The general practitioner (GP) system is the cornerstone of healthcare in many countries, providing individuals with their first point of contact for medical care. GPs are trained medical professionals who diagnose and treat various health conditions, from minor illnesses to chronic diseases, while emphasising preventive care through regular checkups, vaccinations, and health education. Acting as gatekeepers, GPs coordinate patient care, referring them to specialists when needed. Countries that have achieved universal health coverage—such as the UK, Australia, and Canada—rely heavily on GP systems to improve accessibility, ensure continuity of care, and enhance health outcomes.

Despite progress in Bangladesh's health sector, primary healthcare (PHC) remains inadequate, particularly in rural areas where access to qualified doctors is limited. Urban areas, on the other hand, lack a structured PHC delivery system, forcing citizens to rely on hospitals and informal healthcare providers. This leads to high out-of-pocket expenses.

UHC, which envisions accessible, affordable, and quality healthcare close to home, remains an elusive goal in Bangladesh. A well-structured GP system could take us one step ahead. It could revolutionise healthcare delivery by ensuring that every individual has access to a registered family doctor. A proposed GP model for Bangladesh would assign a medical team to every 5,000 people, led by a graduate doctor. Families would register with a GP team, with the flexibility to change providers every six months. GPs would be contractually appointed, with performance-based renewals tied to measurable outcomes like healthcare provision and patient satisfaction. Vulnerable populations would receive free or subsidised services, while emergency care, including ambulance services, would be universally free.

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Priorities for Bangladesh’s health sector

Under the system, the existing infrastructure, such as community clinics in rural areas, could minimise implementation costs. In urban areas, rented facilities could serve as GP centres. An integrated approach linking the GP system with the broader healthcare network would be essential for success. Public-private partnerships (PPPs) are essential for bridging gaps in the country's healthcare system. While current PPPs focus primarily on construction models, there is untapped potential in service-driven contracts, such as operation and maintenance, and greyfield upgrades.

However, the integration of the GP system into government structures requires a robust payment model. Salary-based systems may fail to motivate, whereas pay-for-performance or fee-for-service models incentivise quality. Bundled payments, capitation or global budgets offer flexibility, but payment models must prioritise comprehensive care, including promotion, prevention, treatment, and rehabilitation.

PPP agreements must include clear quality indicators. The private sector is adept at maximising profit; therefore, the government must skilfully set and enforce quality standards within contracts. Transparent performance reporting and strong monitoring frameworks are essential to maintaining accountability and ensuring that healthcare providers meet their obligations. The experience of integrating PPPs in other sectors offers valuable lessons for healthcare. By aligning community clinics, government structures, and private partnerships, Bangladesh can create a more equitable, efficient, and patient-centred healthcare system.

Even so, the financial viability of a GP system poses significant challenges. Bangladesh's low tax-to-GDP ratio, lack of social insurance frameworks, and predominantly informal workforce are major barriers. Global models, such as tax-based systems in the UK and Canada, performance-linked funding in Sweden and New Zealand, and mixed approaches like Singapore's, offer valuable lessons. Emerging economies like Rwanda and Thailand demonstrate the feasibility of community-based insurance and capitation-based funding for GP systems.

For Bangladesh, direct contributory mechanisms for the informal sector are impractical in the short term. Despite these challenges, several avenues could be explored, such as: i) redirecting unutilised funds within the health sector budget; ii) imposing targeted taxes on sugary beverages, luxury goods, and tobacco; iii) leveraging corporate social responsibility (CSR) funds; and iv) introducing minimal monthly charges or per-minute phone call fees. However, university students, formal workforce groups like garment workers, and other groups like bank account holders and microcredit beneficiaries, may be brought under compulsory health insurance schemes.

Bangladesh's COVID vaccination programme which successfully registered over 13 crore individuals using national identity cards (NIDs), highlights the potential for technology-driven healthcare solutions. A nationwide health card system could centralise patient data, enabling personalised, data-driven care. Additionally, artificial intelligence (AI) and the Internet of Things (IoT) could streamline healthcare processes by enabling real-time health data tracking, efficient referrals, and better care coordination.

The feasibility of these models has already been demonstrated through initiatives like UNICEF's Aalo Clinic programme in urban areas and Palli Karma-Sahayak Foundation's (PKSF) Samridhi programme in rural areas across Bangladesh. These examples highlight the scalability of the GP system in both rural and urban settings. By leveraging existing infrastructure, integrating advanced technology, and prioritising primary care, Bangladesh can build an equitable, efficient, and future-ready healthcare system.

Integrating the GP system into Bangladesh's broader healthcare infrastructure is a critical step toward achieving UHC. While it presents challenges, health experts generally agree that it is feasible with clear aspirations and a comprehensive, well-thought-out plan. Annual performance audits, based on defined quality metrics, will identify service gaps and areas for improvement, with public reporting enhancing transparency. A well-functioning complaint redress system will also be crucial for resolving patient grievances and maintaining satisfaction. It is important to avoid shortcuts and carefully consider the ground realities to prevent the common pitfalls that often arise during implementation.

The authors are members of UHC Forum and PPRC and experts in the health sector.

Views expressed in this article are the authors' own.

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