[🇧🇩] Healthcare Industry in Bangladesh

[Saif]

We must be bold with health sector reforms

While we have made significant achievements, complacency cannot be allowed

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We must be bold with health sector reforms
While we have made significant achievements, complacency cannot be allowed

VISUAL: SHAIKH SULTANA JAHAN BADHON

The health sector holds an important place in a nation's development. The past few decades have witnessed some remarkable strides in Bangladesh's health sector. However, this has largely stalled since 2010. Between 1990 and 2010, Bangladesh reduced its maternal mortality ratio from 600 per 100,000 live births to 194, an astonishing achievement. After almost a decade, however, there has been little improvement. Such stagnation was similarly observed in several other indicators of a nation's development.

It is said that we harvested the "low-hanging fruits" well. Bangladesh is committed to reducing the maternal mortality ratio to 70 by 2030, but given the current situation, this seems like an unachievable target. To attain progress, we need to focus on the more difficult, "high-hanging fruits." Civil society activists and health experts repeatedly highlighted this challenge to the previous government, but sadly, serious efforts were not made. Instead, a sense of complacency prevailed. The result was that any idea suggesting reform faced resistance.

The anti-discrimination movement has inspired the nation and sparked hope among the masses. It has given us a chance to rethink our future. In the health sector, we now have an opportunity for comprehensive reform. If we want to move forward in line with the times, we must be ready to tackle some difficult tasks.

We know, for instance, that good governance is a major issue for development in Bangladesh. Poor governance leads to many problems, and the health sector is no exception. The absence of doctors in health centres is a perennial issue. The corruption that surfaced during the Covid pandemic is still fresh in our memory. We know these issues arise due to the lack of accountability and poor management. The private healthcare sector has become a behemoth without any control whatsoever, harbouring severe inequalities. In 1982, an ordinance was passed giving special priority to the private sector, but it has not been updated since. There is no clear regulatory provisions to control them, leading them to get away with unethical and illegal practices. Despite the presence of the Bangladesh Medical and Dental Council which was established decades ago to monitor the professional behaviour of doctors, many still engage in unethical practices without facing any consequences.

One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.

Another significant drawback in our healthcare system is poor investment. Currently, the government's spendings on healthcare is one of the lowest globally: only 0.7 percent of the GDP. With such meagre investment, it is impossible to imagine modern healthcare. We have seen to our dismay that two of the important pillars of human development, health and education, were among the lowest priorities for the previous government. Our neighbour Sri Lanka, which is far ahead of us in most indicators, spends nearly four times more on health than we do in Bangladesh. Even the small funding that the health sector gets is not fully utilised, with the utilisation rates remaining below 80 percent. One of the main reasons for this is the lack of adequate capacity in the ministry of health, whose inefficiency in drafting a proper budget, planning, and utilising funds is very well-known. The lack of vision is yet another reason. A "poverty of vision" seems to have gripped the ministry. If we want to emerge as a prosperous nation, our health planners must have a clear vision befitting the health system of a developing country, and our budgets should be framed accordingly.

One of the benchmarks for countries that have made significant progress in health is their investment in primary healthcare. Bangladesh's primary healthcare system extends from upazilas to unions and community clinics. Ignoring the primary level and focusing on urban-based big hospitals is an action equivalent to nurturing social inequality. Increased investment in primary healthcare with an effective referral system would significantly reduce the pressure on urban hospitals.

In addition, another significant issue plaguing Bangladesh's healthcare system is its human resources. Doctors, nurses, and midwives are in severely short supply. To address this crisis, the previous governments licensed new institutions in both the public and private sectors which contributed in alleviating the crisis to some extent. However, there is no effective mechanism in place to ensure the quality of these institutions. Similarly, we need to focus on research. Recently, Bangladesh Health Watch published an extensive research-based book documenting Bangladesh's first 50 years, which shows how Bangladesh has surpassed its neighbours in various health indicators. One of the findings revealed that in recent years, Pakistan has been able to overtake Bangladesh in health research.

The previous government had expressed its commitment to achieve Universal Health Coverage (UHC). Unfortunately, it never felt the need to explain in detail how this would be done or where the additional funds would come from.

The recent uprising is a massive achievement, with tremendous sacrifices made by students and common citizens. We know that every crisis also presents an opportunity. After World War II, the European countries built their health systems on the ruins of war, ensuring free healthcare for all citizens. In the 1990s, after a horrific genocide, Rwanda launched its UHC programme. As I see it, the student revolution has similarly given us a golden opportunity to overhaul our broken health system. Experts have agreed on what needs to be done. This can be broadly divided into five actions: i) establish a high-powered permanent national health commission to create and monitor a roadmap for implementing UHC nationwide; ii) establish a national health security office to ensure accountability in the health system by separating the ministry of health's roles as a "purchaser" and "provider"; iii) ensure good governance and proper management; iv) increase healthcare investment to two percent of GDP, with increased priority for primary healthcare; and v) enhance the quality, efficiency, and oversight of institutions involved in professional health education and research.

I believe that if we follow this path, we will confidently move towards achieving our national goals. While we have made significant achievements, complacency cannot be allowed and must be kept at bay. To bring about a real and lasting change, there is no alternative to reform. This is something the student leaders have repeatedly emphasised. The interim government must take a bold stance and move towards reforms in the health sector that lead to the public being served.

Ahmed Mushtaque Raza Chowdhury is convener at Bangladesh Health Watch, and professor of population and family health at Columbia University, New York.​

 

[Saif]

Healthcare in tatters: Health workers must go to the distressed

When it is not possible for the distressed people to come to the Upazila Health Complexes for treatment, then the health workers themselves have to reach out to them. More medical teams should be sent to the affected areas on an urgent basis. Sending only the medical teams won’t do, they should...

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Healthcare in tatters: Health workers must go to the distressed
Editorial Desk
Published: 01 Sep 2024, 19: 02

Healthcare experts had warned already that various water-borne diseases will spread out in the flood affected areas as soon as the water recedes. Especially there looms the risk of a diarrhoea outbreak in these areas due to the lack of pure drinking water. And that’s exactly what happened in reality.

The healthcare system we have here is the one where the patients are required to go to the hospitals, clinics and physicians. The physicians or the health workers do not go to the patients. This might be acceptable under normal circumstances.

But that seems no longer a possibility for many during natural calamities like floods and cyclones. Though the water has receded in many areas the road communication could not be restored yet. In Bangladesh, Upazila Health Complexes are the main support for reaching out health care at the grass root level.

However the problem is that these establishments lack in the necessary manpower, infrastructure, equipment and medicines. The condition of the community clinics that were established to reach out healthcare to remote areas during the Awami League government’s regime is also of the sort that even if they do have the wish to provide healthcare they lack the capability. Besides, not all the villages have clinics either. And, the villages where there is a clinic are visited by the people seeking health care from the surrounding villages.

The communication system in some districts of the eastern region has been completely destroyed by to severe floods that continued for several days this time. There is not even a way to go to the next house let alone the next village. As reported in Prothom Alo, people in the flood affected areas started suffering from diarrhoea, skin diseases, fever, cold and cough as soon as the flood water receded. Plus, sores and skin rashes are being noticed on the hands and feet of many.

Since the flood situation continued for nine days, the elderly and the children are suffering more from fever, cold and diarrhoea in Feni, Noakhali, Lakshmipur and Cumilla districts. Residents of the affected areas complain that many of the community clinics are closed due to waterlogging. The ministry of disaster management and relief has stated that a total of 619 medical teams are working in 11 districts to provide medical services to people in the flood-affected areas.

Then where are these many medical teams are working? Are their activities limited only to the side of the roads and the highways?

Civil surgeon in Feni, Md Shihab Uddin has also admitted that the number of diarrhoea cases is very high in the flood affected areas. The number of patients has increased in all hospitals of the upazilas as well as of the districts. For the time being there is not that much shortage of saline and ORS for diarrhoea.

According to the office of the civil surgeon in Lakshmipur, as many as 40 community clinics and three sub-health complexes on the union level have been submerged underwater. Strong efforts are being made to provide good treatment to the people affected by the flood at various places including the shelters.

The in-charges of all the hospitals and clinics are providing records of how many patients they have received. However, they are saying anything on how many patients they reached out to. When it is not possible for the distressed people to come to the Upazila Health Complexes for treatment, then the health workers themselves have to reach out to them. If there are some issues with boats in this case, those have to be solved as well. Plus, arrangements have to made quickly so that the closed down community clinics can be reopened as soon as the water recedes.

More medical teams should be sent to the affected areas on an urgent basis. Sending only the medical teams won’t do, they should also have the necessary medicines and medical supplies. There should not be even a single day of delay, especially in the areas where there has been a diarrhoea outbreak already.​

 

[Saif]

Bold, pragmatic measures can revitalise Bangladesh’s health sector

Investment in the health sector must unquestionably be enhanced with the objective of major overhauling.

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Bold, pragmatic measures can revitalise Bangladesh’s health sector

FILE VISUAL: SHAIKH SULTANA JAHAN BADHON

Bangladesh, with a population of over 17 crore, is the eighth most populous country in the world. With the annual population growth rate of around one percent, it is likely to stabilise at around 240-250 million, posing considerable challenges for Bangladesh given its small land area and other resource constraints.

From high fertility (TFR of over six) until the mid-1980s, fertility declined to 3.3 during 1994-2000, and further to 2.3 by 2011. However, it has stalled at that level since then. The family planning programme achieved commendable success until 2011, with the contraceptive prevalence rate (CPR) rising from around four percent in the 1960s to 61.2 percent in 2011, but it has remained almost unchanged (64 percent in 2022, according to Bangladesh Demographic and Health Survey) since then. This is on account of several factors, including, but not limited to: i) decline in the relative share of longer-acting and permanent methods (LAPM), from 32 percent of modern method use in 1994 to only 14 percent in 2022; relying on temporary methods rather than accepting LAPM by women who have completed their family size poses a major problem for the efficiency of the programme; ii) Relatively high unmet need for contraception (10 percent); if users of traditional methods (nine percent) are considered, the total unmet need for modern methods was 19 percent in 2022; iii) relatively high discontinuation, implying huge system loss for the programme (around half of the users stop using a method within 12 months of starting its use; and iv) erratic interruptions in supplies of contraceptives.

Since independence, Bangladesh has achieved considerable success in most health indicators, though there are inequities based on the socioeconomic status of the population. The infant mortality rate (IMR) declined from 144 deaths per 1,000 live births in 1971 to 25 in 2022, though it is higher than in Sri Lanka, Nepal, Maldives and Bhutan. The under-five mortality rate declined from 223 to 31, but it is higher than in Sri Lanka and Maldives. The maternal mortality ratio (MMR) declined from 574 deaths per 100,000 live births in 1990 to 176 in 2017, but it is higher than the average MMR in South Asia (157 in 2017), and also higher than in India, Sri Lanka, Bhutan and Maldives. Over the past five decades, there has been a rise in life expectancy from 45 years to around 74 years, but it is lower than in Sri Lanka and Maldives.

Between 1990 and 2019, the total number of people with non-communicable diseases (NCDs) increased from 9.55 crore to 14.5 crore. Deaths due to NCDs increased, with 14 of the top 20 leading causes of death in 2019 due to such diseases, with stroke at the lead. If this trend continues, management of the increased burden of NCDs will be a considerable challenge for the country's healthcare system. Cost-effective, multisectoral efforts are needed to prevent and control NCDs, promote healthy lifestyle, and prevent premature mortality and disabilities. There has been a substantial decline in deaths due to communicable diseases—malaria, dengue, AIDS, tuberculosis and diarrhoea—though they still remain significant causes of illness and premature deaths. Bangladesh is also a high-risk country for emerging communicable diseases as a result of its high population density and poverty.

Although there has been considerable decline in child and maternal malnutrition, it continues to be a serious public health problem in the country. Also, there are sharp differences in child malnutrition based on mothers' education and household income.

Women of reproductive ages are vulnerable to chronic energy deficiency and malnutrition, the major risk factors for adverse birth outcomes. The double burden of malnutrition is becoming more prevalent among Bangladeshi women. Those with uneducated husbands, those with little or no education, and those belonging to less well-off households, especially from rural areas, are more likely to be underweight than women in other groups, while overweight is higher among the educated and those belonging to relatively well-off households. High rates of maternal malnutrition and low birth weight (LBW) can lead to a high burden of NCDs in adult life. The prevalence of LBW in Bangladesh is around 16 percent, similar to that in India and Pakistan, but higher than in Nepal and Sri Lanka. LBW is inversely associated with mothers' education, household income, and occupation.

In addition to problems specific to population, health and nutrition, there are several constraints that cut across all three of these sub-sectors. Quite importantly, there is an apparent lack of political commitment, affecting the overall healthcare sector. This is clearly evident from i) low investment in the health sector (less than one percent of GDP), the lowest in South Asia; ii) high out-of-pocket (OOP) expenses—about 70 percent—the ever-rising cost of healthcare making quality healthcare services virtually out of reach, especially among the poor; iii) both the health and population policies of 2012 not updated for 12 years; iv) human resource problems—inadequate staffing, lack of trained staff, absenteeism at different levels, one of the worst nurse-physician ratios in the world; v) lack of coordination among various actors and stakeholders, resulting in duplication, inefficiency, wastage, and gaps in service delivery; vi) bifurcation of the Ministry of Health and Family Welfare into two divisions, thereby further hampering coordinated service delivery from the Directorate General of Family Planning (DGFP) and Directorate General of Health Services (DGHS); vii) lack of effective coordination between the health ministry and the Ministry of Local Government, Rural Development and Cooperatives, thereby adversely affecting urban healthcare delivery services; viii) lack of effective monitoring and supervision; and ix) lack of transparency and accountability at different levels of the programme.

Bold and pragmatic reform measures should be undertaken to revitalise the entire health sector to overcome the constraints identified above in order to improve access, quality, and sustainability of healthcare services to people, with special consideration given to the poor and the needy. Investment in the health sector must unquestionably be enhanced to around two percent of GDP, together with enhanced spending capacity of the programme with the objective of major overhauling of the sector, wherever needed, such as in human resource-related issues, procurement, and helping reduce OOP. Likewise, allocation to the education sector should be enhanced to raise not only enrolments but also—and more importantly—to improve quality of education at different levels, with special consideration given to female education. The latter will help reduce child marriage and raise child-bearing age as well as female employment.

The outdated health and population policies should be updated, taking into consideration both demographic and epidemiological changes as well as socioeconomic changes that have occurred during this period. Pragmatic mechanisms should be put in place to ensure effective monitoring and supervision, meaningful coordination among all actors and stakeholders in the programme, including between the health and local government ministries, and address issues related to the lack of accountability and transparency at different levels of the programme. To give further impetus to political commitment, a high-level body—a national health council—should be formed under the leadership of the head of the government, to review progress and constraints, and provide oversight to programme activities, at least biannually. The council should include concerned stakeholders, including high-level professionals from relevant disciplines.

Barkat-e-Khuda, PhD, is a former professor and chairman of the Department of Economics at Dhaka University.​

 

[Saif]

WB points out myriad issues in healthcare

The World Bank has committed to giving Bangladesh $400 million for implementing the next five-year plan for the health sector, which is estimated to cost around $9 billion.

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WB points out myriad issues in healthcare
Commits $400m to Dhaka for the next five-year plan

The World Bank has committed to giving Bangladesh $400 million for implementing the next five-year plan for the health sector, which is estimated to cost around $9 billion.

The government expects $2.3 billion of it to come from multilateral and bilateral partners, including the World Bank (WB), the Asian Development Bank (ADB), and the Japan International Cooperation Agency (JICA).

According to finance ministry officials, negotiations with the WB were completed on Monday, and the first round of talks with the ADB and JICA also concluded.

Officials of the Economic Relations Division of the finance ministry said they would soon finalise each development partner's contribution to the plan. The government would foot the rest of the bill.

The plan, titled "Health, Nutrition, and Population Sector Development Programme (HNPSDP)", is renewed every five years. The current plan is set to expire in June next year.

Experts said the existing budget for health is insufficient and that the sector has struggled to effectively use the funds allocated to it.

In recent review of the health sector, the WB said, "Bangladesh's Health, Nutrition, and Population (HNP) sector faces numerous challenges, including maintaining immunisation coverage, improving child nutrition, enhancing the quality and reach of services, reducing socio-economic and regional disparities, addressing emerging health challenges, and strengthening financial management in the health sector."

Syed Abdul Hamid, health economics professor at Dhaka University, said the current health system is ineffective, preventing people from truly benefiting from it.

"The main issue is that the sector lacks sufficient funding. We are unable to even fully utilise the limited funds. The money is often inefficiently spent," he told The Daily Star, adding that corruption was a major issue too.

The World Bank has identified several challenges, including the slow pace of poverty reduction amid widening inequality, as well as malnutrition.

It noted that even though the maternal mortality ratio has declined to 143 per 1,00,000 live births, it is still more than double the global Sustainable Development Goal target of 70.

It observed that malnutrition threatens health outcomes and human capital. Nearly one in five women in Bangladesh is undernourished, one in three women aged 15-49 is anaemic, and one in six babies is born with a low birth weight, it said.

Improving the quality of antenatal care by including measures like multiple micronutrient supplementation could help prevent these poor outcomes, stated the WB.

Action is urgently needed as Bangladesh is also vulnerable to climate change, which threatens to exacerbate malnutrition and increase the risk of climate-sensitive non-communicable diseases, it said.

"Underlying these trends is a low-quality health system," the WB said, adding that maternal health services suffer from poor quality, with issues like inadequate midwife support during childbirth, overuse of cesarean sections, and ineffective referral systems for timely care of complications.

The WB further mentioned that "primary healthcare facility performance is about 60 percent", contributing to a high rate of preventable complications, increased reliance on more expensive and climate-intensive services, and a high out-of-pocket payment rate of 68.5 percent.

Prof Syed Abdul Hamid held the sector's inefficient management accountable for these issues and suggested that recruitment for managerial positions needs to be overhauled, with rigorous training provided for both managers and supporting staff.

He advocated for block allocations for public hospitals to address emergency crises and recommended involving the private sector for repairs of machinery.

Hamid also called for streamlining the medicine supply chain, strengthening Essential Drug Company Ltd., increasing dedicated drug storage capacity, overhauling the rural healthcare sector by consolidating health and family planning services under a single framework, and establishing primary healthcare services in urban areas.

To reduce out-of-pocket expenses, he suggested lowering medicine consumption, regulating pharmacies, and controlling drug prices.​

 

[Saif]

Bangladeshis spend $4b annually for healthcare abroad

DCCI Senior Vice President Malik Talha Ismail Bari says in a seminar on outbound healthcare tourism

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Bangladeshis spend $4b annually for healthcare abroad
DCCI Senior Vice President Malik Talha Ismail Bari says in a seminar on outbound healthcare tourism

Bangladeshis spend around $4 billion abroad every year for healthcare, according to Malik Talha Ismail Bari, senior vice president of the Dhaka Chamber of Commerce and Industry (DCCI).

This is due to a lack of specialised treatment, trust on doctors and advanced technology within the country alongside costs being comparatively lower abroad, he said.

Bari, also a director of United Hospital, was delivering a keynote paper through a presentation at a seminar, styled "Reversing the Outbound Healthcare Tourism", at the DCCI today.

There are 5,461 private hospitals and clinics in Bangladesh, of which 1,810 are within Dhaka division, he said.

People in rural areas are deprived of quality and adequate healthcare services while pressure is created for an influx of patients at healthcare facilities in Dhaka.

Limited infrastructure, a lack of skilled workforce, quality and safety concerns, low doctor-patient ratio and long waiting periods are some of the bottlenecks to access advanced healthcare in Bangladesh, he added.

Bari informed that Bangladesh allocated Tk 30,125 crore, or 3.78 percent of its national budget, for public healthcare in fiscal year 2024-25.

Pre-capita health expenditure, or annual government spending for healthcare per person, is $110 in Bangladesh whereas $401 in South Asia, he said.

Patients sometimes go abroad for healthcare services due to a lack of facilities, trust and comfort and reversing this trend requires formulation of a proper plan and identifying the bottlenecks, said National Professor AK Azad Khan.

"Since medical science is an ever-changing process, we need to have a proper curriculum to adopt the best technological advancements," said Khan, also president of the Diabetic Association of Bangladesh.

He also stressed on the standardisation of laboratories, adequate budgetary allocation, facilitating more research and strengthening the Bangladesh Medical and Dental Council (BM&DC), which is the regulatory authority for medical and dental education in Bangladesh.

Trust is a crucial factor when considering this sector's development, said Rezaul Karim Kazal, professor of the obstetrics and gynaecology department at Bangabandhu Sheikh Mujib Medical University.

Quality hospitals should be established in rural areas for wider coverage alongside customised services for all types of patients, he added.

Only doctors should be appointed through Bangladesh Civil Service for the public health administration to be run efficiently, said Syed Abdul Hamid, professor at the Institute of Health Economics of the University of Dhaka.

Moreover, a "health service commission" should be formed similar to the Bangladesh Judicial Service Commission, which assess the suitability of persons for entry-level appointments as assistant judges or judicial magistrates, he added.

Liaquat Hossain, registrar of the BM&DC, suggested that the national policy for registering foreign doctors to practice in Bangladesh could be simplified.

Of the 1,34,000 doctors in Bangladesh, only 33,000 are in public service, said Abul Bashar Md Jamal, a former professor of surgery at Dhaka Medical College Hospital.

However, over 10,000 foreign students are studying in different public and private medical colleges here, he added.

Members of middle-income households are increasingly seeking healthcare services abroad, mainly for a lack of confidence and satisfaction, said DCCI President Ashraf Ahmed.

Only a few types of advanced treatments, such as robotic surgery, are available locally, he said.

The trend can be reversed by outperforming regional competition, ensuring customer satisfaction and enhancing quality of medical services, reliability and branding initiatives, he added.

"We need to be more open to foreign doctors, nurses, medical technologists and other specialists," opined Ahmed.​

 

[Saif]

Accessibility of healthcare in Bangladesh

What should be the government’s main role in health service delivery?

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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.​

 

[Saif]

Priorities for Bangladesh’s health sector

Crucial steps are needed in the health sector for lasting change.

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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.​

 

[Saif]

Reform for equitable primary health care

New Age, a Dhaka-based leading English language daily newspaper, is a major source of news of Bangladesh and international affairs

www.newagebd.net

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.​

 

[Saif]

Separated conjoined twins leave BSMMU for home

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...

www.newagebd.net

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.​

 

[Saif]

Stop unethical practices in health sector

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

thefinancialexpress.com.bd

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.​