Cover Story

The Changing Face of Health

Overcrowded wards inside a public hospital.

Care

Hana Shams Ahmed
Photos: Zahedul I. Khan

It is like entering a posh hotel. Outside the lawns are immaculately groomed. The visitor is greeted with a heartfelt smile and a bow by the well-dressed guard. Inside the fully air-conditioned large lobby there are comfortable couches, a large screen television and a breathtaking interior. Large signs written in English tell you exactly where you can get the particular information you need. Smartly dressed attendants working round the clock make sure that not a speck of dirt appears inside the four walls. For a moment a visitor can forget that she is actually inside a hospital in Bangladesh. For a patient, if a part of the treatment is to feel that he is in a place where he will be taken care of, then these designer hospitals are doing a great job.

Roushan-Ara has come to Dhaka all the way from Feni. She and her sister Jahan-Ara have come to the Apollo Hospital in the city's posh Bashundhara area with their ailing mother. Their mother is around 80 years old and is suffering from several complications. The two sisters have been dragging their mother from one hospital to another with different diagnoses from each hospital. “I don't trust the doctors at the hospitals at Feni,” says Roushan-Ara, “they don't care about us and if the patients are too poor they just leave them to die.”

The interior of a private hospital is comparable to a posh hotel

Someone at another hospital suggested to Roushan-Ara and her sister that if they wanted good treatment for their mother, they would have to take her to Apollo Hospital where she can expect to get a proper diagnosis. At Apollo, the doctor said she would have to stay at the hospital for two days, get blood transfusion and some other treatments and the bill would be Tk 35,000. For the two sisters the expense was too high, but they said they would be able to come up with the amount by selling off some land they own. “It's my mother life,” says Roushan-Ara, “I would do anything to save her”.

It's not really feasible for a middle-income family like Roushan-Ara's to have their family members treated in an upscale hospital like Apollo. But an increasing number of people are starting to take their health care needs away from the public hospitals to the private ones. Because the public hospitals in Bangladesh have failed to maintain even the very basic standards of health care, more and more people are starting to look at private health care to get treatment for more serious ailments. Although the costs are astronomically high compared to those in public hospitals, and certainly compared to the average income of a Bangladeshi, many people choose to sell off their assets in order to get that life-saving treatment. Whether private hospitals are being ethical in charging such sky-high prices is an ongoing debate, but at least one can be sure that the rooms will be clean, the beds will be tidy, the nurses will respond to calls and the doctors will care. That is an unthinkable phenomenon in many public hospitals.

Most public hospitals are a place of endless horror stories. Inadequate number of beds means that most patients have to end up sleeping on the floors in filthy wards where nurses are sparse and uncaring. Even the wards become so full that patients in critical condition have to take shelter in the halls and under banisters, basically any available open space. The stale smell of sweat, grubby floors and filthy toilets in these hospitals can make even a healthy person fall ill. Add to that the unavailability of medicine, nepotism and corruption by all levels of staff and it's no wonder that people like Roushan-Ara want to take their loved ones to a hospital that seems more caring about their welfare even if it is at exorbitant rates.

Private hospitals put a lot of effort to maintain cleanliness

Apollo Hospitals Dhaka, a joint project of Apollo Hospitals Enterprise Limited and STS Holdings Limited, is a 450-bed facility that started its Bangladesh operations in 2005. The hospital provides a complete range of the latest diagnostic, medical and surgical facilities for the care of patients. The hospital claims to have all the characteristics of a world-class hospital with a range of services and specialists, state-of-the-art equipment, technology and quality of service.

Dr Ed L. Hansen, Chief Executive Officer, Apollo Hospitals, notes that the demands and expectations on a public health system are uniquely different from the demands on a corporate system. "When people are at a public hospital they accept crowded activity and inattentive care, they do not accept these things in a corporate hospital," he says, "as soon as people reorient to a new system, notwithstanding the fact that it is a better system than the one they were a part of in the past, they become as challenging or more challenging of the new system than they might have of the old system."

Hansen assures that the hospital takes every complaint very seriously and addresses them. "Because if we don't they will take their needs somewhere else. Any time a complaint comes in, it's probably going to impact our processes and is probably going to result in a process improvement. If a doctor's performance is questioned he or she is evaluated by his peers, and if it's a nurse the same thing occurs," he says and adds that Apollo is committed to international standards. "We don't really consider what Bangladesh has or doesn't have in terms of standards."

Hansen also says that relative to the other corporate hospitals of Bangladesh, Apollo is not more expensive. He attributes their high cost to the cost base, which is greater than the public hospitals.

Corporate hospitals claim that less people are going abroad for treatment because of them

Square Hospital, a concern of Square Group is a 300-bed tertiary care hospital. The hospital is an affiliate partner of Methodist Healthcare, Memphis, Tennessee, USA, Christian Medical College, Vellore and Care IVF (Invitro fertility centre) Centre, Singapore. The main hospital building is 18 stories and is approximately 450,000 sft. The second building is located across the street and is 16 stories with 136,000 sft.

KM Saiful Islam, Director, Square Hospitals Ltd says that although there are no exact statistics on the amount of money that goes abroad every year on health expenses, it is in the range of thousands of crores. “I agree that the services at the hospitals are not yet up to the mark,” says Islam. He says that there is an attitude among people in our country that they will only be good doctors if they are from abroad. “There is also the concept of medical tourism where people want to also do some shopping and sightseeing along with healthcare, so that hasn't still developed in our country,” says Islam, “and although I would say that the costs are high compared to ordinary clinics but if one compares with the cost of medical care abroad it is less because when you go abroad you also have to think about the airplane fare, and the living expenses of other people. And if we want to compromise too much we cannot maintain the quality of service.”

Another corporate-style hospital located in the city's upper class Gulshan area is United Hospital. The hospital building is a purpose built facility, accommodating 450 beds in wards, cabins, emergency, ICUs, CCUs, ICCUs and other facilities. There is also a parking lot for over 350 vehicles. United has a large number of departments for different ailments.

Dr Rubaiul Morshed the AMD of United Hospital says that the public hospitals have a good infrastructure but the lack of management is what failed them. He believes that this is where the private hospitals have a lot of responsibilities to fulfil. “One of the biggest roles the private hospitals have played is in stopping the brain drain that was taking place from our country,” says Morshed. All the doctors at United Hospital are from Bangladesh, many of them are NRBs returning from abroad.

“The number of people leaving the country for treatment abroad has also gone down,” says Morshed although there are no official statistics on the amount of money spent abroad for medical treatment, as the government does not 'officially allow' patients to go abroad for treatment if that particular treatment is already available inside the country.

Giving emergency treatment to a patient inside an ambulance	State-of-the-art technology seem to be the selling point for corporate hospitals.

Dr Abu Sayeed M. M. Rahman, director of Clinical Development and Governance says that United takes care of all the needs of a patient from when he enters the hospital to when he leaves. “It might apparently seem that the costs are very high,” says Rahman, "but the quality of our services is also very high and I don't think the costs are unreasonable. This kind of service you can only receive in other countries. This massive logistical support that we are giving, costs will naturally go up. And we also have a system of accountability. We ask patients to leave their comments and if we find anything negative, we investigate it.”

Labaid Hospital is one private hospital that has, in recent times, come under a lot of scrutiny from the public. A father of a 45-day-old child Afia complained about how his child, after going through an operation, suffered because the ventilation machine broke down. To add insult to injury, the administration delayed him from moving his child to another hospital until he paid the bill.

Another case was highlighted where a 65-year-old man A.K.M Fazlul Haq was admitted to a specialised cardiac hospital after he had a massive heart attack late last year. He was given an injection and later a ring put around his heart. Later that week, Haq's chest x-ray revealed dark areas over the lung where he received lung treatment. The doctors said that a Bronchoscope was needed immediately. After the Bronchoscope TB tests were carried out in two different diagnostic centres. The two hospitals gave opposing results. The patient's sons later learnt that their father had suffered from massive brain injury right after being admitted to the hospital, which was not detected by any of the doctors. After repeated requests by his sons to call for a neurologist to check his brain, the doctors did not listen to them and Haq eventually died. "When I confronted the doctor," says Masum, "the doctor slapped me and ordered me to get out".

The lack of hygiene management inside public hospitals has made them utter failures

Mesbah Aajad, the Media Coordinator of Labaid Group complains that the media only present half of the story. “Different people have different needs and it's impossible to fulfil everyone's needs. It's important for us to see whether the patients are happy or not with the service they receive from when they get admitted to when they are discharged. The gap in the health care system that the public hospitals created cannot be completely fulfilled by the private hospitals yet, it is going to take some more time to do that,” he says.

He says that there is a system of accountability at the hospital. “There are regular meetings with the doctors and staff,” says Aajad, “and we take all complaints very seriously.”

“We are a business and we have a reputation to maintain so we give a lot of priority to the customer needs, because we want the patients to be satisfied with our service so that they come back again next time they have a problem,” says Major (retd.) Dr AKM Mahbubul Haque, the coordinator.

Fariha Arman, a 35-year-old development worker had a very bad experience at one of the private hospitals. “One day while I was at work I was feeling extremely ill -- so bad that I went directly to the emergency department of the hospital. I didn't realise I had measles. I was told that if I went to the emergency they would call the dermatologist and the process would be much faster that way. At the emergency they concluded that it was an adverse reaction to a drug and referred me to a dermatologist. When I went to see the dermatologist they asked me to wait and asked me to make the payment first,” says Arman.

They said that she would have to wait for 10 minutes but it was two hours before a specialist came to see her. “I just wondered that if this is how the situation is for someone who had come from the emergency, what would it be like for the others,” says Arman.

Even when she went back for a follow-up she had to wait for around three hours before her doctor saw her, although she had made an appointment beforehand.

Sumehra Karim complains that the private hospitals are very class-conscious about the way they treat their patients. “My first negative experience was when I took a rickshaw to the hospital nearby my house to see my sister-in-law. The guard stopped me at the entrance by the road and informed me that only cars were allowed into their premises. I had to walk all the way uphill to the entrance of the building. For all the guard knew I could have been a heart patient.”

A lack of accountability means that the public are largely kept in the dark about the systems inside private hospitals

Karim also complains that the hospital assigns too many tests to figure out an illness. “My husband was once really unwell and we had no idea what was wrong with him but we suspected paratyphoid. After going back for four days and still being told that we would have to take more tests I told the doctor that it is getting very frustrating for us to keep coming back day after day, without knowing what's wrong with him, without even having medication to ease his suffering and on top of all that, having to pay fees every time we went. When I mentioned all of this the doctor lost his temper and asked my husband and I to leave the room because he didn't want to attend to us anymore.”

Fahad Mahmud, whose father had a successful open-heart surgery at one of the private hospitals, is very glad that the private hospitals exist. “When we called the hospital in the middle of the night, the ambulance came very fast and after that we had nothing to worry about. They took care of everything. And look at him now,” says Mahmud, “he's talking and laughing with us like nothing happened. I would not have had the same service at a public hospital. And it would have been days before we could have arranged to take him abroad.”

Dr. Zafrullah Chowdhury

Dr. Zafrullah Chowdhury, the founder of Gono Shasthya, laments on the quality of health care in Bangladesh in general. “If people don't get the adequate service of course they will go abroad for treatment,” he says, “the growth of the private system is a result of the failure of the public system. People don't go abroad for treatment just on an impulse.”

He criticises the whole public medical education system saying that while children from well off families are virtually getting medical education for free they are not being urged to give to the country in return for what they are getting. He says that one has to pay only Tk 5 to stay at a medical college hostel including all utilities while the girls working in the garments factories have to pay around 7 to 800 takas for a room in the slums.

Zafrullah says that whilst the students only have to pay a nominal amount for fees, the government does not send them to the villages where most people of the country live. And as soon as they pass their exams the government creates opportunities for them to pursue an FCPS abroad. “The medical students are not paying their debt to the nation. The government should also create more opportunities for students from the villages to come and study at the medical colleges here.”

Zafrullah says that there is no accountability for private hospitals and that is dangerous for the health care system of the country. The BMDC (Bangladesh Medical and Dental Council), the government health watchdog, is almost non-functional now. There are no audit of the deaths that take place at the private hospitals. Zafrullah says, "Every death at a hospital should be reviewed thoroughly. The government should force hospitals to carry out post mortems.”

Zafrullah criticises the private hospitals because of the exorbitant charges they make. “There's no care for the emergency, they will start by talking about the money. They wont listen to you if you say you will have pay later, you will to pay the deposit first.” He agrees that some medical equipment is costly but he questioned the necessity of all the equipments. “They did make a lot of investment but they have also made a lot of unnecessary investments. I don't think their charges are justified,” says Zafrullah.

Many people sell off their assets to get treatment at a private hospital because they believe they will get the best treatment here and they don't want to compromise on the health of their loved ones

Faustina Pereira, an Advocate of the Supreme Court of Bangladesh, specialising in the field of Human Rights, says that the term medical negligence needs to be used with a great degree of caution and understanding of the ground reality. “The term 'medical negligence' does not really exist in the law. The way we come about it is by a patchwork, an analogy of several provisions within the criminal procedure court and penal court together with all of these laws. At the moment what there is that there is the issue of due care but what constitutes due care is nowhere clearly defined,” says Pereira. According to the criminal proceedings court if the doctor had done everything that was in his capacity and skill and he had done so in good faith then the doctor cannot be held responsible for the outcome.

Pereira says that until now not a single proper medical negligence case has been successfully litigated. According to Pereira a whole array of laws but not one single law from the perspective of the doctor-patient relationship. She points out that there should be a law that clearly defines what constitutes duty of care, negligence, and good faith. “Whereas for other service sectors there is actually a professional body which is not only a licensing body but is also a disciplinary body. But there is no practice of such things in the medical profession.”

Pereira puts great emphasis on a Consumer Protection Act, which is in the same league as the Right to Information Act. “We need a system whereby services are seen as a product of consumption and we as taxpayers are actually consuming services. And we need to be able to ask questions as a way of accountability. I strongly feel that there has to be a regulatory body. This is a sector that has gone scot-free for too long.”

Private hospitals like any other private sector services are the manifestation of a capitalist economic system. The existence of more than one such corporate-style hospital will ensure that there is healthy enough competition that ensures that each hospital will try to give the best of service at the most affordable price. In terms of infrastructure and logistics there's no doubt that these hospitals are vying for the very top spot. Most of the doctors at the hospitals have impressive records.

Most of the equipment at the private hospitals is imported from abroad. This, they claim, justify the high charges on the patients

But it is not always as rosy as one would expect after paying such high fees. Apart from incidents of medical negligence by doctors or nurses in most of these hospitals the lower-ranking staff do not always live up to the standards claimed by the hospital. Brash behaviour, inability to explain things properly, inefficiently handling the patient, gossiping with co-workers in front of the patient and worse, not attending to the patient on time, are some of the less serious complaints against these expensive private hospitals.

What is clearly needed is a system of accountability conducted by the government and open for public scrutiny. Hospital staff have to be better trained and be more professional in their service. Because after all, if it concerns human life, no compromise is small enough.

Copyright (R) thedailystar.net 2008