Stressed doctors and helpless patients: Bangladesh’s chaotic healthcare system

For more than a month, Bangladesh's healthcare system has been in disarray.

Deaths in hospitals, criminal charges against doctors and arrests, followed by physician's strikes demanding their release, have resulted in prolonged sufferings for patients in Bangladesh.

Many critical patients requiring immediate medical attention had to wait until the strike was called off Tuesday afternoon.

The turmoil began after a newborn died at Central Hospital on 10 June, which his father alleged happened because of negligence and wrong treatment. 

We saw another murder case in June against LabAid MD and five other doctors for the death of a teenager due to alleged wrong treatment.

These incidents have raised questions about the culture of hospital management in Bangladesh, the accountability of medical professionals, the rights and safety of patients, as well as the workload and rights of doctors.

While it is beyond question that Bangladeshi patients often face malpractice and have very few effective avenues to seeking recourse, criminal charges against medical professionals are deemed by most experts as excessively reactionary. Bringing for criminal charges also raises further complications about how and whether law enforcement are qualified.

Protection for patients

When it comes to allegations of medical negligence, the Directorate General of Health Services is responsible for addressing complaints against medical institutions, while the Bangladesh Medical and Dental Council (BMDC) investigates allegations against doctors.

Doctors, indeed, rarely ever face consequences for medical negligence in Bangladesh. The BMDC has only punished 14 doctors in its entire history, with only one doctor permanently losing their licence.

Contrast this with neighbouring India, where, every year, about 5.2 million cases of medical negligence are filed. The National Consumer Disputes Redressal Commission (NCDRC) of India awarded compensation in 135 of the 253 medical negligence complaints it reviewed from 2015 to 2019.

A BMDC official claimed that cases don't make headways because most people don't come up with proper documents while filing a complaint. But health experts believe people don't have confidence in BMDC, and that is why they instead file cases with the police. 

"Instead of ensuring people's interest, these professional bodies often look after their own interest," said Professor Dr Be-Nazir Ahmed, former Director of Disease Control at the Directorate General of Health Services. 

This often leads people to seek recourse through legal action. 

In the absence of laws directly dealing with medical negligence, patients usually resort to Section 304A, as well as Sections 336 to 338 of the Penal Code 1860, which deal with personal injury cases. Besides the 2009 Consumer Rights Protection Act also has provisions to safeguard the rights of the patients, by treating them as consumers. The aggrieved can also file cases in civil court for compensation for medical negligence.

"In most cases the doctors and patients' families resolve the issues by mediation," says Barrister Tahmidur Rahman, a lawyer who specialises in medical negligence cases.

These legal ambiguities and lack of public trust in professional bodies seem to have factored in the unfortunate arrests of the doctors that health experts and the physician community described as 'illegal' because the existing law 'doesn't allow the immediate arrest of doctors'.

"By charging murder cases against them, you are turning the doctors, nurses and the entire physician community as opponents," public health expert Dr Mushtaq Hussain said. 

Indeed, a patient's death is not necessarily a fault of a doctor. So doctors being arrested for the deaths of a patient might create a negative effect, as doctors, in general, will not want to treat critical patients in fear of being charged with murder in case the patient dies.

The route to mitigate the trouble here is investigating such issues with professional bodies. But the question is how professionals are these medical professional bodies? 

Dr Mushtaq also recommended forming a special tribunal to address such issues. "If there can be a money loan court, why not a special court to address medical issues?" he added.

The pressure on doctors

Bangladesh stands second from the bottom among the South Asian countries in the doctor-patient ratio. The World Health Organisation (WHO) says that there are only about 5.25 doctors per 10,000 populations in Bangladesh. 

This extremely low supply against massive demand is palpable in every hospital, whether government or private. From the capital's most sought-after hospitals for well-to-do families to the government hospitals and private facilities at Upazila levels, the hospitals are overcrowded. 

It is almost impossible for doctors here to provide adequate time to a single patient as that would mean many others might miss out on the treatment. 

Besides, the patients who consult with the doctors don't always have a clear idea about their disease because doctors here hardly communicate with patients well. 

This lack of communication doesn't only put the patients in the dark about their disease, it also creates mistrust between doctors, patients and their relatives, that sometimes results in enraged relatives endangering the doctors' safety. 

"If necessary the doctors should employ an assistant to explain the condition to patients or their relatives," Dr Mushtaq said. "The developed world has separate departments for communication that explain issues with patients or relatives. And if they are not happy with the explanation, they are instructed on the way to file complaints or sue…Not only that, it helps patients understand the condition. This way the doctors are also not misunderstood." 

How can the situation be remedied?

Dr Chowdhury H Ahsan, Chief of Medicine at University Medical Center, Las Vegas, while explaining the importance of medical accountability, oversight, and disseminating information to the patient about his condition, emphasised the necessity of 'rational fear' among physicians in a previous story. 

"Nobody is a saint. I work here. I am not a saint. But since there is regulation and oversight here, I have fear. This is a rational fear," Dr Chowdhury said. 

Healthcare specialists have long advocated for a category-wise arrangement of the hospital system where the community-driven first layer of hospitals will be followed by secondary hospitals that treat patients with long-term diseases like diabetics, blood pressure etc – if necessary by admitting them in intensive care for several days.

The community-driven hospitals would ensure reduced patient suffering as they don't have to rush to district, private or medical hospitals for everything. The outdoor services, in that case, could be community-based where patients would get services for free or at a token price.

The hospitals, especially the medical hospitals, should be for complex, critical cases and operations, according to the public health experts.  

In pursuit of proper management and service mentality 

Hospitals in Bangladesh are often managed by businessmen or doctors, instead of people with expertise in the relevant field. However, hospital management is a distinct and crucial field of expertise. Emphasising the importance of specialised knowledge in management can improve overall effectiveness and outcomes.

Relying solely on common sense for managerial roles can hinder the efficient utilisation of resources. Human resource management also faces challenges, as manpower deployment is not always based on scientific principles. Many individuals working in administrative roles within the health sector lack proper training. Consequently, this common-sense approach doesn't earn desirable outcomes. 

"Our size, both in regards to private and public hospitals, has increased. But their capacity hasn't increased," Dr Be-Nazir said. "The business side is always prioritised here…We lack in service mentality."

Healthcare experts believe that the environment would have been different if the mindset was to serve people. The cost wouldn't be so high, the patients were treated better, and the patients could be satisfied with the services. 

Dr Be-Nazir said, "Whatever we have, if we could bring them under an efficient management, our healthcare system could be developed."