Bangladesh has achieved significant progress in health sector. A tiny little portion of this achieved success is my contribution! I feel proud when I think about it. And then the disgrace of some failures and irregularities depress me. I wonder if these irregularities were removed, we could have advanced more. Though healthcare is a basic right, still 64 per cent of the cost is borne by the citizens on their own. It is a matter of hope that recently we have raised ourselves among the countries with lower medium income range. But wastage and misuse are also happening here.
Fifty eight per cent of the total workforce involved in the health sector is employed in private organizations. The World Health Organization, The World Bank, several local and international donor agencies and research institutions have frequently drawn attention to the necessity of government surveillance and control over these private institutions, health centres, hospitals and clinics. Unfortunately the government could not undertake any significant initiative, except a few. But overall improvement in the health sector is not possible without improving the surveillance of the government on the private sector.
When we talk about irregularities in the health sector, we bring forward the absence of doctors in the work place, unhygienic hospital, disabled machine, lack of necessary medicine supply, etc. But if we observe closely, we may find that the doctor who is supposed to be at her/his work place assigned by the government, s/he is busy in her/his roster duty in some private hospital at that very moment. It appears that some people like to keep the disabled machine and shortage of necessary medicines as they are, rather than informing the appropriate authority about the problem. And for this reason the clinics, diagnostic centres and pharmacies owned by them get higher revenues. There are patients who do not want to stand in a big queue in public hospitals and want to avoid the troubles at every step. They are coming by these medical facilities from private hospitals and clinics at double, triple or even quadruple higher cost. And those who cannot afford the cost are staying in public hospitals or seek refuge in kobiraj, charmed water or charmed cure.
There should be accountability with regard to our activities in this profession. We need to explain why a patient is transferred from one centre to another, why the patient is sent to another centre for lab test, why antibiotics are used so frequently and exceed the dose, etc.
Although only 30 per cent of the population lives in urban areas, most of the advanced medical facilities are city centered. For any medical treatment in developed countries, at first you need to visit the General Practitioner (G.P.). A Specialist Doctor will only be available if the G.P. recommends you to the Specialist. In our country, we have a tendency to directly visit the Specialist Doctor in case of any illness. But General Practitioners can give better advice about which Specialist to visit in case of, say for example, pain in the abdomen. In many cases, medical treatment by the General Practitioner cures the patient. Here it looks as if we are killing mosquitoes with cannon balls. As we are bearing 64 per cent of the healthcare cost from our own pockets, we are taking decisions as we like. And thus in many cases we are deceived, or paying three to four folds than the actual cost.
In our country, we can visit a Specialist Doctor very easily. But as there is a huge queue of patients, my serial may come at 2 O'clock in the morning. Or maybe the Specialist is not available to be consulted for the next three months. Now my question is, in such a crowd of patients, can the Specialist Doctor provide quality treatment and adequate time to every patient? Probably the solution would be possible for many of the patients through appropriate counseling and first aid. But the patients are suffering due to ignorance or wrong choice. The report quality and higher cost in private diagnostic centres have been subject matters of many discussions. When a doctor refers any patient to a diagnostic centre, s/he gets a referral fee from that centre, which is 25 per cent to 30 per cent of the patient's test fees, sometimes even more. Although according to government rules and regulations all the test fees should be displayed to inform the people, most of the private service providers do not comply with this. These five-star hotel look-alike diagnostic centres do not display any kind of test fees anywhere.
In aristocratic areas like Dhanmondi and Gulshan, monthly rent for every square feet of commercial space is high. The diagnostic centres in these places also have doctors' chambers. The doctors do private practice there. The area of every chamber is at least 200-300 square feet, which indicates a monthly rent of at least BDT 20,000 to 30,000. Most of the diagnostic centres invest BDT 30,000 per month and give the doctor an opportunity to sit there. This doctor then feels an obligation to think about the welfare of the diagnostic centre while examining and prescribing the patients, or counseling them for lab tests. No matter whose welfare is preserved, at the end of the day the patient has to bear the cost.
Like the diagnostic centres, the owners of private medical colleges, hospitals and clinics want to fill up all the hospital beds. The responsibility of this filling up goes to the doctors working there. They are rebuked for vacant beds. Many doctors suffer from excessive mental pressure due to this. And for this reason, some of them are forced to admit patients and perform operations, only to avoid showing vacant beds.
The number of medical colleges is increasing in the country. Every year many students are graduating and becoming doctors. What examples are we setting for them? I am involved in the teaching profession. At a reception ceremony for fresh intern doctors in a college, one renowned Professor said, "You all need to be post graduate doctors. Nowadays, the MBBS has no value. Nobody goes to them."
In this way, we are setting an objective for the young doctors. But the results will be devastating. My question is, why will people not go to MBBS doctors? Then why did we certify them as doctors after teaching? In developed countries, General Practitioners cure patients with first aid. Then why do we need to go to Specialist Doctors for cure? That day that Professor did not even notice in what uncertainty and despair he had thrown these fresh doctors! Where he drowned their self confidence! I have visited many places to build awareness of healthcare issues among people. There I have observed people at the root level without any healthcare knowledge, and full of superstition. An MBBS doctor is quite sufficient to remove this problem with a scientific solution. I am compelled to tell our fresh young doctors that we are showing them the wrong direction. They have the capability to build a healthy nation. If required, the General Practitioners can be put under better rules and regulations, observation and surveillance.
In developed countries, medicines are prescribed according to their generic names. But in our country, we prescribe the trade names. Probably we get biased and prescribe the medicines of the company whose Medical Representatives visit the doctor's chamber regularly; provide television, refrigerator, cost of visiting abroad, materials of personal need, etc. We do not even care about the quality of those medicines. Sometimes we prescribe such medicines which the patient cannot find even after covering half the city.
We shall find a group of people in front of hospitals and diagnostic centres, who carefully observe the prescriptions of the patients. The objective is to find out which doctor prescribes their medicines and which doctor does not. The infiltration of these medical representatives in the hospital premises could not be prevented despite many initiatives taken so far. Now if the doctors prescribe the generic names, shall we find these medical representatives in front of our chambers?
In this age of information technology, people are much more conscious than earlier. Patients are no more satisfied with the idea that the doctor talks very little and s/he may get angry if one more question is asked.
The quality of medical treatment is not bad in our country. But we do not give adequate time in counseling the patients. For this reason they cannot rely on it, or cannot follow the instructions properly.
A proper initiative of the present government is the Community Clinics. At primary stage, every patient will go to the General Practitioner at the nearby Health Centre. If the General Practitioner feels it is required, s/he will recommend the patient to a Specialist Doctor. If required, the government appointed doctors can be provided with "Non Practicing Allowance" to keep them present in their work places. Because the doctors who work in more than one centres, they cannot consider any centre of their own, and also cannot concentrate in their work.
The list and registration number of doctors working in private health centres should be available to the government regulatory authority. The same registration number cannot be used by two different centres. BMDC should be more effective in preventing unethical medical treatments and irregularities. The Health Education Bureau should be more active to build public awareness.
The objective of this writing is not to belittle anybody or obstruct the interest of anyone. In my professional life, cooperation from countless colleagues, respect from students and affection from people have given me the courage to speak the truth. I want to draw the attention of my colleagues to the fact that doctors are the best children of a nation. In your work place, the patients consider you as representatives of God. After working so many years with irregularities, we have forgotten the real rules and regulations. Now it is time for us to turn back. The nation has a lot of expectations from doctors. To ensure good health for all, we need to work
together, putting a bridle on our personal interests.
Dr Nowsheen Sharmin Purabi can be contacted on her website: www.drpurabi.com;
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