Its remains astounding that the private healthcare services is still deemed far superior in terms of service delivery ahead of the public sector even today. A 2015 research study by the Centre for Equity and Health System (CEHS) at ICDDR,B found that 99% of Dhaka's healthcare service is delivered by the private sector and NGOs, which should validate that claim. But after the recent series of lofty fines imposed on some of the city's top hospitals, as well as the grim news of an untimely death of a three-year old in Chattogram's Max Hospital due to "negligence", it has rejuveneted an old debate of whether private healthcare service is meant for public service or a commercial source of income.

Bangladesh has witnessed a five-fold growth in the number of registered private hospitals and clinics since 2000. According to the government's Health Bulletin 2017, the number of registered private hospitals and clinics under Directorate General of Health Services (DGHS) has increased to 5,023 in 2017, which was 3,026 in 2011 and only 1,032 back in 2000. This rapid growth of private sector is a sign of increasing demand and lack of capacity and shortage of health workforce in public sectors, experts opine.

They said the government has to put more emphasis on private healthcare sector to achieve Universal Health Coverage (UHC) by 2030, a must to attain Sustainable Development Goals (SDG).

A large portion of the country's population depends on private medical sector for getting health care services but the government has very little attention for the capacity building as well as monitoring and regulating it, speakers said at a recent DGHS seminar.

Dhaka's scenario

In a mobile court drive on March 21, Rapid Action Battalion (RAB) fined Dhaka's United Hospital Tk 20 lakh for the use of an expired reagent in its laboratory and for selling unapproved drugs at its pharmacy.

"United Hospital has been fined Tk 20 lakh and they have also been given 15 days' time to correct the issues. After the time frame has passed, we will conduct another drive at the hospital," RAB executive magistrate Sarwar Alam had told reporters back then, but the follow-up, according to the media, never arrived.

In a press release following the drive, United Hospital defended itself saying the reagents were in fact within their date of expiry, and that the receipts cited by the mobile court were actually from 2014.

On July 2, Dhanmondi's Popular Diagnostic Center was caught keeping expired pathology reagents and medicine, for what it was fined Tk 25 lakh by another mobile court. Expired pathology reagents worth Tk 7 lakh and a huge amount of expired medicine, especially injections, were found in its storage room and confiscated. The mobile court also found irregularities in the storage temperature for medicine.

Transparency International Bangladesh (TIB) had published a study report back in February this year that most of the private healthcare facilities are running without proper rules and regulations.

Conducting its survey on 116 private healthcare facilities, it read that the private hospitals at the district and upazila parishad level provide services far below the expected level.

The study attributed this bleak situation to the lax enforcement of existing laws, lack of monitoring, transparency, accountability and profiteering attitude of the private hospitals owners.

It recommended forming an independent commission to control the private hospitals and diagnostics centres, enhance monitoring and create awareness among the service-takers.

Chattogram case

On June 29, three-year old Raifa was admitted to Max Hospital with a complaint of sore throat. She died from wrong treatment of doctors of the hospital, her parents alleged. Chittagong Union of Journalists has been demanding a fair and proper investigation into the death of Raifa. The journalists over there have been able to raise uproar as Raifa's father is a journalist himself. But it remains to be seen how many Raifas have died previously due to gross negligence and ignorance on the part of the healthcare providers.

Upon investigation, a probe body from the Directorate General of Health Services (DGHS) has found 11 irregularities of the hospital that include no issuance of appointment letters to doctors, nurses, cleaners and other employees. The hospital authorities did not renew its licence in 2017-18. Besides, there is no list of specialist doctors, though the hospital is specialised. The committee has also found that there is no detailed information of pathologists who prepare test reports.

The hospital was again the subject of a mobile court drive conducted by RAB, which examined the chemicals used at the biochemistry lab, medicines, the hospital's documents and appointment letters for the staff, according to RAB-7 Senior Assistant Director (Media) Mimtanur Rahman.

They also found a plethora of irregularities, which compelled them to fine Max Hospital Tk 10 lakh.

But this sparked outrage among the private hospital authorities across the city, uniting them to shut down their services for twenty hours, effectively shutting down private healthcare on the basis of their announcement and with total disregard for the public.

Private clinics, hospitals and diagnostic centres in Chattogram withdrew their indefinite strike on July 9, 20 hours after causing immense suffering to the patients. The strike was withdrawn following assurance from the authorities concerned that the demands of clinics, hospitals and diagnostic centres would be met. The strike was enforced at 4:00pm on July 8 hours after a RAB mobile court had conducted drives at four private hospitals in the port city.

The rise of private hospitals

In response to the growing disappointment in the role of the public healthcare sector, the number of private-run facilities has increased. An estimated 15 per cent growth has been observed between 1996 and 2000 in this sector. However, quality is still a major concern both in public and private healthcare services.

Such concern is prompting a large number of Bangladeshi patients to seek foreign medical care despite the additional costs, travel, lengthy visa procedures, etc. According to the official record of the Institute of Health Economics, University of Dhaka, Bangladeshis spend approximately TK 50 crore on foreign healthcare services.

The recent growth of private sector health providers have seen to do good business and quite a huge number of people seek healthcare services from these hospitals. However, there's a difference between 'care' and 'business'. According to Masud Ahmed, former business development manager at Apollo Hospitals Dhaka, there is a difference, but "you need the profit as your organization has to be able to earn the overhead costs".

Masud says the concept of seeking services under one roof is quite new. "It has developed in the past decade," he says. He adds that the hospital he worked with is the only JCI Accredited multi-disciplinary super-specialty tertiary care hospital in the country, confidently providing comprehensive health care with the latest medical, surgical and diagnostic facilities, backed by expert medical professionals and a strong administrative team. JCI Accreditation is an international stamp for excellence in clinical practices in patient care and safety. "We have to comply with the international standards; our patients can challenge us any time they want to," he explained.

Bangladesh has seen the development of hospitals with such facilities. Hospitals such as Square, United, Labaid etc., have been trying to render a total service under one roof in the private sector. A good number of people, who would have thought of going abroad, now seek healthcare services at these hospitals.

However these hospitals are also not above criticisms. Exorbitant charges, post-hospital care, compensating the patients if there's a wrong treatment and the lack of government monitoring are some of the allegations that arise against almost all the hospitals in the country all the time.

So, what's the future of seeking health services in Bangladesh? Masud says, "It's going to be more expensive in the future, say, in ten years' time when more multinational healthcare providers come to this country."

As far as healthcare is concerned, Bangladesh still has a long way to go; several measures have to be taken up for making the services friendly to the people. The number of care-seekers would surely increase in this country and they will wait for the expected transformation to take place.

Realities

A research conducted by icddr,b between 2013 and 2014 on the urban regions found the private sector has lots of challenges and problems such as lack of appropriate law enforcement and regulations, absence of skilled fulltime doctors and nurses, lack of quality care with very limited treatment period along with excessive cost.

It also showed that the doctors usually do dual practices that mean government hospitals' doctors checkup patients privately in the afternoon and on the other side the private hospitals do not get efficient nurses as they typically are transferred to government jobs.

Dr Iqbal Anwar, Scientist and Director of the Strengthening Health, Applying Research Evidence (SHARE) project of icddr,b, said that there left no other way for the private sector but to engage with the government to ensure universal health coverage (UHC).

He recommended some ways to improve the private services such as accreditation of the sector by the government as a contributing body, improving its quality by strengthening regulations with participatory monitoring, building its capacity and resource with government training and equipment facilities.

Dr Iqbal also recommended for providing financial support for underprivileged patients, through Public Private Partnership (PPP) and encouraging health insurances to disseminate health care for all.

Director General of DGHS Abul Kalam Azad said the government is working to improve the health services to achieve UHC.

He said government started experimenting health insurance programme in three upazilas of Tangail and if the experiment is found fruitful, they replicate the same all over the country.

Regarding Raifa's death, Professor Raqibul Mohammad Anwar, Professor of Colorectal Surgery, Convener of Examinations and Ambassador of the Royal College of Surgeons of England, said that there is a gaping hole between the public's high expectations and existing health facilities. It is also not unusual for socio-politically motivated propaganda to feed and inflate this expectation without supporting and supplying the required resources to the health professionals at the fore-front of health care delivery.

"The disappointment these patients and families feel stems from perceived inadequate, inappropriate, untimely or delayed care. If this is the case, it's the result of insufficient supply of resources (both human and material), overwork, expectation of care from health professionals beyond the limit of their skill and knowledge, and demand of care with little or no support."

He added that immediately on arrival, patients and relatives expect to be treated by the higher management. Every patient and their relatives feel that their need for medical attention is more important as such emotions are dictated by the pain, fear and uncertainty they feel while waiting for treatment. Emotions during traumatic and potentially life threatening situations is usually a complex admixture of physical, social and mental variables that run high. As a result, both patients and families are unlikely to be prepared to rationally manage those feelings.

"Chronic exposure to such emotional stress may lead to tardiness, absenteeism, mistakes at work and work place conflict all leading to further patient dissatisfaction and increase in death and disability in hospitals. This is mostly because the responsibility of dealing with such highly charged situation falls squarely on the health professionals that are at the front line".

In order to avoid or at least reduce the incidence of violence in hospitals, the gap between patient's expectations and the care received has to be addressed in a systematic fashion. For decades, Bangladesh health care has been crying out for a sector wide human resource planning. Although policy makers have been fully aware of the need, very little progress has been made.

The Ministry of Health and Family Welfare had published the Bangladesh Health Workforce Strategy in 2008 followed by a stakeholder dialogue with the objective of starting advocacy on the need for an adequate and skilled health workforce for a well-functioning health system. However, it has not been effective.

Dr Anwar says that "We really cannot create delays in developing a workforce that has the right capacity, skills, values and behaviours to meet future patient needs".