Healthcare system needs total overhauling, decentralisation

Bangladesh's healthcare services trace back 48 years to the 1971 Liberation War. Bangladesh Hospital, also known as Bangladesh Field Hospital or Bangladesh Forces Hospital, was built as a makeshift facility which grew from a 30-bed camp to a 480-bed hospital in the Indian state of Tripura, and became the centre of treatment for freedom fighters as well as people living in refugee camps. Dr Zafrullah Chowdhury left his higher studies in medicine in the United Kingdom to organise the nation's first healthcare facility. In independent Bangladesh, he set up Gonoshasthaya Kendra, which means 'Peoples Health Centre,' with a mission to provide quality healthcare services at an affordable price to everyone, a mission he still pursues. Dr Zafrullah recalled his days in 1971 and voiced his thoughts on the present and future of healthcare services in Bangladesh in a conservation with The Business Standard on November 26, 2019. 

Since 1971, Bangladesh has made good progress in certain areas of the healthcare sector. If we look into these developments, we find they were not done mainly by the government, while doctors have the least contribution. The major contribution came from women's emancipation. In 1971, conservative Bangladeshi Muslim women came out of the home. The situation forced them to be on the street, in refugee camps in a foreign country. As a result, their vision expanded. They were looking at a wide horizon. They realised that they have to look after themselves. They cannot simply be dependent on the state.

Since then, healthcare became demystified because of the need of the day. In 1971, Dr Mobin [Dr MA Mobin, orthopaedic and trauma surgeon] and I left England to provide healthcare to freedom fighters and to refugees living in camps. We had only a few doctors and hardly any surgeons. Nurses were not available. People were afraid, they were not willing to come and work in refugee camps. In those days, Muslims did not think of nursing as a respectable profession. Hardly any Christian nurses left East Pakistan during the war, so we were in difficulty. When we set up the Bangladesh Field Hospital, we thought we could get British nurses. MAG Osmani [commander-in-chief of Bangladesh Forces in 1971] was in favour of this. But the then Prime Minister Tajuddin Ahmad said that would not be a wise decision as the country was at war. He advised looking for alternatives, and that forced us to think of other ways. We saw a large number of young girls and women sitting idle in the refugee camps. We thought why not train them. We trained them for two to four weeks and they became very good nurses, good helping hands. They all wanted to be guerrillas. They were all willing to go to war. But our commanders were not too willing to take them on as guerrilla fighters. We had plenty of boys and there was no need for girl recruits as well. That prompted us to recruit some of the girls from refugee camps. To our utter surprise, they become very good nurses, good healthcare providers just with two to four weeks training.

That was the beginning of healthcare for Bangladesh. The women healthcare providers also spread the philosophy of healthcare to the community quite easily. That is what primary healthcare should be. What you see today in Bangladesh had its beginning in 1971 from the Bangladesh Field Hospital. That was the beginning.

This is the contribution of people's awareness, availability of food and primary healthcare by women. Unfortunately, medical professionals did not rise to the occasion in the way they should have. They were not willing to go to rural areas. Our freedom struggle was for social justice, equality for all, and for democracy. Unfortunately, we have not achieved that goal. As a result, only the privileged class gets the opportunity to become doctors, to become engineers, to become… Our villages remain neglected.

Bangladesh is a fortunate country in the sense that we have upazila health complexes. We have almost 5,000 union health and family welfare centres. So physical structures are in place. We have deep tube-wells and electricity. The only thing missing is a boundary wall around most centres. Otherwise, it is a good place to live. But these facilities are underutilised. This is the failure of the government, of successive governments, I should say. Our first success was with training a large number of women on healthcare services. They in turn could train villagers and raise awareness. Bangladesh eradicated Smallpox because of these health workers who made sure that people got vaccinated. It is their contribution. Today Bangladesh's population is motivated. If you say they need to be vaccinated, they do not run away. They come in large numbers, and they bring their children with them.

But in the early '70's people would run away. They were afraid. So these are the changes we have made through our healthcare providers who are mostly women.

Another thing is education. Healthcare improved hand-in-hand with education. Basic primary education improved with better nutrition. We remember we had a famine in 1974. Today Bangladeshi people do not suffer from famines. They may not have adequate nutrition, but they do not starve. These are the positive sides.

But on the other side, we have got a new problem. As people now live longer, we have "old age" problems. Elderly people are not being looked after properly. As a large number of our people go abroad to find work, their parents and relatives get neglected. The state is not giving them enough thought. This is one of the things we should really think about.

Family planning is a thing we thought of even during and immediately after the war in 1971. I and my fellow colleagues had the privilege to see the country in-depth. We realised that this newly independent country has a very large population. So we started promoting family planning right from the beginning.

Gonoshasthaya Kendra introduced new family planning methods in Bangladesh, and trained young women on those new methods. It demystified healthcare and became an example for the world. Our article was made the lead article in the Lancet, the world's most prestigious medical journal. We introduced a policy for every health worker to carry and use blood pressure machines. Our medical professionals did not like it. They felt their tools were being taken away by the so-called 'illiterate' health workers. These were the real innovations in Bangladesh.

We also realised that people must have integrated healthcare: Preventive, curative, nutrition and family planning altogether. These were the things we introduced. Gonoshasthaya Kendra, was instrumental in promoting 'health for all' by WHO in 1977. It is our contribution and it was cited globally as an example of how healthcare can be improved. While doing that we also realised that for improved healthcare, people must have medicines at affordable prices. The most important contribution to this end was the national drug policy, which lowered drug prices to almost one-third. The quality of drugs was also improved.

But we still do not have a proper national health policy because of resistance by doctors and backtracking by the government. This government promised to put two doctors in every union health centre which caters to 15,000 people. If they had full-time doctors there, the healthcare service would have been much better. Unfortunately, the government backtracked on this.

The government also backtracked on the drug policy. As per the 1982 drug policy, all drug prices were to be monitored by the government. Drug prices must also be approved by the government. But today it is the company that decides the price. In 1982, 1700 medicines were cancelled because those were unnecessary and harmful. Today the price of only 117 medicines are controlled. The rest of the drugs are not regulated.

Another thing you see now is a change in the types of disease that affect people the most. In the 70s, 80s and 90s, the most common diseases were infectious ones such as diarrhoea, pneumonia and tuberculosis. But today the main diseases are non-communicable ones, such as hypertension, high blood pressure, diabetes, heart disease, cancer, kidney failure, etc. The treatment for all of these is very expensive. The Gonoshasthaya dialysis centre is the largest centre in the whole subcontinent, and also the cheapest. Even at this centre, people who need dialysis two to three times a week need to spend Tk20,000 every month, which is not easy. The government is not looking into that. We are asking for support from the government, but not getting any. But we do get support from philanthropists.

Also the country has some bad laws. The best treatment for kidney failure is kidney transplant. In many countries including the USA, the UK and Canada, and even Muslim countries like Saudi Arabia, anybody can donate organs, whether related or not related. But in Bangladesh, like Pakistan, donation is limited to close relatives. This does not make sense. The government is doing something illogical. Recently there was a court case awaiting judgement [The High Court on December 5 ruled that voluntary donors beyond certain relatives can donate kidneys, and ordered the government to amend in six months the Organ Transplantation Act which limits donation to near relatives]. The court asked seven specialists, all of whom said if organ donation is made free and non-related, then poor people will be cheated and deprived. But poor people are doing just that through the backdoor, and they are being cheated and deprived even more.

Take the Iranian model. Iran since 1988 made a provision that any healthy adult person can donate organs. You do not need to match it, you can donate your organ and someone will get it matched. My organ may not be a match for you, but may be a match for someone else. Anyone who donates an organ gets rewarded by the state. The rewards are both monetary and social. They are honoured in meetings and other occasions, offered seats in the front row. They get priority in treatment and in jobs. All these things have encouraged people to donate organs. Iran has become the only country in the world where there is no waiting list for kidney transplant. Anyone can come and get the organs they need to save a life.

Non-relatives can donate in America and in other countries. I think this is important because Bangladesh needs at least 10,000 transplants every year. Of them, only 2,000 get it done abroad, 200 or 250 do it in our country.  We have got a bad law that forces people to tell lies and to pay a lot of money for this essential treatment.  

My suggestions

Firstly, healthcare, though it is a commodity now in capitalist societies, cannot be left to the control of market forces. The government has to intervene. It has to really look into and fix the price, giving an adequate profit to manufacturers, to providers. As was done in 1982, the government should fix the profit margin and other things while setting prices of drugs, investigations and other health services. This will help improve healthcare tremendously.

Secondly, one thing is missing in the country. There is no good training centre for health professionals in specialised treatment. As I said, every year 40,000 to 45,000 people need kidney care. We are the only ones who can provide specialised training for kidney treatment. But the government has not approved our training yet. These are the anomalies.

We should reorganise our army medical services by incorporating the police hospitals and the prison hospitals with it. We have almost 90,000 prisoners. They have hospitals, but no doctors.

We have 250,000 police members who do not have a good healthcare system. I suggest police and prison healthcare services should be incorporated with the army medical services.

Thirdly, our medical education needs total re-hauling. Every student must spend three to four months in rural area – maybe one month every year – to know their country. Now urban youths are going to medical colleges. They need to be introduced to and become acquainted with the country. They need to overcome their fear of villages.

The government wanted to get interns to spend one year in rural areas. It should formally implement that plan.

Fourthly, recruitment of doctors and other healthcare professionals should be locally organised. Now everybody is recruited from Dhaka. As they are recruited from Dhaka, they give bribes and do other things [to get postings of their choice]. Building [of healthcare centres] is not enough, you need personnel. Availability of medicine is not enough as well. Qualified people must be there. What I am suggesting is decentralisation of the whole system – recruitment of doctors, administration and governance. Like other countries, there should be a local health authority to recruit their personnel. That will provide more attachment, and will create a sense of competition.

We usually say that if you get one doctor, you need 20 other service people including nurses, physiotherapists, technicians, biomedical engineers and microbiologists. You need more technicians than nurses. Also, our nursing education is very bad. They are not geared to giving care to the elderly, or taking old patients to the bathroom, washing them and doing other things for them. They even refuse to give them medicine. The main principle of nursing is to help. They have become officials now, so they are dependent on ayas. Ayas are not competent.

In short, our total healthcare system needs to be re-hauled immediately. It needs demystification. It needs local authorities. And people should be involved.