Cover Story

The Fight for Affordable Healthcare

Aasha mehreen Amin

Photos: Zahidul I. Khan

If you ask a CNG driver to take you to Nagar Hospital in Mirpur Road, chances are that he will not ask you again about its location. This is because the Gonoshasthya Nagar Hospital, is probably the only full-fledged non-government hospital where anyone, no matter how poor, will be able to get medical care. In a country where government hospitals are overcrowded, understaffed and inefficient and where private clinics or hospitals charge sky high fees, this several-storied building in the heart of the city, is the only hope for the poor or those with modest incomes.

At any given time, the hospital's waiting areas are bustling with people. Patients rush to and fro from the reception area to the doctors' little chambers or go to the pathology for tests or to consultants upstairs. Some go straight to the physiotherapy department or to the pharmacy where medicine costs far less than regular drug stores. They are people from all walks of life domestic workers, day labourers, teachers, government servants, even beggars. Curiously, the staff are overwhelmingly female the operator , receptionist, paramedic, pathologist, on-duty doctors even the drivers driving the hospital cars. Patients line up at the counter, buy a 20 taka ticket and are soon on their way to the doctor's room. Here the doctor on duty will examine the patient, prescribe the medicine or order for tests to be done; if it is a complicated case the on-duty doctor will refer the patient to a specialist in the same hospital. For insurance holders, there is no fee for the on-duty doctor consultation and the specialist's fee is around TK 200, tests and surgery if required, will be highly subsidized. An insurance card costs TK150 and can include several family members. If the patient does not have a card the fees are a little higher. Even without the insurance the cost of treatment is significantly lower than a private clinic, the emergency department is open 24 hours which is why the hospital is always full of patients.

GK's health insurance allows patients to pay for treatment, according to their ability

For those who need difficult operations or long-drawn-out treatments the 250-bed hospital has all the necessary facilities and charges fees that are determined according to the patients' means. In one of the wards an old woman lies on a hospital bed with a broken hip. She will need a complicated surgery that involves a prosthetic to be inserted in her hip joint. Normally, the cost of such treatment would run into lakhs of takas but for a poor, elderly woman like her it may be only a few thousand. There are others in the ward, most of them old, frail, poor and helpless, this is the only place they can come to when they are sick. Paramedics and intern doctors can be seen handling the patients with compassion and care, quite a novelty in this sector where even a bit of kindness has a price tag.

Gonoshasthya's Health Insurance Scheme is the most innovative way to make essential health care affordable to people. A form must be filled out by a patient with details such as the patient's own and family health history, occupation (rickshaw wallah or lawyer, they even have a category for journalist and photographer), area of residence, how the person commutes, whether the person lives in a rented flat or owns a house, what kind of a home (tin roofed or marble ceiling), whether there are school-going children in the family, who lives with them, how many earning members there are, what the school or college fees are and so on. The health insurance is grouped under six categories representing the different social classes: destitute (treatment is practically free for these people) extremely poor (in which case the health services are heavily subsidized), poor (highly subsidized) lower middle-class, middle class and upper class (who have to pay the most). Thus the patient and all the family members who are entered into the insurance 'book' will pay according to their ability to pay but will get the exact same service as anyone else.

Nazma Begum, in her 30s has come to the Savar Gonoshasthya Kendra with severe stomach pains. She has come with her mother Kajali Begum, all the way from Dhamrai, quite a few miles away. “ About 4 to 5 years ago we heard from our neighbours that this hospital was good and offered medical services at a low price,” says Nazma, “so we made a 'book' (insurance card), all our family members are in it and can get medical help through it.”

“ It's very convenient,” adds her mother Kajali, “ all the tests X rays, ultra sonograms, blood tests, are done here and the cost is much less than the private clinics; we always tell people to come here.”

The Nagar Hospital on Mirpur Road is a symbol of hope for the urban poor	Dr. Zafrullah Chowdhury, a hero in the public health sector

Everyday around 200-300 patients come to the GK Savar's outdoor clinic and nobody is turned away. Porina Begum, a 45 year-old housewife, has been coming to the hospital for the last 20 years. She lives close by and nine family members are included in the insurance card. “You just need a TK 5 ticket to see a doctor, it is a lot cheaper than other clinics and the medicine is half the price,” says Porina. “The doctors are good; if this hospital was not here it would have been impossible for me and my family to get regular treatment as clinics are very expensive.” While government-run hospitals offer low-cost medical care, they are too far away, overcrowded and often do not have enough doctors or health care workers to attend to the patients. At present, GK serves around 1.2 million people in rural areas over 60 percent are poor or ultra-poor.

What is most striking about this hospital is the number of women in their blue uniforms and white overalls who can be seen everywhere, advising patients, taking blood samples, taking patients for tests and so on. They are known as paramedics and are trained in basic health care.

The man behind this innovative, pro-poor health care system is of course Dr. Zafrullah Chowdhury whose vision and steely determination has resulted in Gonoshasthaya Kendra (GK) which is a multidimensional development programme. It involves the community as a whole and includes activities ranging from primary healthcare centres and hospitals, community schools, agricultural cooperatives, women's vocational training centres to economic enterprises to help finance GK Trust activities. But GK's most obvious success is its primary health care programme (mainly in the villages) that benefits over a million people. It has 13 health care units (including three hospitals) all over Bangladesh.

Whether it is the paramedic who gives basic health advice or takes the patient's blood, the intern doctor on duty, the consultant who gives his expert opinion or the highly qualified surgeon who performs the operation, everyone in Dr. Zafrullah's team works with sincerity and compassion.

The subsidised cost of treatment makes it worth the wait.

This is the result of the man himself who is regarded as a mentor and hero by the staff he constantly motivates. He insists on being addressed as Boro Bhai instead of Sir or Dr and is regarded as a bit of an eccentric, blasting his staff at the top of his voice when he goes on rounds for the slightest transgression yet showing extreme compassion for those in genuine need. With longish white-hair and clad in a batik Hawaii shirt and trousers, his sandal shoes not properly worn, he looks more like an absent-minded professor or an eccentric artist trudging along the corridors and walking into the wards to talk to patients or inspecting the various departments. The paramedics and doctors become a little tense as he approaches, he may shout at them for some slip up that is rarely missed by his hawk eyes or he may crack a joke that will make everyone laugh in relief. The admiration and respect that this man evokes, however is obvious and has motivated many of the doctors and surgeons and paramedics to stay on despite lucrative opportunities elsewhere, and to join his movement to provide essential care to the needy.

It was during the war of independence in 1971, that Dr. Zafrullah Chowdhury, then a young vascular surgeon and Dr. M. A. Mobin left their studies in London, to join the resistance by offering their medical expertise to the wounded freedom fighters. It was this act of patriotism that formed the beginnings of the Gonoshasthya Kendra with Zafrullah and his fellow doctors setting up the 480 bed Bangladesh Field Hospital near the border with India, to treat the wounded and sick. While Zafrullah had a few doctors to help in this formidable task, he still needed nurses on his team and none were available. It was then that he came up with the idea of training young women in the refugee camps as nurses who could learn to give first aid as well as assist in operations. “The girls learnt very fast in treating the patients, cleaning wounds, giving IV fluids etc”, says Dr. Zafrullah, “ I realised that it was not the amount of training that was important in this context but the access to training.” After the war, the Field Hospital became known as Gonoshasthya Kendra and was relocated to Savar with sub centres in surrounding areas as well as in a few other districts. Girls who had completed their SSC (Secondary School Certificate) were eligible for training and became known as paramedics. The paramedics, aged between 18 to 30 years, would go to the villages by foot or bicycle to visit households and inform people about basic health care, the services available at the hospital, and sometimes take care of simple health needs such as immunization and deliveries.

In those times it was quite an unusual sight for villagers to see young women on bicycles going from house to house to talk to people. “We had to answer a lot of questions and face a lot of obstacles,” says Beauty Rani De, who heads the paramedic training

Beauty Rani De heads the paramedic training programme. She started as a trainee paramedic at age 16

programme and who started as a 16 year old paramedic and has been with GK for 30 years. “Some people would not let us pass through their homes and were very suspicious. Even the local people we went to did not trust us and were very reluctant to listen to us.” With time however, the local people realised that these women were bringing to them essential services such as giving tetanus or small pox vaccines. But sometimes the obstacles proved to be more serious. In November 1974, a male paramedic named Nizamuddin who was in charge of a GK's health sub centre in Shimulia, was brutally murdered. It was widely believed that local quacks who feared that they would lose their business to the sub-centre paramedics, were involved in the murder although none of them have been brought to book even now.

Now, apart from some hostility from pharmacies or private clinics in some areas, paramedics and the sub-centres are generally welcomed by the local community. “While those who are better off may opt for private clinics or hospitals, poor people usually come to our sub-centres or the hospital in Savar; now even the imams are positive about GK,” says Beauty.

Doctors and paramedics are motivated to show compassion to the sick, no matter what their background

Beauty believes that GK has been able to bring about significant changes in attitudes in the rural areas. “Before, expectant mothers were not allowed to go to the doctors by their in-laws; now the in-laws bring them to the sub-centres for regular check ups. GK's health project, through its community-based approach, has in fact, had an important role in making the national family planning, immunisation and ORS campaigns successful.

At present paramedics are given a 6 month training during which they learn the basics of community health care. It includes how the human body works, who in the community, has the greatest health needs, what is preventive care, reproductive health care, the use of certain drugs and their contraindications, how to behave with people etc. Some paramedics are trained in diagnostics; all of them know how to handle micro-surgery, give IVs, take blood samples and do blood grouping.

GK's concept of community health care, says Dr. Zafrullah, addresses the health needs of the community as a whole and involves the members of the community in its governance the service takers, providers, doctors, paramedics, local government officials and so on. This coordinated effort is in complete harmony with the Alma Ata declaration (adopted at an international conference in 1978 on Primary Health Care that called for 'Health for all' by the year 2000) and provides a successful model of Primary Health Care. Conversely says Dr. Zafrullah, although the GK's project predates the Alma Ata Declaration, the latter has given universality to Primary Health Care, not just to the poor but to the whole world.

A woman security guard opens the door to the entrance to the GK Shimulia sub-centre

While Bangladesh is a signatory to the Alma Ata Declaration, little has been done to make PHC a significant part of the national health care policy. Dr. Zafrullah blames it on a lack of political will. “In Bangladesh there are 4000 (government-run) family and health care centres in all the unions,” says Dr. Zafrullah, “but they are empty most of the time. The doctors come for 2 to 4 hours a day; a health centre should run 24 hours a day.”

Gonoshasthaya has always been regarded as a pioneer in the People's Health Movement in Bangladesh which can be traced back as far as the early 80s. In 1985 Dr. Zafrullah, along with other health activists of the world had a meeting regarding why, despite extensive programmes initiated by WHO, the health of the world's people in general had not significantly improved. “It was evident that organisations such as WHO and UNICEF had shifted their emphasis from PHC recognised as an essential part of the Alma Ata declaration in 1978, to a vertical approach that focused on 'specific primary health care',” says Prof. Dr Qasem Chowdhury, the Vice Chancellor of the Gono Bidyalaya (GK's university) and a spokesperson for the People's Health Movement. “This completely destroyed the concept of PHC as part of health care. So health activists decided that from the people's point of view, something must be done.” A core group of 8 organisations, including GK as well as individual members, decided to hold a People's Health Assembly in 2000 and the core committee included Bangladesh with GK being a representative “because it had already 30 years of experience in PHC,” says Dr. Qasem. The Assembly, held at GK's premises, was attended by1,453 health activists representing 92 countries. “We decided that we would start a national health movement,” says Dr. Qasem, “and a People's Charter for Health was drafted after a range of workshops and seminars and collection of people's health related stories.”

The Charter, says Dr. Qasem, is a document of the movement. “We have given it to the health ministry, to NGOs; we have translated it and distributed it. Whenever we get a forum we use it to voice our cause.”

On the move with his chauffer Rekha. all GK drivers are women and many have been recruited by international organisations

Despite the compelling arguments for universal Primary Health Care, there has been little change in government health policy to make it a reality. One reason for this says Dr. Qasem is the cutting down of funds for social services by donors and international agencies in South Asia so governments find it difficult to finance an efficient national health care system. This has resulted in health being taken over by the private sector. Over the last 35 years while private health care has mushroomed and become a booming business, the quality of care has not been maintained as the government does not have a proper regulatory mechanism to monitor the sector.

Donors, moreover, says Dr. Zafrullah, are not enthusiastic about giving funds to the health or education sector thus the contribution of NGOs in these vital areas have been insignificant.

For an organisation that has been working to provide affordable health care to the country's mainly poor, rural people, GK's achievements are many. It has for one thing put the concept of 'community health workers' on the global map and has proved that PHC can be made a successful, sustainable system. GK's pioneering effort in forming the National Drugs Policy in 1982 has allowed local companies to produce essential drugs at much lower prices than multinationals. It's own pharmaceutical company provides essential drugs at subsidized prices. It's unique approach of involving paramedics has empowered many women, making them more visible and giving them the opportunities to train and prove their value in the development process. GK's Gono Bhishwabidyalaya or People's University trains doctors and paramedics so that they can provide secondary and tertiary health care and has the same pro-poor approach to healthcare. GK's model in fact, has been central in keeping the global People's Health Movement going.

The woman paramedic from GK taking her bicycle to counsel villagers has become a common sight

A Background in Ethics

Dr. Zafrullah Chowdhury's life-long preoccupation with welfare of the poor has a lot to do with his unusual upbringing. He was born on December 27, in Chittagong. Chowdhury's mother Hasina Begum, now 93, came from a conservative Muslim family, her father was a religious cleric but Hasina was self educated with an innate sense of generosity towards the poor. His father Humayan Murshed Chowdhury, now 97, entered the police force yet managed to remain unstintingly honest as well as patriotic despite being in the service of the British Raj. Going to school was out of the question for Hasina and so she poured over her brothers' school textbooks. “Every month the school inspector would come and would often take my mother to the local school classroom and make her answer questions on various subjects which she would always answer correctly”, says Dr. Zafrullah.

When she became a mother, Hasina Begum's dream was to make sure her daughters went to university and that one of her sons would become a doctor. “We grew up listening to her stories about the '43-'44 famine when people used to come to my mother's parents house begging for 'phan' (the strained water from boiled rice)”, he says. “She would always encourage us to share things with less fortunate people and say that you would get back more if you gave.” In 1946 the Zafrullah's father was posted in Calcutta and the family lived in Park Circus. During the horrible communal riots Muslim rioters came to attack the house where Zafrullah and his family lived as there were Hindus living in the ground floor apartment. “My mother shouted at them,” says Zafrullah, “demanding why they should attack the very same people who had saved them when Hindu rioters had come to kill them. She also held up her two sons (myself and my brother) who were very little and threatened to throw us down saying 'If you attack those people I will throw down these two sons of a Muslim'. After a while the rioters left.” Hasina Begum was also a regular at Fatima Jinnah's meetings where the issue of women's equal rights were discussed. “This also influenced me”, says Zafrullah who has been an ardent champion for women's empowerment. Dr. Zafrullah has equally inspiring anecdotes about his father. In 1952 his father was posted to Dhaka as the Sutrapur thana's OC. “Students had burnt down the Morning News offices and press and my father was heavily criticised by his superiors for not going there to protect it. Some of the students had been arrested and my father kept them in his house instead of sending them to the jail.” Even during the non-cooperation movement Humayan M. Chowdhury would deliberately go late to a venue where a political meeting by Sheikh Mujib was scheduled to take place so that he would not have to break it up or arrest people. Zafrullah's father was also a principled man and has remained honest all his life. “He always thought that too much wealth would lead to deterioration of values”, says his son.

Zafrullah went to the KL institution in Sadarghat, later completing his HSC at Dhaka College, going on to Dhaka Medical College passing out with distinction. He then entered the Royal College of Surgeons UK. He could not sit for the final FRCS examination as he decided to come back home to join the liberation war which is when he began his movement to provide basic healthcare for the poor. He is married to Shireen Huq and has two children Brishti, a photographer and Bareesh, a school student.

Although not much in the limelight in his own country, Dr. Zafrullah's groundbreaking projects have recognized internationally. He has won innumerable awards - the Swedish Youth Peace Prize in 1974, the Independence Day Award 1977, the Ramon Magsaysay Award in 1985, International 'Heroes of Public Health' Award in 2002 from University of California at Berkeley.

A surgeon by profession and a socialist at heart, Dr. Zafrullah seems satisfied with GK's successes and believes that NGOs can only provide innovative approaches but the state has to take care of vital sectors like health and education. "We (GK) have already achieved some of the millennium goals. If GK can do it, the state can do even better."

Copyright (R) thedailystar.net 2007