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Cover Story

What Healthcare can be

Healthcare has become a luxury for most people in Bangladesh, although the country's constitution says that it is a fundamental right of each citizen. With the deterioration in the quality of care in public hospitals and exorbitant costs imposed by private hospitals, for the ordinary citizen healthcare is drifting out of reach. Against such a bleak scenario the Dhaka Community Hospital has been a shining exception to the rule by making standard healthcare accessible for everyone.

Ershad Kamol

It was just a 20-bed hospital, when it was established at Malibagh Chowdhury Para in 1988. But with the dedication of the trustees to open the door for providing quality health service, Dhaka Community Hospital emerged as a progressive and innovative organisation creating access to equal and standard healthcare for all. At present Dhaka Community Hospital (DCH) is a 250 bed modern hospital located at Moghbazar, Dhaka. It works as a referral centre and provides mainly tertiary level health care. This centre is also used for planning, development and training. It is a trust owned private, non-profit making and self financed hospital. However, the trustees do not claim it as a charity or a hospital only for the poor. Rather, they claim it is a model of an integrated and sustainable health care delivery system at an affordable cost for both the urban and rural areas of Bangladesh.

The hospital provides a community-based scheme in the rural and urban areas. If every household in a community of 3,000 families pays Tk 10 a month, it can have a qualified doctor and a number of health workers. DCH has got primary health care centres at 30 locations in Bangladesh. Primary and secondary level of health care is given at these centres.

Under this programme, any family can get a 'Family Health Card' against a yearly payment of a small amount of money. Any member of the cardholder family can receive the services of an out patient specialist doctor managed and financed by the local community. Besides, if the family wants to get other services of DCH they will receive 10 percent commission on the overall expenditure of the treatment. The card is renewable every year. Moreover, it arranges demand based special programmes for health camp, field hospital for cyclone victims, camps during diarrhoea outbreaks and so on.

For Dhaka the registration cost is Tk. 50. Each time one has to pay Tk. 30 for an outdoor service. In case of any complex issue the duty doctor in the outdoor service will refer to the consultant. No fee is needed for such appointments. But if anybody wants to visit the consultant directly she or he will have to pay Tk. 300.

It is the standard of health service that attracts people from all economic backgrounds to go to Dhaka Community Hospital.

Bakul Begum a 55-year-old woman came to the hospital to treat her arthritis. "I prefer Dhaka Community Hospital to other hospitals because I am pleased at their service" she says. "Doctors, nurses and other officials are very caring and friendly."

Habibur Rahman, from Abdul Hadi Lane, Old Dhaka, went to visit the dentist at the outdoor service section of the hospital. Rahman says, "It's not the low cost rather the standard of their treatment that motivated me to come to this hospital. I don't think treatment in this hospital is remarkably cheap. In fact, there are many hospitals in the city, which provide treatment at cheap rates. This hospital is better in terms of quality of medicare at a comparatively reasonable rate."

Common complaints against public hospitals include the apathy of doctors and nurses regarding their job and negligent attitude towards the patients. There are allegations of negligence, absence in the workplaces, misbehaving with patients, utter disregard for accountability, tendency to ask for 'commission' and general corruption. As a result people prefer private hospitals although only a few can afford them. On the other hand most NGOs working in healthcare mainly provide preventive services such as sanitation and immunisation. Prescribed and funded by the donor agencies, millions of dollars have been spent so far in the name of different primary healthcare services run by the NGOs such as Health and Population Sector Programme (HPSP) and Health, Nutrition and Population Sector Programme (HNPSP) during the last one decade. Yet no major change has been noted in the health sector crisis. The philosophy behind both programmes is to conform to the principles of a free market economy where the 'patient' is now a 'consumer', and the 'doctor' the 'service provider' and 'treatment' a consumable 'good'. Inefficiency in health governance, corruption, lack of transparency, incompetence in fund management, partisan policies and favouritism result in funds not being allocated properly. As a result, people are worried about getting standard health service at an affordable rate. Dhaka Community Hospital, with an approach to give standard healthcare for everyone in the community, shows how healthcare can be made both affordable and of high quality.

The poor state of health management and the appalling way in which many people die because of lack of medical treatment deeply disturbed Professor Quazi Quamruzzaman and his friend Professor Mahmuder Rahman and prompted them to start thinking about building a hospital with the aim to serve the community with equal standard medical services.

The ICU at the hospital. Chemists are testing water at the arsenic laboratory.

"The idea to bring modern health care facilities to the less affluent section of the population came to my mind during the Liberation War," Professor Quazi Quamruzzaman, the chairman of the trustees of the hospital, says. "Fighting in the frontline during the Liberation War, I saw the sufferings of the people who don't have any access to healthcare."

Professor Zaman came to join the Liberation War though he was an established medical practitioner in Britain. After independence he again went back to the UK to get more training in the health sector.

"In the mid 1970s I permanently came to the country and joined as a paediatric surgeon at Dhaka Shishu Hospital. I was involved with the Gonoshasthya Hospital, pioneering hospital that provides health service for the masses, since its inception. However, I was not satisfied at all," says Professor Zaman, who is the pioneering paediatric surgeon in the country.

"Working as a surgeon in Bangladesh I found a huge gap between the training as a physician and the practical scenario. I, along with my friend Professor Mahmuder Rahman, who also trained in England as a physician, discussed the issue several times and contemplated doing something for the people living below poverty line."

Professor Quazi Quamruzzaman
A consultant at the hospital treating a baby.

“We thought the situation would never improve unless we could create a sustainable health service targeting all,” says Professor Zaman. “Then we thought to develop a community based health scheme following the model of the National Health Service in UK. Together we decided to adopt the health insurance system we saw in England in 1960s and 1970s in our country considering the socio-economic scenario of the country.”

"We don't claim Dhaka Community Hospital is a charity organisation for the poor. At the same time our intention is not to do business in the health sector. It is a community based health service, where people get the same care, but pay according to their earning. We provide quality healthcare to the poor at a cheap rate from the profit of giving service to the rich and running some integrated programmes such as training of the paramedics at our institute. But we also give free service only to those who cannot afford to pay any. Even the rich people come at the hospital to get our service. But our target is the people who earn less than 15,000 thousand taka per month, which is above 90 percent of the total population. As a result, the activities of the hospital are ever expanding.”

Professor Madmuder Rahman

However the path was never smooth for developing a community based heath service from 'zero' level. Financial crisis was obviously a major constraint. They could not even pay the junior doctors and nurses the first six months. However, even the young doctors and nurses continued their service without taking any remuneration so motivated were they by the trustees, to serve the nation. The huge response from the local people was also encouraging; it was the dominating sector that became the enemy.

“The advocates of the donor agencies whose self interest took precedence over national interest, became our enemy,” Professor Zaman recalls the bad experience, “We have always advocated that the government has one of the best infrastructures in the world. And there is no need of involving donors or NGOs in the health sector. The public private partnership even did not work in England. How can we expect that it will work here? And the policymakers know it very well.”

Donor agencies come with projects costing millions of dollars in the health sector, however, the people don't get the service, says Professor Zaman. “Such concepts are basically imposed but not well adopted. As a result, implementation of such ideas prescribed by the donors does nothing but create a huge burden of foreign loan on the whole nation,” Professor Zaman continues, “We understand it's a global pressure. To be more specific, such programmes are donor driven, interestingly, the donors claim it to be 'demand driven'. And there is no transparency of the expenditure of such investment. For example, 3.3 billion dollars have been spent in the HNPSP programme. But most of the people do not even know the benefit of the huge expenditure, neither was it discussed in the parliament.”

According to Professor Zaman, unless the government takes a bold stand considering the national interest to tackle such situation, the health sector will never improve. Just improving the management system of the available infrastructure, the government can ensure primary healthcare to its citizens, he says. “I've seen younger doctors have the intention to serve the nation, however, it is the faulty system that ruins their intention. So the system should be changed immediately. Through the activities of DCH, we have proved that better management can radically change the situation,” Professor Zaman claims.

The employees meet everyday to discuss and coordinate the daily duties.

At present DCH has many outdoor services to provide primary healthcare in rural and urban areas such as community clinics, family health insurance programme, school health programme, industrial health insurance programme, arsenic mitigation programme, need based special programme and several training programmes.

Trained health assistants provide primary health service to the community. “We have sufficient doctors. But for the proper healthcare we need many trained health assistants and nurses. For the proper service of a doctor in a hospital, she or he needs at least 10 assistants. However, neither public nor the private hospitals follow it. They totally depend on the doctors for which the doctors cannot provide the required service” explains Professor Mahmuder Rahman, coordinator of the trustees of DCH. The UK trained Professor of medicine has been involved with Dhaka Community Hospital since its inception.

“Actually we have set a model in the community health service in Bangladesh. And this model has received appreciation by well-recognised foreign institutes. It has an exchange programme with British General Practitioners' Association and collaboration on arsenic programme with the School of Environmental Studies (SOES), Jadavpur University, Calcutta, India.”

We are also sharing our experience with several other international organisations, he says. Professor Rahman further claims that DCH is working as a research institute in the health sector. “And it is a continuous programme: we always incorporate new technology and ideas considering our national interest. For example, in the Dhaka Community Medical College a medical student from the first year is attached to 10 families for consultation for the next five years. Through this process they will grasp the basic philosophy of healthcare.”

Dhaka Community Hospital received international exposure because of its crusade against arsenic contamination of water. The hospital played the pioneering role in bringing the arsenic issue into the limelight. The DCH deserves the sole credit for detecting the serious health hazards caused by arsenic contamination in ground water of the country. In 1996 the doctors of DCH while conducting an annual health camp at Pakshey in Pabna district found some patients affected with diseases caused by arsenic poisoning. Since then DCH has run some sustainable arsenic programmes in arsenic affected areas. To combat serious arsenic health problems, the DCH formed the Arsenic Action Group (AAG) involving various local and foreign organisations and government institutions which include UNDP, Harvard School of Public Health, AusAid, DFID, NIPSOM, WHO, Unicef and others. To increase public awareness on arsenic pollution the Arsenic Action Group took initiative to build a cooperative social movement by exchanging information and keeping contact with various organisations.

Dhaka Community Hospital trains health assistants (paramedics).
Doctors busy in the operation theatre.

“Since then we have been continuously creating pressure on the government to take immediate steps for the mitigation of the problem," says Professor Rahman. "Surprisingly we found government played a hide and seek game with it. Meanwhile, involving the foreign experts in this sector we developed our facilities to help the people. We have taken the arsenic problem as a crusade. We have several idea sharing programmes with foreign institutes. At the same time we have continued lobbying with the government. At last the government set up an arsenic mitigation action plan. But it is not functional.”

Considering the health issue of the poor, DCH has introduced health cards for the garment workers. Under the 'industrial health insurance' programme each worker/employee is provided with a 'Health Card' against a nominal monthly fee. At present twenty-four industrial units are receiving these services. Moreover, it has introduced school health programme which is being implemented in urban and rural schools. The children are the target beneficiaries. Students are provided with a 'Health Card' against a nominal monthly fee. Only 12 schools are receiving these services at present. But the hospital has plans to increase the coverage.

DCH is also planning to expand its training division called The Institute of Community Health-Bangladesh by introducing masters courses on Health Delivery System. Currently it has been organising a series of training programme for the paramedics of both rural and urban areas on child survival component of the Essential Services Packages. It also hopes to introduce a nursing training institute very soon.

The outdoor department of the hospital. Using the family health card, a member of a family can get treatment at a very reasonable rate.

With the majority of the population being poor, underfed and undernourished and an inefficient, inaccessible public health care system, ill health has become the biggest obstacle to development. Undoubtedly Dhaka Community Hospital has emerged as a model for community based health service in Bangladesh where people don't have access to healthcare, especially primary healthcare, which is the first and most important step towards achieving the 'Health for All' goal. More such organisations should operate in the country. At the same time the government should do something to improve the health sector following the model set by Dhaka Community Hospital, where everybody will have equal and standard health service.

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