[🇧🇩] Healthcare Industry in Bangladesh

Accessibility of healthcare in Bangladesh


While the public health infrastructure in rural areas is considerable, this infrastructure needs an upgrade for maintaining quality PHC services. FILE PHOTO: STAR

Health is a fundamental human right and all citizens, regardless of their socio-economic status, have the right to enjoy optimal health. This article emphasises on the issue of equity in health systems. It underlines the importance of a comprehensive multisectoral approach to improve the health system. Though Bangladesh has an adequate health infrastructure, a cause for concern is the uncontrolled growth in the private health sector. The challenge is to regulate the mushrooming private sector from exploitative cost of treatment. The aim is to ensure that the disadvantaged and vulnerable population have better access to basic healthcare without the current back-breaking cost.

The government needs strengthen the Primary Health Care (PHC) system in partnership with the NGO sector. The NGOs lead the way in community-based initiatives and outreach at the grassroots. Utilising the private sector is also a priority but needs coordination and regulation. At the macroeconomic level, initiatives need to be undertaken that nudge the Bangladesh Ministry of Health and Family Welfare (MOHFW) towards reform and the adoption of new evidence-based practices that strengthen the health information system.

While the public health infrastructure in rural areas is considerable, this infrastructure needs an upgrade for maintaining quality PHC services. The quality of services remains a major issue, areas that need urgent attention is lack of investment in facilities. There is also an imbalance between availability and placement of human resources in the healthcare system. Frequent staffing mismatch in relation to demand-supply affect efficiency. The regulatory process to implement policies and laws is slow and often delayed in operation.

As Bangladesh becomes increasingly urban, the government's role in establishing a PHC infrastructure to deliver services in urban areas appears to be lackadaisical at best. Most commentators want to see the government considerably strengthen and fulfil its governance role in overseeing and monitoring aspects of health services. The government also needs to coordinate critical strategic developments, especially around the financing of this sector.

This begs the question, what should be the government's main role in health service delivery? Both the NGO and private sectors could be given specific tasks that are quantifiable to assess progress. They can develop guidelines and operational plans to help the ministry, donors, NGOs and the private sector work in a more coordinated manner.

Meanwhile, health experts in Bangladesh have felt a dire need for greater inter-ministry and intra-ministry coordination and collaboration. This is especially true between the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP), and between the MOHFW and the Ministry of Local Government, Rural Development and Cooperatives (LGRD). With the latter being responsible for urban health, there is a need to decentralise the urban health system whereby city corporations can take primary responsibility for the health of urban people.

Some sector experts recommend a full-scale reform of the MOHFW with a modern structure and practices that make it fit to guide and govern the development of a modern PHC system in Bangladesh. Any serious changes within this ministry can only be brought about by decisions at the highest level of government. The latter, however, is mainly interested in wielding political power, rather than pushing bureaucratic reform and healthcare for the poorest.

The health system in Bangladesh needs dynamic leadership that is prepared to design and enforce evidence-based policies and programmes. The stewardship of the health system must have a strategic vision and determination to improve and strengthen both the public and private health sectors of the country. Equity must be the overarching guiding principle underpinning the health system.

A starting point for reform would be to ensure that a wider range of health personnel are included in health planning: women and men with an understanding and experience of PHC needs at community, union and upazila levels. People with requisite qualifications and expertise should be hired. Increasing representation of women in management and decision-making within the MOHFW should also be a priority, along with serious efforts to institutionalise gender equality. This would help improve understanding, thinking and practices across operational units and departments.

Similarly, there is a need to expand and develop the non-doctor health cadres to meet the basic needs of PHC. Such paramedics and non-medical professionals need training, and support for acting as the first-line service providers. They also need support for clear career paths and further personal growth. Nurses and medical technicians are two key professionals that require investment and augmentation by way of better training.

The current referral system at the primary care level also needs to be strengthened through capacity building. The current dynamic climate around healthcare in Bangladesh offers opportunities to explore the possibilities for more equitable financing mechanisms, especially for the poorest. A more inclusive and equitable health system will never be achieved if out-of-pocket expenditure on health is as high as 67 percent, as is now. This is pushing an estimated five million people into deeper poverty each year.

To facilitate strategic communication, policy advocacy to push the universal primary healthcare approach is needed. This can be achieved through regular engagement and convening with the senior leadership at all levels to support government efforts in formulation of Human Resources for Health (HRH) action plan. This will go a long way in implementation of the HRH strategy and action plan to bolster HRH production, mobilisation, deployment, and retention of human resources. The goal is to improve HRH competencies to deliver high quality health services.

If the expertise of personnel in the MOHFW, such as those at the Health Economics Unit of the DGHS, can be harnessed with field workers having exposure and understanding of ground realities, as well as innovators from the NGO and private sectors, the vision of an efficient healthcare system in Bangladesh can become a reality. For that to materialise, a strong leadership with necessary political will is essential.

Dr Md Khurshid Alam Hyder is public health specialist.​

Priorities for Bangladesh’s health sector
A healthcare reform roadmap for the interim government


VISUAL: HEALTH REFORM

The interim government has set a reform agenda for itself. In early September, six commissions were established to address reforms in various cross-cutting areas, including the constitution, electoral system, judiciary, anti-corruption, public administration, and police. The heads and other members of each commission were also named. In mid-October, four more commissions on health, media, labour, and women were formed. The formation of these commissions has been widely welcomed, with expectations that they will lead to meaningful and lasting changes in their respective areas.

The interim government has recently completed 100 days. As expected, the demand for a "roadmap" for the transfer of power through parliamentary elections is gaining momentum. There is no concrete announcement from the government yet, but some have suggested that elections could possibly be held by December 2025. This leaves about 400 days from now. Within this short timeframe, only a few substantive reforms can be carried out. A myriad of reforms is needed, but which ones will be prioritised? In my opinion, the commissions should focus on areas that are impactful and can be meaningfully completed within the government's tenure.

One important sector requiring urgent reform is health. Public health experts have been voicing their concerns and frustrations about the state of this sector. With the new opportunities created through the July movement, there is hope for significant changes in the health sector as well. I am confident that the relevant commission will thoroughly examine the issues paralysing this sector and propose impactful reforms. Below, I outline a few ideas which, if implemented, could help the country progress towards the national goal of universal health coverage (UHC).

Investing more in health

The government spends only 0.7 percent of GDP on health which is the second lowest globally. This is circumscribed by the government's inability to spend even this meagre amount. Good health cannot be achieved without good investment and optimum spending. The commission should recommend more money for the health sector, but more importantly, how to spend the additional money for achieving UHC.

Creating accountability

There is a demand for establishing an independent National Health Security Office (NHSO), which would enhance accountability by separating the service delivery function of the Ministry of Health and Family Welfare (MoHFW) from its purchasing function.

Free drugs for all

Bangladesh has one of the highest rates of out-of-pocket (OOP) expenses in healthcare, most of which are for drugs. Despite the country's near self-sufficiency in medicines due to a thriving pharmaceutical industry and government production, free drugs and contraceptives provided through community clinics are often in short supply. Introducing free drugs within a specified timeframe could significantly reduce OOP expenses and health inequities.

Restructuring healthcare administration

The current administration under the MoHFW is divided into several directorates (DGs), many of which are artificially and irrationally created. Primary health care (PHC)—encompassing basic curative, preventive, and promotive services—is delivered at the upazila level and below, up to community clinics. Unfortunately, PHC is deprioritised under the current system, with poorly defined roles, accountability, and financing. Establishing a separate directorate general for PHC would be beneficial. Additional DGs could be created for tertiary hospitals, medical education and research, drug administration, and other areas.

Strengthening community participation through youth engagement

The July movement demonstrated the value and potential of involving youth in development. Community engagement is a critical health system building block. Management committees exist for almost every facility, from district hospitals to community clinics, with civil society members included, at least on paper. Unfortunately, most of these committees are dysfunctional and have not met in years. Introducing youth representatives could revitalise these committees. Similarly, regulatory bodies like the Bangladesh Medical and Dental Council (BMDC) could benefit from youth participation.

Regulating the private healthcare sector

The private sector now caters to over half of the population's health needs but remains largely unregulated. Since the ordinance on private healthcare was promulgated in 1982, no significant updates have been made over the past 42 years. The interim government has an opportunity to address this by revisiting and modernising regulations.

Establishing a permanent health commission

The current commission cannot address all necessary reforms within the given timeframe. Once its work is complete, it would be prudent for the interim government to establish a high-powered, independent, and permanent health commission. This body would create a national health vision, tackle corruption, and plan and monitor progress towards UHC. One important task of the permanent commission could be revisiting the health policy recommendations made by Dr Zafrullah Chowdhury and colleagues in 1990, which emphasised decentralisation and remain highly relevant for Bangladesh.

Leaving a legacy through dengue management

The spread of dengue in Bangladesh is alarming. Despite this, definitive steps to contain this preventable menace are lacking. Kolkata has successfully managed dengue—why not us? Although the interim government is preoccupied with various challenges, focused attention on this issue could save hundreds of lives and alleviate the suffering of millions. The recent focus on treating those injured during the July movement is commendable. Similarly, successful dengue management could be a lasting legacy for the interim government.

Ahmed Mushtaque Raza Chowdhury is convener of Bangladesh Health Watch and founding dean of the James P Grant School of Public Health.​

Reform for equitable primary health care
29 November, 2024, 00:00



A health commission incorporating public health managers and local government institutions could manage tax funds to procure and regulate healthcare quality and coverage, writes Abu Muhammad Zakir Hussain

REFORMS are expected to address problems in quality and quantity coverage or target attainment or both. Problems may be due to poor planning, budgeting, management and leadership skills, including weak supervision for quality and poor monitoring for quantity. Good management should consider human resource development and management; the management of medicine, logistics, technology and information; physical structures; and services. One fundamental aim is to ‘leave no one behind’, addressing equity, the fulfilment of health needs of all, which needs appropriate and adequate financing.

Financing for universal coverage

PUBLIC tax-based Beveridge model, which allows people to buy private insurance, funds health care in many western countries. Besides public hospitals, governments recruit private hospitals as well, when necessary. Primary health care is given through individual general practitioners or groups of such people, contracted by local public bodies. Social health insurance is an approach where premiums are paid by the management and the staff. For the jobless, premiums are covered by public taxes. National health insurance is universal health coverage, funded by pooled insurance premiums but managed by contracted organisations.

Out-of-pocket payment is the most regressive and inefficient method of healthcare procurement as it is not based on informed decision and has no negotiating power. The purchase of care by a single purchaser chosen from multiple providers offers price negotiating powers to the purchaser, besides imposing favourable purchasing conditions that benefit service receivers. A single management entity accrues a smaller administrative cost.

The Bangladesh government also organises healthcare services through public taxes. But the tax base is inadequate for universal health coverage, especially in urban areas. To address this problem partly, local government institutions must allocate at least 15 per cent of their budget for health care. Additional taxes, eg, sin tax must be channelled to health care. Two per cent tax should be levied on health services on certain foods, drinks and private vehicles, which have adverse health implications. Fund might also come from co-payment from patients through registration fees for all, at all levels, as per the economic status of service seekers, which would also prevent the moral hazard. A portion of the corporate social responsibility from entrepreneurs should also be realised for health services. The finance ministry should fund local government institutions directly to enable them to undertake their health responsibilities.

A health commission with national, divisional, district and upazila offices, incorporating public health sector managers and local government institutions may be entrusted to manage the tax fund to procure and regulate healthcare quality and coverage by the public sector and the private sector. The combined entity should also participate in planning, budgeting, monitoring, review and public hearing at all levels.

Healthcare financing should be needs-based and the internal rate of return should dictate the priority of budgeting. Budget heads should be (1) human resources, its management and development, (2) planning and budgeting, (3) financing and accounting, (4) public communication, (5) knowledge and information management, (6) service and programme management, including clinical care, (7) incentive, (8) medicine, (9) vehicles, machines, supplies and equipment, (10) technology and innovation, ((11) sustainable and user-friendly physical structure, (12) renovation, maintenance and repairs, (13) stakeholder engagement and (14) operational costs, including transport costs for supervisory travel.

Addressing in-service inefficiency

ON THE fringe. three categories of service providers have been entrusted with providing primary healthcare services. But their services are not complementary. The community health care providers are wrongly supposed to provide alone all sorts of stationery services at community clinics which overburdens them. The field staff may be given the same responsibilities while dividing their target population equally. This will enable the catering of more necessary services at the entry, the community clinics. A task group should develop an efficient terms-of-reference for them.

Operational budget for these fringe staff is nominal and fixed for all weathers, distances and conditions which compels the poorly paid staff to spend additional money on travel especially in hard-to-reach areas. Community health care providers pay electric bills for community clinics from their salary. Although 65 local influential form community groups and community support groups to support community health care providers and bear the coast of repairs and maintenance of community clinics, they are hard to find around. They are also alleged to demand medicine from community clinics, which comes free. It is warranted that the community support groups should be abolished. It is also warranted that the operational costs for community clinics should be sent to the upazila health and family planning officers on a yearly basis.

Planning flaws at unions and solutions

THE union health sub-centres, 1,260 in number, are the most inefficiently managed health care units in the sector. All of them should have adequate office space for an assistant health inspector and other required officials, who will provide outpatient-based preventive, promotive and limited curative care, primary diagnostic services and normal delivery services. They will be given through medical officers — two although WHO recommendations 15 — a medical assistant, a midwife, a medical technologist, a pharmacist, a guard and a support staff. All of them, except the last two, should have separate office/clinic and residential arrangements as per entitlement. The last two officials will be selected from among local people.

Assistant health inspectors and medical officers should also function as supervisors for community clinics. Besides, medical officers should also provide consultation services for waiting patients enlisted with the community clinics. Adequate travel and food allowances should be allocated for them to cover travel to distant clinics. A 20 per cent top-up needs to be added to the salaries of medical officers and 10 per cent for other non-local staff to attract them to stay in unions. No private practice or collaboration with the private sector by them should be allowed. If the conditions are not abided by public-sector service providers, local general practitioners or these people and providers of other categories as a team with due skill mix may be contracted in or out.

Contracting the general practitioners will have to be needs-based, efficient, based on the number of people to be served and the illnesses to be treated by complexity. The qualifications and readiness of general practitioners and their chambers should be assessed for contracting. What additional support, including training and logistics, will be required by the general practitioners to be contracted will have to be assessed before contracting. Information is also required if chambers of general practitioners will need to be renovated or supported with logistics. A law will be required for these sorts of contracting. The process of buying services from the private sector, including general practitioner services, should be left with the divisional level, which will be participated in by the upazila and district level management and public bodies concerned.

A public-private partnership scheme may be thought of, conversely, where general practitioners or groups of general practitioners will finance the construction or renovation of union health sub-centre complexes on government land (concession), operate and transfer the sub-centres after the contract period is over, to the government. The government may then again invite all local general practitioners to submit bids which will then require a lower bid amount.

At this point, we advise the government to reign in the infrastructural duplication between family planning and health departments. Both the departments have medical officers and medical assistants providing maternal and child health services in unions. To prevent duplication, family planning personnel should cater the same services from those 3,300 unions where there are no health department facilities.

Equitability of clinical, public health services

UPAZILA public health units will be responsible for planning, budgeting and implementation of locally planned activities and nationally bestowed programmes, undertake personnel management and the management of logistics, physical facilities, information, training, monitoring, review and supervision and submit performance and expenditure reports for all the three primary healthcare tiers. Public engagement will be ensured at each level in planning, budgeting, review, public hearing and community awareness.

The upazila clinical and diagnostic care may be tagged to district hospitals, where upazila health and family planning officers will have no role. Upazila health and family planning officers will act as field, community clinic and union-level top planners, implementers, reviewers, supervisers and monitors. It would include disease prevention and control activities through disease surveillance and vaccination. They would also assess and address patient complaints, pharmacovigilance, polypharmacy, induced care, patient and provider safety, and adverse effects of vaccines, service coverage, health communication, staff attendance in all kinds of health facilities, all health-related procurement, all health management information and the regulation of both the public and the private sector health facilities in upazilas and unions.

They should be supported by a medical officer for disease control and prevention, a nutritionist, a health-related communications officer, a management information officer, a logistics officer and an accountant. A mirror image functioning is also warranted at district and divisional levels for primary healthcare services. Local level planning, both activities and budget, may be developed within a given ceiling at unions, upazilas, districts and divisions.

The family planning department has maternal and child welfare centres in districts and upazilas and in a few unions. These are duplications. Maternal and child welfare centres are not at the centre of patients’ interest as district hospitals and upazila health complexes with expert service providers are available nearby. Maternal and child welfare centres should come under a unified system of care under the health department.

Resource management

Human resources: Allocation for adequate and appropriate human resources with right kind of service provider mix for a given epidemiological profile at a given location should be a priority. The World Health Organisation suggests 4.45 service providers as a minimum per 1,000 population to attain Sustainable Development Goal 3. The organisation also suggests a skill-mix ratio of 1:3:5 physician: nurses: paramedics. The WHO proposition would lead to a staggering estimate. We suggest that our efforts are driven towards recruitment along this line, starting with 10 per cent of the estimates now.

We recommended the provision of technical personnel for urban areas from the ministry of health and family welfare and administrative and support staff from the local government, rural development and cooperatives ministry. This should be the practice for urban primary health care. Additional fund for urban primary health care should come to local government institutions from the finance ministry directly. Planning, budgeting and implementation review of urban primary health care should be the combined responsibility of local government institutions, health and family welfare ministry and the local government, rural development and cooperatives ministry.

Line/programme directors and their assistants will have to be deployed based on their proved experience, educational qualification and leadership quality and should be selected through interviews by a board to be constituted of five superior officers and guest selectors who have required qualifications in the relevant field and are well known for their honesty.

Logistics: Human resources and logistics should be complementary to each other and based on local needs. Appropriate skills must be ensured to handle the allocated logistics before procurement. Assessment of local needs should be a requisite for any deployment and procurement. An equitable availability of resources could address all the health needs of the population on every location. Logistic support for urban areas should come from the health and family welfare ministry through its divisional, district and upazila primary healthcare offices.

Additional health facility: If need be, private hospitals, clinics and diagnostic centres might also be contracted when warranted. The situations for such contracting will be clear in writing, eg, in emergency or overloaded situation. The contracting conditions, i., payment conditions should be clear. The conditions should be reflected in their licensing conditions.

Improving quality and coverage

Medicine: Medicine is the most important commodity that service seekers appreciate. The existent list should be reviewed and updated every five years. There should never be any incidence of stockout of enlisted medicines. It is necessary that use of the medicine given at community, union and upazila levels is monitored and the quality of prescription is supervised by clinical experts. Fund for medicine in urban areas should come from local government institutions and the finance ministry should top this to ensure the remaining fund from government revenue.

Technology: A table of necessary equipment, furniture, vehicle, supplies and the other relevant tools should be available at three tiers of primary health care and at the district and the divisional offices relevant for urban primary health care. This list should be reviewed and updated every five years. The latest available technology, eg, software-based automated data recording and transmission, telemedicine, e-medicine etc should be ensured inasmuch as possible that would ensure efficiency.

Physical facilities: Physical facilities should be distributed equitably with efficient designs. Adequate and appropriate offices, residence and clinic spaces should be available to relevant officials as per eligibility of the positions that either exist now or will be created in future. Four-room community clinic archetype facilities should be developed throughout the country. But the number of such facilities should be based on population dispersal and density. While in urban areas, one such facility may suffice for 50,000 people, in hard-to-reach areas, one may be necessary for 2,000 to 3,000 people. Health facilities owned by other sectors, usually in urban areas, should be checked for their use and, if necessary, a corner of such facilities may be used as a community clinic or equivalent to a union health facility.

A continuous availability of electricity and safe water should also be ensured by the government at all tiers. It is also necessary to ensure that the health facilities and their basic amenities should ensure sustainability and disaster adaptability. Every health facility/office should be comfortable for officials and for waiting service seekers, or patient attendants, suitable for different ages and sex. At least two cleaners should be recruited at union health facility, and one at each community clinic, selected through contracting, to be held at divisional level in the presence of the relevant civil surgeon, urban health and family planning officers and one local public representative. In urban areas, additional physical facilities should be built by the local government institutions. Any shortfall in this regard should be met up by the finance ministry.

Community engagement: Since the engagement of the community has been suggested, adequate fund — budget for snacks and tea for meetings, for example — should be needed to bring them into the system. Every health facility should have a public management body composed of upazila and union chair as per relevance and local healthcare providers. These should replace the older ones.

Orientation, training and continuous education: The personnel promoted to a position should always be given training to suit the newly assumed position. The orientation and training should be preceded with a need assessment exercise and the training or orientation curriculum be organized according to its findings. As part of capacity build-up, seminars should be organised at union and upazila levels to be participated by the community and union level workers every month. Community workers would bring complex cases to the discussion table, for solution or referral by attending medical officers.

Patient-centred services: Every healthcare worker at upazilas, union and community levels should know of the various quality indicators and parameters. Induction and refresher trainings should be organised for them, that should emphasis on service quality and competency.

Supervision: Supervision has to be done through some structured protocol and job-related tools. Clinical audits would be warranted for medical prescription.

Monitoring and supervision: Monitoring might be conducted online. It has to be continuous or episodic, according to the applicable tier. A standing monitoring framework should be developed and used. Dedicated monitors may be recruited from among retired officials, the private sector or private individuals with required experiences. Selection would be through an interview board composed of officers. Their contracting should be based on an agreed terms-of-reference.

Various groups of monitors should be deployed for different purposes, ie, for the monitoring of the fulfilment of contracting conditions in various fronts, eg, covenant on free services to 10 per cent of the poor service recipients in private hospitals; the submission of service-related information by private service providers and hospitals and other functions mentioned. The monitoring teams or groups would be supervised and monitored by the urban health and family planning officers, civil surgeons and divisional directors. Adequate allowances but only for supervisory and monitoring and, in rare cases, travels should be ensured for supervisers of upazila and union levels.

Other management functions: Management decision should be evidence-based. This is a culture that needs to be developed fast. Managers should learn how to manage programmes, personnel, finance, logistics, information technology and software and contracts. Healthcare management should be gender- and poverty-sensitive and emphasise improving community awareness on family planning, adolescent care, disease prevention and nutrition improvement and other services mentioned. A government order should be in order in this regard. Management and review meetings should be supported with adequate logistics and fund.

Regulation of clinical and diagnostic services: Health and performance related information should cover both the public and the private sector. Urban health and family planning officers, civil surgeons and divisional directors should be entrusted to monitor, not supervise, licensing conditions only for the private sector and other performances and services, mentioned. Leaving these responsibilities to the hospital management will ensue a conflict of interests.

Innovation, change and learning: No de novo action or recommendation that brings in any change in the system should be adopted ever, without unbiased piloting and job analysis. The condition of efficiency and reduction in price and cost in services delivery should be ensured. The catchment area of each facility of all tiers should be mapped which would also help to line up the referral system. Every family and its members should be registered with the help of a unique number. Community-based birth, death and marriage registration by age and sex should be a priority to assess the impact of the healthcare interventions and goal attainment.

Referral and transport: Strong emergency and critical care services should be ensured at referred sites. High-level health facilities should also be able to provide care for complicated non-communicable diseases as per competence. Health services should be available round the clock in referred facilities. A penalty fee should be applied to those who seek care at higher levels without referral. Ambulances may be of different types based on the topography of a location, eg, boats, three-wheelers, pedalled four-wheelers, etc and should be free for every registered family. Except motor ambulances, other types may be given to local entrepreneurs to run and maintain, conditional to their use as an ambulance, when necessary, on a priority basis. Public bodies, linked to the health facilities, may be entrusted to monitor their use.

Incentive: The health sector should develop a culture of incentivising good performance annually. The incentive may be monetary or non-monetary. Monetary incentives may be given as a top-up of the salary. It may also be recognition given at public meetings at district and national levels. Contrarily, non-performance should make a staff liable to punitive action, eg, the degrading of salary by one or two steps. Transfers should never be considered a punishment.

Abu Muhammad Zakir Hussain is a former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO and former staff consultant, Asian Development Bank, Bangladesh.​

Separated conjoined twins leave BSMMU for home
Staff Correspondent 26 November, 2024, 01:14


The authorities of Bangabandhu Sheikh Mujib Medical University release twins Nuha and Naba from the BSMMU in Dhaka on Sunday after they were separated successfully through a series of critical surgeries. | Press release

The authorities of Bangabandhu Sheikh Mujib Medical University on Sunday released conjoined twins Nuha and Naba, who were separated successfully through a series of critical surgeries.

As a result of combined efforts of the various departments’ of the BSMMU, they were released after 2 years, 7 months, and 20 days through five successful surgeries, said a press release on Monday.

The BSMMU academic pro-vice-chancellor Professor Dr Md Shahinul Alam, pro-VC for administration Professor Dr Md Abul Kalam Azad, pro-VC for research and development Professor Dr Md Mujibur Rahman Hawlader, treasurer Professor Dr Nahrin Akhter, registrar Professor Dr Md Nazrul Islam, director for hospital Brigadier General Dr Md Rezaur Rahman, paediatric surgery department professor Dr AKM Zahid Hossain, among others, were present on the occasion at the BSMMU in Dhaka.

Born on March 21, 2022, and admitted to the BSMMU on April 4, the daughters of Nasrin Akhter and

Alamgir Hossain, residents of Shibram Kanthalbari village in Kurigram Sadar, Nuha and Naba, were conjoined at the back and bottom.

Neurosurgeons led by Professor Dr Mohammad Hossain, paediatric surgeons led by Professor Dr AKM Zahid Hossain, anaesthesiologists, and specialists from various departments, doctors, and nurses had worked to treat Nuha and Naba.

The university administration had also been keeping a close eye on them and had provided necessary assistance.

So far, 3 pairs of conjoined babies have been separated at the BSMMU, and preparations are underway to separate another pair of conjoined twins, added the press release.​

Stop unethical practices in health sector
Atiqul Kabir Tuhin
Published :
Nov 30, 2024 20:58
Updated :
Nov 30, 2024 20:58



Over diagnosis through excessive tests and unnecessary medication prescribed by some doctors is a common complaint. It is widely alleged that these doctors prescribe many redundant tests and costly medicines more to oblige to diagnosis centres and medicine manufacturers than to benefit patients in exchange for gifts or commissions.

A swarm of pharmaceutical representatives can be found crowding hospitals, clinics, and other medical facilities, often gathering in front of doctors' rooms despite long queues of patients. They even dog patients as they leave doctors' chambers to check or take photograph of prescriptions - seemingly to verify whether their influence on the doctors is yielding results.

This is a manifestation of how aggressive the ever increasing numbers of medical representatives has become in pushing the sales of their products and pressuring doctors to prescribe them. Many of them are high-salaried with attractive perk and packages. They are under obligation to fulfil their district or zonal sale quota. The contribution of these pharmaceutical salesmen to healthcare is not clear. Often the pressure and persuasion to get the prescription written their way take the shape of inducement, with gifts offered in both tangible and intangible forms.

Owing to intense competition most drug companies give more attention to promotional activities than to research and quality control. However, it is beyond question that Bangladesh has drug producers who are internationally known for maintaining high standards. But even their position will be adversely affected if the dishonest elements are allowed to carry on with their business.

The patients have to bear the brunt of it all as treatment gets costlier. What is more, substandard drugs are marketed and prescribed, thanks to the manufacturer-salesman-physician nexus. Reports carried by the media from time to time indicate that there are fake companies engaged in manufacturing spurious drugs that can cause irreparable damage to the human body. Allegation has it that some of doctors prescribe substandard medicines to patients in exchange for valuable gifts.Because of unscrupulous conduct of a few, the practitioners of the noble profession are suffering from an image crisis.

The activities of the low quality drug producers and the dishonest doctors are a direct threat to public health. Their fraudulent practices have made the people in general- who do not have access to good treatment facilities-even more helpless.

Of late the Ministry of Health and Family Welfare has banned pharmaceutical company representatives from hospital premises as part of its plan to improve hospital management. This is a praiseworthy decision. But some of the doctors exhaust their time and energy attending private clinics which leaves them with too little time for government hospitals which are their main responsibility and for which they are paid out of tax payers' money. Many, therefore, believe that merely barring drug company representatives from hospital premises is unlikely to yield the desired outcome without stricter enforcement of rules and regulations.Recommendations by some experts include introducing the system of mentioning generic names in the prescription to stop aggressive marketing of pharmaceutical companies.

But above all, a lot more are expected from the doctors. They are in a profession where the slightest deviation from ethical standards means great suffering to the people. They must not forget that human life is more valuable than those valuable gifts. The doctors may follow some finest examples of dedication on the part of some revered members of their own profession, in which case no regulating body or external agency will be required to put them on track.​

SWAp’s effectiveness for Bangladesh’s health sector


There is an urgent need for a comprehensive overhaul of Bangladesh’s health system. PHOTO: ORCHID CHAKMA

UHC Forum is a coalition of health sector practitioners, advocates and academics dedicated to a strategic push on the universal health coverage (UHC) agenda. UHC Forum Health Debates is one of its flagship activities carried out in partnership with the Power and Participation Research Centre (PPRC). This op-ed is derived from the health debate on the Sector Wide Approach (SWAp) modality adopted for health sector planning and implementation since 1998.

The Sector-Wide Approach (SWAp), introduced in Bangladesh in the late 1990s, sought to improve the health sector by uniting the efforts of government, donors, and NGOs under a unified national plan. The strategy proved effective in several areas—enhancing coordination, reducing duplication and ensuring more efficient use of resources. It fostered a government-led approach, empowering the Ministry of Health and Family Welfare (MOHFW) to take ownership of health programmes and make decisions that align with national priorities. The pooling of funds from various donors simplified financial management and allowed for a more harmonised implementation of health services. Moreover, SWAp contributed to capacity building by strengthening institutional frameworks, enhancing local expertise, and promoting evidence-based policymaking. However, SWAp also faced substantial challenges. Key stakeholders, such as the private sector and the Ministry of Local Government, Rural Development and Co-operatives, were excluded from planning processes, limiting its scope and effectiveness. Centralised decision-making created bureaucratic delays, slowing programme implementation. Additionally, larger donors, such as the World Bank, exerted disproportionate influence, at times, prioritising global agendas over local needs. The risk of mismanagement also grew as pooled funding lacked adequate oversight and accountability mechanisms.

To address these shortcomings, I advocate transitioning to a new model, termed Sector-Wide Inclusive Planning and Evaluation (SWIPE) to integrate private sector actors, and decentralised planning and budgeting to the district level.-----Dr Abu Jamil Faisel is a public health expert.

There is an urgent need for a comprehensive overhaul of Bangladesh's health system. The existing dual-budget structure, which separates operating and development budgets, lacks coherence and prevents effective symbiosis between routine operational costs (staff salaries, fuel and utilities, repair and maintenance, travel, etc), and development costs for new infrastructure development and health service improvements.

The Health Population and Nutrition Sector Program (HPNSP) under SWAp brought advantages such as faster decision-making, delegation of authority to health managers, health workforce capacity building, improved coordination, monitoring and supervision. However, critical issues remain unresolved. Universal health coverage, elimination of healthcare discrimination, substantial improvements in healthcare quality, avoidance of verticalisation in healthcare delivery, and the reduction of out-of-pocket expenses continue to elude the system.

The fragmented and verticalised delivery of healthcare services limits integration and patient-centred care. Bangladesh's age-old health systems have many inherent defects. The HPNSP or any similar prescription will not remedy it. Bangladesh urgently needs a serious and massive overhaul of its health systems in overall structure and processes to enable it effectively meeting the population's health needs through integrated primary healthcare, sustainable universal health coverage, health sustainable development goals (SDGs), and client satisfaction.----Professor Dr Abul Kalam Azad is former director general of health services.

Exploring alternatives to SWAp in Bangladesh's health sector is a pressing discussion, given the challenges faced in achieving sustainable programme outcomes. One of the critical considerations is whether it is time to pivot back to the original revenue-based system or implement a hybrid model that leverages the strengths of both approaches. The revenue-based system, rooted in direct budget allocations, could potentially offer more flexibility and control for domestic health programme funding. Ensuring financial sustainability remains a key focus as stakeholders debate these alternatives. The path forward must address how Bangladesh can maintain or enhance programme effectiveness without depending heavily on SWAp, which, while comprehensive, often leads to dependency on external funding and complex coordination issues.

A well-articulated roadmap is essential for transitioning from SWAp to a new or modified system that prioritises local ownership and resilience. The government must lead with robust policy frameworks, while development partners can assist with technical expertise, transitional funding and access to global best practices.
-----Dr Md Aminul Hasan is a health system expert.

SWAp has played a pivotal role in shaping Bangladesh's health sector, improving coordination, ownership, and resource management. However, its limitations, including rigidity, donor dependency, and exclusion of key stakeholders, necessitate a reimagined approach.

Hybrid models, public-private partnerships, national health insurance schemes, and decentralised planning offer pathways to address these challenges. As Bangladesh works toward achieving universal health coverage and the health-related Sustainable Development Goals by 2030, a collaborative, inclusive, and forward-looking strategy will be essential.

Health system reform requires technical solutions, strong political will, and a commitment to equity and sustainability. While reform is essential, political will and strategic intent are critical in driving meaningful health sector reform. Bangladesh's health system requires a clear focus on necessary and actionable reforms. The challenge lies in crafting precise recommendations and mobilising the political leadership needed to implement them effectively. Without sharp, actionable strategies, opportunities for impactful reform may be missed. It is essential to foster collaborative efforts across stakeholders to address systemic gaps and meet the health aspirations of the population.-----Hossain Zillur Rahman is executive chairman of Power and Participation Research Centre (PPRC) and convener of universal health coverage (UHC) Forum.​

Three examples of badly-run public hospitals
Prioritise recruitment and efficient management



We are appalled by the findings of a report by The Daily Star on three hospitals run by the Dhaka South City Corporation (DSCC), highlighting an acute shortage of staff and underutilised facilities, which cause unnecessary suffering for patients. In a city where accessible healthcare is increasingly out of reach for ordinary citizens, it is unacceptable that these public hospitals offer substandard services. This is a direct result of neglect and apathy from the Directorate General of Health Services (DGHS) and the Ministry of Health, a situation that has worsened over decades.

These hospitals are vital for low-income and lower-middle-class communities, as they offer subsidised healthcare. However, patients are forced to wait for hours due to the severe shortage of doctors, nurses, and other essential staff. As patient numbers rise, one hospital operates with half the required manpower. For instance, Mohanagar General Hospital, which installed ICU units and high-flow oxygen equipment during the Covid pandemic, cannot use them because there are no trained personnel. The surgery department has been non-functional since 2015, and high-dependency unit (HDU) beds installed in 2021 remain unused. Many posts are vacant, further crippling the hospital's ability to function.

A similar manpower crisis exists at Dhaka Metropolitan Children's Hospital, where the paediatric surgery department has been inactive since 2012, and 40 of the 100 beds remain unused. Nazirabazar Matri Sadan is also grappling with a shortage of doctors and essential medicines.

In all three hospitals, staff are spread too thin, leaving patients without the necessary medical care. Despite repeated official letters sent to the health ministry and DGHS, no action has been taken. These hospitals reflect the dysfunction plaguing public healthcare across the country, with severe staff shortages making them nearly non-functional. The DGHS and health ministry have ignored the needs of these hospitals for years. Why has this been allowed to continue? What happened to the allocated budgets? If they were insufficient, why wasn't more funding provided?

The healthcare system, especially in public hospitals, continues to be marked by gross inadequacies. And the conditions at these hospitals are a perfect example of that. We urge the interim government to immediately investigate these issues and take corrective action. The recruitment of medical personnel should be a top priority, along with the training of staff to operate specialised equipment. Meanwhile, strict management oversight is necessary to ensure that no resources go underutilised. Access to healthcare is a basic right, and the government must restore functionality to these hospitals as soon as possible.​

A wake-up call for Bangladesh to reform its healthcare

India's visa restrictions on Bangladeshi nationals, while initially perceived as a barrier, could serve as a wake-up call for Bangladesh to strengthen its healthcare system and regain the confidence of its patients. With as many as 3.5 lakh Bangladeshis seeking medical treatment in India annually, the restrictions offer a unique chance for local providers to address systemic issues and retain patients who would otherwise travel abroad. Experts urge Bangladesh's health authorities to rise to the occasion and rebuild trust among its citizens.

This systemic overhaul is especially urgent given the personal struggles of individuals like Sanjida (not a real name), a Mirpur resident, who faced a critical health challenge in 2020. After undergoing surgery at Dhaka's Green Life Hospital to remove an ovarian cyst, her biopsy reports delivered devastating news: she had cancer. Advised to start chemotherapy, she followed her oncologist's recommendation for additional tests, only to realise that the tests she had completed earlier had been overlooked. It became apparent that her doctor's approach was perfunctory at best. Terrified and disillusioned, her family decided to seek treatment abroad.

Sanjida travelled to Mumbai's Tata Memorial Hospital, where doctors reviewed her medical history and conducted fresh diagnostics. They concluded that the surgery in Dhaka had been incorrect. With an appropriate operation, her cancer could have been addressed earlier. After another surgery and three rounds of chemotherapy in Mumbai, she returned to Dhaka. Today, she takes regular medication and visits India every six months for follow-ups. Reflecting on her ordeal, Sanjida laments the inattentiveness and unprofessionalism she experienced in Bangladesh's medical system, contrasting it with the care she received in India.

"Even with the high cost of living and transportation, Indian hospitals are more affordable and trustworthy than those in Dhaka," she said.

Sanjida's story is not unique. Retired government officer Shahidur Rahman, 69, sought cardiac care in 2019 after experiencing chest pain. Diagnosed with three heart blockages at two leading hospitals in Dhaka, he was advised to undergo stent placement. Sceptical, Shahidur travelled to Bengaluru to consult Dr Devi Shetty, a renowned cardiologist. Additional tests revealed no blockages, and he was prescribed medication instead. Since then, Shahidur has lived without chest pain and has lost faith in Bangladeshi healthcare providers.

A CRISIS OF CONFIDENCE

The healthcare industry in Bangladesh is dominated by the private sector, which has seen significant growth in tertiary hospitals and diagnostic centres.

The stories of Sanjida and Shahidur are emblematic of a deeper issue -- a healthcare system grappling with a crisis of trust. On the surface, Bangladesh's healthcare infrastructure appears robust. The country boasts 566 public hospitals, which include 37 state-run medical colleges providing hospital services, and around 5,000 private medical facilities. Private sector investment has led to the growth of tertiary hospitals and diagnostic centres, creating an illusion of progress. Yet, beneath the numbers lies a stark reality: many Bangladeshis still feel compelled to seek treatment abroad, believing that local facilities cannot meet their needs.

The reasons for this exodus are manifold. Experts point to rushed consultations, diagnostic errors, steep treatment costs, and a perceived indifference from medical professionals. Many patients complain of being treated like mere numbers -- hurried through appointments with little to no time for questions, clarification, or reassurance. This lack of a personal touch often proves just as alienating as the more tangible deficiencies. In contrast, some patients argue, India has built a reputation for offering not only medical expertise but also a level of care that feels holistic and humane.

Bangladeshi patients primarily travel to India for cardiology (14 percent), oncology (13 percent), gastroenterology (11 percent) and other complex issues, according to a 2023 study published by the National Library of Medicine. The same report found that India's healthcare infrastructure -- including skilled specialists and comprehensive follow-up care -- attracts an estimated 3 lakh to 3.5 lakh Bangladeshi patients annually. Kolkata, Chennai, Vellore, and Mumbai are the most frequented destinations.

"Bangladesh's healthcare system lacks sufficient skilled physicians and technologists, especially for complex diseases like cancer and organ transplants," said Rumana Huque, a health economist and professor at Dhaka University. "While we have capable doctors, they are overstretched and unable to provide the level of care patients expect."

Bangladeshis spend over $5 billion annually on medical treatment abroad, with India and Thailand as top destinations. Yet, Huque emphasised, many of these expenses could be curtailed if local healthcare providers improved their practices.

Tamzeed Ahmed, a clinical and interventional cardiology specialist at Evercare Hospitals Dhaka, observed that the past two to three months have seen an uptick in patients seeking consultations in India. This trend persists despite India's visa restrictions.

Meanwhile, Md Esam Ebne Yousuf Siddique, chief operating officer of Square Hospitals, highlighted the uncertainty surrounding the long-term impact of these restrictions. He noted that, over the last three years, Square Hospitals has not recorded any significant fluctuation in patient numbers, suggesting that the effects of visa restrictions on local healthcare utilisation may still be unfolding.

SYSTEMIC CHALLENGES AND PATIENT DISSATISFACTION

Patients often cite Bangladesh's under-resourced diagnostic facilities and dismissive medical culture as significant deterrents. Even private hospitals equipped with advanced technology struggle due to a lack of trained personnel to operate it effectively.

Syed Abdul Hamid, a professor at the Institute of Health Economics, Dhaka University, pointed out that poor diagnostic accuracy, inadequate consultation time, and indifferent behaviour from medical professionals erode trust. "Doctors in India excel in patient communication, providing detailed explanations and emotional support. This starkly contrasts with the rushed consultations typical in Bangladesh," he said.

During the Covid-19 pandemic, when international travel was restricted, Bangladeshi patients had no choice but to rely on local healthcare providers. Many received quality care, proving that the country's medical system can deliver when adequately supported. However, the lasting perception of neglect and inefficiency continues to push patients abroad.

CALLS FOR REFORM

Industry leaders acknowledge the gaps. AM Shamim, founder of Labaid Hospital, admitted that while Bangladeshi doctors are technically skilled, they must improve their bedside manner and spend more time with patients. "We have the capacity to treat complex illnesses, but patient trust is eroded by behaviour and insufficient consultation time," he said.

Similarly, Prof Md Moazzem Hossain of Aichi Medical Group called for systemic reform. "We need skilled technologists, uniform cost structures, and better regulation from the Directorate General of Health Services," he said. "Patients need to feel confident in their care, and hospitals must prioritise patient-centred service over immediate profits."

India's visa restrictions, while inconvenient, offer Bangladesh a rare opportunity to reflect and reform. It's a chance to rebuild confidence, invest in patient-centred care, and address the systemic flaws that push patients abroad. Without addressing these issues, experts warn, the country risks perpetuating a reliance on foreign medical services -- a dependency both costly and avoidable.​