A growing rural healthcare sector that fails in quality

When he tripped and fell, Aminul Islam knew it was going to be bad. The pain was unbearable and he couldn't stand upright.

The 54-year-old from Noakhali's Begumganj first got treated for "torn ligament" at a local clinic where an orthopaedic doctor from Chattogram sees patients once a week.

Eventually Aminul had to come to Dhaka to see a specialist because his condition did not improve. Many consultations, a 7-day physical therapy session, and hotel stays later, he returned home cured. It cost him Tk30,000 plus the hassle of getting quality treatment.

"Had there been the therapy in Noakhali, both the costs and hassle could have been reduced," Aminul told The Business Standard.

"I am ready to pay for treatment, but the service should at least satisfy me. In the countryside, quality medical services are still not available even if you are willing to pay," he lamented.

With better road connectivity, education and rapid urbanisation, people in faraway districts and even villages are becoming increasingly aware of better medical and health services.

At the same time, better lifestyle and consumption patterns in rural areas have given rise to non-communicable diseases such as kidney and heart ailment, diabetes, high blood pressure, knee and back pain and it is becoming more common than ever, according to surveys.

This means the need for healthcare for rural people is now growing in scope. But rural public healthcare facilities – mainly 482 upazila health complexes – are falling behind this transformation.

Most of these hospitals are still understaffed and inadequately equipped – forcing people to seek treatment  at local private diagnostic centres, clinics and hospitals. Most often than not, patients needing critical care have to be moved to the capital.

The patient rush to Dhaka overwhelms the already saturated healthcare facilities in the capital, while shaky patient confidence and questionable service quality dog the local clinics.

Infographic: TBS

Chairs empty, machines out of order

The X-ray machine at Koyra Upazila Health Complex in Khulna has been out of order for the past five years. The ultrasound machine also does not work. The health complex has the posts for basic healthcare like paediatricians, gynaecologists, dentists and surgeons vacant for years.

Brahmanbaria's Bijoynagar Upazila Health Complex has no doctor for medicine, surgery, gynaecology and anaesthesia wings. The hospital, therefore, cannot even perform any minor surgery.

Although the hospital has X-ray and ultrasonography machines, those are useless to patients as the hospital does not have the technologists.

This is a common picture of most of the upazila health complexes across the country. According to the health directorate data, 58% of upazila hospitals have vacant physician's posts.

"Surgeries are performed only in a few of the upazila health complexes," Prof Dr Abdul Aziz, a member of parliament and also a member of the Parliamentary Standing Committee on Health and Family Welfare, told TBS.

The rural health facilities can only offer treatments for common cold, cough, fever and headache.

Health experts call for making the public health facilities at upazila and district levels better equipped, and keeping the rural private clinics well supervised.

This will take off some pressure on the secondary and tertiary hospitals in Dhaka and reduce the treatment cost and hassle for rural people, according to Prof Dr Muzaherul Huq, a former adviser to the World Health Organization's South Asia region.

"Rural patients are literally forced to go to nearby private clinics thanks to the lack of doctors, equipment and technologists at public hospitals. In many cases, they are deprived of quality services by the clinics despite paying steep medical bills," he told The Business Standard.

Cashing in on a medical vacuum

There are currently 7,854 registered private hospitals and clinics in the country, according to the health directorate. Almost each upazila has several private health facilities and diagnostic centres.

The number of private clinics, their growing business and out-of-pocket medical spending by patients are proof enough that entrepreneurs in the sector are filling in the healthcare vacuum in rural Bangladesh.

In Cumilla, there are more than 400 private hospitals and diagnostic centres. Of them, more than 200 are in Cumilla city, according to official data.

In Barishal district, every upazila has at least one clinic and three to four diagnostic centres that offer a wide range of medical tests round the clock.

Drugmakers shifting focus to rural areas

The healthcare blackhole compels many – mostly the lower-middle class and the poor – to rely on self-medication and getting even by-prescription-only drugs over-the-counter.

Drug market data show medicine consumption has been on a gradual rise in rural Bangladesh, prompting the drug-makers to shift their sales focus to rural pharmacies.

In Brahmanbaria, the number of drug stores has increased more than 10% in the past couple of years. In Satkhira district alone, there are 2,733 registered pharmacies, while Lakkhipur has more than 2,500 drug stores.

Md Fariduddin Kawsar Khan, managing director of Novo Healthcare and Pharma Ltd, said the consumer market for viral and infectious diseases, allergies and gastritis drugs are growing faster than in the urban areas.

But the sales profile is changing rapidly, as the demand for non-communicable disease drugs are now also high in rural areas.

The drug-maker said they have an efficient distribution channel covering all the areas of the country.

"Novo products available in Dhaka are also available in Nijhum Dwip or Saint Martin's Island," he told TBS.

It's possible to serve 70% patients at their doorsteps

If the rural hospitals have adequate doctors and are well-equipped, it is possible to treat 70% of the patients at their doorsteps, says a study conducted in May this year.

Currently, upazila hospitals don't have adequate service and people are not getting quality treatment, notes the study titled "Bangladesh health sector: present challenges and future guidelines".

It said if the grassroots-level hospitals can offer adequate and quality treatment, the patient load on Dhaka hospitals will be greatly reduced.

The report advocated health policy decentralisation, and making the upazila hospitals self-sufficient in diagnosis and treatment.

Health Secretary Dr Anwar Hossain Hawlader said they are inspecting the rural hospitals and making notes of their needs.

"We are now working on upgrading the hospitals in phases and maximising their services. Besides, some specialised hospitals are being built at divisional headquarters to reduce the pressure on Dhaka," he told TBS.

He also talked about intensifying monitoring of the private hospitals so that patients get quality services.

At a virtual programme with the upazila, district and divisional health facilities in November, Health Minister Zahid Maleque also said they have already inspected local hospitals in Rajshahi, Chattogram and Cumilla and will cover other regions gradually.

"In many cases, doctors were found absent and machines were out of order. This is the main crisis of public healthcare service in rural areas," the minister commented.

"Please update us if you have any vacant post or any machine not working," Zahid Maleque asked the hospital authorities.

TBS correspondents Awal Sheikh in Khulna, Tayubur Rahman Sohel in Cumilla, Sana Ullah Sanu in Lakshipur, Azizul Shonchay in Brahmanbaria, Sanjoy Sarker in Netrokona, and Akramul Islam in Satkhira contributed to this report.