious illness is not only a medical emergency but also a financial catastrophe. Against this backdrop, the e-health card initiative appears both timely and necessary. But its success will depend far less on its announcement and far more on how it is sequenced, targeted, and governed.
At its core, the proposed system seeks to create a digital health platform that allows individuals to access their medical histories – including diagnostic reports, prescriptions, and treatment records – across different facilities. It also aims to facilitate access to free or subsidised care, reduce out-of-pocket costs, and improve transparency and accountability within the healthcare system. If implemented properly, these would not be any marginal improvements. Patients often carry paper-based records from one provider to another, undergo duplicate diagnostic tests, and receive treatment without continuity of care. This not only increases costs but also raises clinical risks. In this context, the e-health card represents more than a technological upgrade – it offers the prospect of structural transformation.
However, a central policy question remains insufficiently addressed: who should benefit first?
The government’s ambition is expansive, with plans to eventually cover all citizens and an initial rollout targeting between 50 lakh and 1 crore households. While universal health coverage is an appropriate long-term goal, practical constraints – fiscal space, administrative capacity, and service readiness – suggest that a phased and targeted approach would be more effective. Bangladesh remains a society marked by significant socio-economic disparities. Large segments of the population – particularly in rural areas, urban informal settlements, and marginalised communities – struggle to access even basic healthcare services. For them, healthcare is not a matter of convenience; it is often a matter of survival.
It is therefore both pragmatic and ethically imperative that the initial phase of the e-health card programme prioritises vulnerable populations. These include low-income households, elderly citizens without social protection, persons with disabilities, and individuals suffering from chronic or life-threatening conditions requiring ongoing treatment. Such prioritisation would serve several purposes. It would allow the system to be tested and refined before broader expansion, ensure that limited public resources are directed where they can have the greatest impact, and help build public trust by demonstrating early and tangible benefits.
Yet access to a card, in itself, does not guarantee access to care. One of the enduring weaknesses of Bangladesh’s health system is the uneven quality and capacity of public healthcare facilities, particularly outside major urban centres. If e-health card holders are effectively confined to under-resourced public institutions, the initiative may fail to deliver on its promise. This underscores the importance of engaging the private sector. Despite regulatory limitations, private providers account for a significant share of healthcare delivery in Bangladesh, especially in specialised services such as dialysis, oncology, and advanced diagnostics.
Financing will be another decisive factor. The commitment to increase health sector allocation to 5 percent of GDP is both ambitious and commendable. For decades, underinvestment has constrained the development of healthcare infrastructure, human resources, and service delivery. However, increasing allocation alone will not be sufficient. The efficiency and prioritisation of spending will be equally important. Redirecting resources from low-impact or non-productive sectors towards health and education would represent a strategic investment in the country’s long-term socioeconomic development.
Within the health sector, a stronger focus on primary healthcare and preventive services is essential. Such an approach can reduce the burden on tertiary facilities and lower overall system costs. Recent public health have exposed systemic weaknesses in planning, surveillance, and accountability. These failures of the past interim government led by Dr. Yunus have resulted in the ongoing measles outbreaks and avoidable loss of life, particularly unfortunate, untimely and preventable death of over two hundred children.
Technology alone cannot compensate for weaknesses in governance. The effectiveness of the e-health card initiative will depend heavily on institutional coordination – an area where challenges are already apparent.
The current administrative structure includes an unusually large number of ministers, state ministers, advisers, and special advisers across ministries, including the health sector. While this may bring diverse perspectives into policymaking, it also creates risks of fragmentation, overlapping responsibilities, and policy incoherence, resulting in poor service delivery.
Effective health sector reform requires clarity of leadership and unity of purpose. Without clear lines of authority, decision-making can become slow and inconsistent, undermining implementation. The e-health card initiative, by its very nature, requires coordination across multiple sectors – health, finance, information technology, and local government – and must be managed accordingly.
One practical solution would be the establishment of a dedicated, high-level implementation unit with clearly defined authority, timelines, and performance benchmarks. Such a mechanism could help ensure coherence, accountability, and timely delivery. Another critical issue is data security and privacy. A nationwide digital health database will contain sensitive personal information. Ensuring its protection is not only a technical requirement but also a matter of public trust. Strong legal frameworks and robust technological safeguards must be put in place to prevent misuse or breaches. Ultimately, the success of the e-health card system will depend on public confidence. Citizens must believe that the system will improve their access to care and that their personal information will be handled responsibly.
The introduction of e-health cards thus represents both an opportunity and a test. It offers a pathway towards universal health coverage, but only if it is grounded in realism and implemented with discipline. The government would do well to focus on a few key priorities: targeting vulnerable populations first, ensuring access to quality services, integrating private providers, securing sustainable financing, and strengthening institutional coordination. Attempting to do everything at once risks diluting impact and overwhelming administrative capacity.
If implemented thoughtfully, the e-health card could become a transformative reform – one that not only improves efficiency but also advances equity and social justice in healthcare. If not, it risks becoming another well-intentioned initiative that falls short in execution. The success of this policy will not be measured by the number of cards distributed, but by the number of lives improved and saved. What is required now is the political will, policy discipline, and institutional coherence to turn that aspiration into reality.
The writer is a Former Ambassador and Secretary, Ministry of Foreign Affairs; Former Senior Public Health Policy Adviser, WHO
