Mahmuder Rahman, chairman of the governing body of Dhaka Community Medical College, also chairman of Ibrahim Cardiac Hospital and Research Institute, talks about the importance of quality medical education among other public health concerns in an interview with Mahtab Uddin Ahmed
New Age: In your view, what is the status of the quality of health care services in Bangladesh?
Dr Mahmuder Rahman: First of all, quality of treatment depends not only on doctors, but also on nurses, paramedics and other associates such as laboratory technicians and those who work in community level. Considering this, it can be said that the quality of treatment in this country has improved in some aspects of health care. However, this improvement is not uniform across the country. As a matter of fact, in some places, quality of treatment even declined. The reasons behind such asymmetrical improvement of treatment quality are many. In the last two decades or so, many private medical colleges were established in this country. The number of public hospitals and medical colleges also increased. Many institutes, colleges and hospitals are established to train paramedics and nurses. However, there is a huge discrepancy between these institutions across the country in terms of providing quality medical education. Infrastructure for medical establishment has been prioritised over quality medical education. There are not enough qualified teachers. The government or private stakeholders have taken no effective initiative to assess or develop the quality of the teachers. As long as these initiatives are not taken the quality of medical education would not increase. We must remember, quality of treatment and quality of medical education goes hand in hand.
I must say, significant improvements have taken place in cardiology, nephrology and paediatrics. In case of bypass surgery or some complex operation of cardiovascular diseases treatment quality has reached to such a level in the last 20 years that one needs not to go abroad for these treatments at present. Local treatment quality is quite fine in these cases. But the problem is that these special treatments are not affordable to common people. Therefore, even in the cases where quality of treatment has improved, it remained inaccessible to the wider public. In terms of availability of advanced medical technologies and quality, we are more or less in the same page with many of other South Asian and Asian countries, although discrepancy in the quality of treatments within the country is more in Bangladesh compared to those countries. And it is about the question of ensuring access where we are falling behind.
At present, a lot of families are facing economic hardship from bearing the highly expensive medical treatment cost. If any survey is conducted in the slums of the capital, we will find out that many of them came here selling their capital and asset to ensure better medical care for their ailing family members. After the treatment, spending all they have, they cannot return to their village, as they have nothing to return to. The city centric treatment system is one of the reasons for this phenomenon. To decentralise the basic quality treatment facilities, the government has to play a vital role. A uniform development of basic treatment is necessary in divisional, district, upazila level so that people need not to come to capital for their treatment.
New Age: Since the independence of Bangladesh, what are the major developments in our public health sector?
Dr Mahmuder Rahman: In the last decades, the establishment of community health clinic is a significant change. Each clinic is for 6000 families. These clinics could have brought a major change in our public treatment system. Unfortunately, these clinics are not equipped with trained manpower and logistics which is incompatible with the philosophy according to which these clinics were established in the first place. There is no effective monitoring form the government on these community clinics. The medical equipments that are available there are not properly maintained. These clinics are established for basic health care, we don’t need highly qualified doctors there. Rather, we need good paramedics and nurses with good grasp on Medicare training. But these basic requirements of good paramedics and nurses are not fulfilled yet. Thus, the quality of these clinics is degrading day by day.
The number of district level hospitals has also increased in the last decades. For specialised treatments, hospitals in district level could play a major role. But those are not equipped with adequate number of trained doctors, nurses, paramedics and technicians. The availability of proper medicines is another issue for these hospitals. Specialised care for cardiac patients or kidney diseases or other non communicable diseases are not either available or equally available to all district level hospitals. Now we have more medical colleges, which are supposed to provide tertiary level treatment, but we cannot say that treatment quality in district level has also increased proportionately. However, building infrastructure alone is not enough. In paper, treatment capability in district level is increased, but it cannot be said that capability has increased in reality.
In case of private sector, we can now find private clinics even in upazila level with ultra sonogram, radiology and pathology facilities. But the problem is that most of these clinics are established for business only, not for giving service to people. As a result the quality of treatment in those private clinics is in lacking. The government has no surveillance and control over these clinics. Despite the shortcomings, however, these private treatment facilities are definitely a symbol of development at upazila level, at least some level of specialised treatment is now reached to that level. But only the local elites can enjoy services from these facilities, although the quality of treatment is in question.
We need to keep in mind that if we focus only on specialised treatments and neglect the basic treatment facilities, common people will be left outside the system. At first we have to ensure the basic treatment demands for all. Without ensuring basic facilities, if the limited resources are spent only to develop something specialised and technology dependent care, it would functionally serve the interest of a particular class from which commoners are excluded.
New Age: What are the main problems in our public health care system now?
Dr Mahmuder Rahman: In the previous decades, a large number of qualified doctors, nurses, paramedics and technicians migrated to abroad, a massive brain drain from this country has occurred in health sector. This is a major loss of public money. These people went abroad for higher studies, but most of them never returned. Brain drain is one of the reasons behind the shortage of qualified health service providers in the country. If they had returned, the average treatment quality could have been far better than present.
The other major problem is the commercialisation of treatment facilities. Some people have become very rich in this country. To cater that particular class, private sector has introduced many posh and high-tech treatment facilities, as well as ‘five star’ hospitals. Even a section of the middle class come to these private facilities selling their last resorts, because those quality treatments are unavailable in public hospitals. However, news about mistreatment in these private treatment facilities is not very uncommon. Whatever the ‘quality care’ they provide, the problem is that they are doing it for unchecked profit. The main objective is business, not service. Often they are imposing treatments that are not necessary in medical terms. Patients and their attendants do not know that, they are left with no choice but to indulge into doctor’s decisions. For example, we can consider the issue of ‘Intensive Care Unit’. Often these private hospitals refer patients to ICU without assessing properly whether ICU care is necessary for the particular patient. Definitely, the reason behind such practices is profit. Sometimes, such patients are referred to ICU who has no chance to survive clinically; therefore ICU cannot make any change for that type of patient. But without informing patient’s such harsh clinical reality to the concerned relatives, ICU is referred instantly, which is an unethical practice also, because of business interest and the patient’s family have to bear a huge amount of financial burden in these ICU-cases just for nothing. These private hospitals have created such hype that ICU care reached to a mythical status. People think that a hospital without ‘ICU’ must not be a good hospital. The reality is any bed of any hospital can be turned into an ICU. It does not need an expensive environment or a separate unit which the private hospitals have been promoting. More importantly, the cost of ICU is definitely not as high as most of the private hospitals are charging the patients with.
New Age: There are a lot of complaints about the commercial attitude of the doctors. What is the root cause of such commercially oriented medical practice? How can the state intervene to bring change in this regards?
Dr Mahmuder Rahman: Undoubtedly, commercialisation process has compromised the quality of treatment. It has also sharply influenced medical ethics in Bangladesh. Although there is widespread criticism about the commercial attitude of doctors, we have to realise that doctors are just a tiny part or ploy of this commercialisation process. The owners of private clinics, drug companies and other strong market forces are using doctors for their commercial interests. The root cause of this commercial attitude of doctors is consumer economy. Doctors are not detached from the society. In the last 30 years, world economy is driven by profit. Medical technological industry intruded the health sector. Globally, these developments have influenced the health care practices as well. Bangladesh is no exception. In this context, all sectors are driven by profit not service. It is quite naïve of us to expect that doctors would practise otherwise. Nobility is not taught anymore in the classrooms and not practised in workplaces in any sector, which was the case 50 years ago. How can we expect the doctors will remain outside of this commercialised system? Without ensuring at least minimum level of state control, strict monitoring of health market, and financial security for the doctors, it is impossible to control their commercial attitude. We cannot force the doctors to stop profiteering activities while keeping other profit-mongers in health sector untouched.
New Age: It is often said that, within a capitalist system you cannot have an ideal public healthcare system. To what extent, you think, public healthcare system can be strengthened in the current economic structure?
Dr Mahmuder Rahman: Even within the capitalist structure many changes are possible. There are many countries in this capitalist world which ensures significant amount of state control on health market. For example, we can look at Britain’s public healthcare system. Although commercialised health system has posed many problems there, but despite all of those problems it has ensured that everyone would get minimum treatment irrespective of their economic status. Here, the role of paramedics and nurses are important. In this regard public private partnership may work well. In this case, we can talk about Dhaka Community Hospital as an example. Ultimately, the political will of the government is necessary to make any change. The government of Bangladesh needs to increase its allocation on health sector in the national budget. In order to do so, government has to increase its income by putting an end to corruption and misuse of public money. It must prioritise health sector and ensure that the allocated money is well spent. More importantly, the state must effectively control the market forces in health sector and increase the quality of health personnel including nurses and paramedics. But so far, the government has not taken any effective initiative in this regard.
New Age: In what ways do you think the recent changes in our National Drug Policy are affecting our treatment system?
Dr Mahmuder Rahman: Many recent changes made in the national drug policy go against the interest of common people. For example, a surrender to the pressure of national and multinational drug companies ended in 1994 the government’s power to control the prices of all medicines but for some listed essential drugs. There is also the problem of drug usage. Situation at hand is so severe that drugs are not used but actually abused in Bangladesh. To ensure that the doctors are prescribing their medicines, drug companies are alluring doctors in many ways including bribery. The medical representatives play an important role in this under the table system. Therefore, many unnecessary drugs and antibiotics are prescribed without justification. Already antibiotic resistant bacteria syndrome has been documented in Bangladesh. Therefore if we do not stop the unnecessary use of antibiotics, that would be disastrous in future. In addition, there are many corporate and multinational treatment centres in the country that give target to the doctors to bring certain amount of money for the centres and compel the doctors to yield to their pressure. Therefore, national policies are necessary to outline a standard treatment procedure for doctors.
New Age: How many more public hospitals are needed to provide adequate care and attention to the patients come from common people in Bangladesh?
Dr Mahmuder Rahman: Definitely we need more standard public hospitals in district and upazila level. However, as I have mentioned earlier, without ensuring proper equipments and trained manpower only building an infrastructure is not enough. Sadly, that is exactly what is happening in Bangladesh now. People have a misconception that only good doctors are required to run a good hospital. Actually, we need to understand that doctors are only a small part of hospital based services. In fact, hospitals are not managed by doctors. Rather, it is mainly managed by nurses, paramedics and technicians. Therefore, without adequately trained and well paid nurses, technicians and paramedics, it is impossible to run a hospital. Our backward social mindset is playing an influential role in the valuation of the work of nurses. Even today, we consider nursing as a low status job. This is a form of stigma. Society treats nurses as someone from lower class. Nurses are not getting their due honour. Their role in the health system is not valued. Inevitably, salary scale of nursing cadre is inadequate. Nurses are given the 2nd class status in salary scale. A qualified ward sister or ward supervisor, who has 20 years experience, why should not s/he get first class salary scale, particularly when s/he is the main pillar of a hospital? Why shouldn’t they enjoy salary increment? We have to think about these facts. Under the current circumstances, meritorious students don’t feel encouraged to join the profession of nursing. Students from the middle class treat nursing as a job of the poor people. For a better and qualified treatment system, we must give the dignity that the nursing profession deserves. Similar changes in the social and salary status of the paramedics are also necessary. Therefore, it is not only about the number of public hospital that matters, there are other far reaching issues involved that demand our attentions.
New Age: To improve the public health system, what do you think should be the role of public? In your view, what are the urgent demands of public health movement today?
Dr Mahmuder Rahman: The common people, however, have also some duties to make a positive change in the health system of the country. They also have to understand what a health system actually is. Many diseases can easily be prevented, if people become aware. The awareness must begin at the family level. Each child must be taught that it is his/her responsibility to maintain his/her health. If people practise the preventive measures in their family, definitely many diseases can be controlled. For example, if we control our food habit, habit of smoking and various types of pollution in community level, many diseases will be easy to control. First, people must play an active role in curbing harmful habits. At the same time, they must ask the government to stop air, water and sound pollution. People must ask for safe drinking water. They must pressure the government to stop food adulteration. They must raise demand for children’s playground as well as parks for citizens in each neighbourhood of the cities where they can breathe for a while. They can raise demand for gymnasiums. They must raise demand for trained health workers in every school to teach students about nutrition and basic preventive measures of diseases. People must also demand balanced diet for every child. And, obviously people must raise their voice against the unregulated commercialisation of health care facilities — unnecessary investigations, ICU charges, making excessive profit through medicine business etc — and pressure the government to control the market forces active in the health sector.