Having lived in urban centers all my life, I was quite excited to have the opportunity to reside in rural Bangladesh for a week long deep dive- a research endeavor that my team and I undertook to get a basic understanding the typical healthcare experiences of the rural population. My destination was a small village in Niyamatpur in the district of Kishoreganj.
The very first thing that struck me early in my experience was the astonishingly relaxed pace of rural life. It was something I had read about countless times, but never truly experienced. The days in Niyamatpur start at the crack of dawn, and by ten in the morning, people completed all the major tasks of the day (shopping, errands, chores, etc.). From 10 o’ clock in the morning till dusk, people simply passed time at their shops (or the shops of others) with tea and ‘adda’ (a Bengali term meaning casual conversation), with the occasional business transaction. Understandably, farmers had a slightly different life, toiling from morning till midday before returning for lunch. Women too completed their work by midday, and went out to socialize with neighbors in the afternoon. Shops closed soon after dusk after which time most men sat at tea stalls for more ‘adda’ before returning home for dinner and bed.
My overall personal experience was bitter sweet- I had to learn to adapt to a great many things, giving up numerous comforts that I have been accustomed to for the greater part of my life; on the flipside, I was able to look at life from the perspective of people that had lived all their lives without those comforts.
Given that the focus of our research was healthcare experiences in rural Bangladesh, I came back to Dhaka with a wealth of insightful stories. This post is an attempt to share some of those stories with you.
For the purpose of protecting privacy, names have been changed.
Our first story comes from a Mr. Saiful Hossain. Saiful lives in Niyamatpur in single unit brick house with a tin roof with his two children and his parents. His family lives on a monthly income of Tk. 10,000, placing him in the middle socio-economic class in rural Bangladesh. When asked to narrate a ‘good’ healthcare experience, he spoke of a time when his father had a severe case of diarrhea. Initially, he chose to do nothing, but when the situation worsened, he sought the help of the local RMP (rural medical practitioner) close to his home. With a total monetary expenditure of about Tk. 3,000 and three days of missed work Saiful was able to take care of his father. When asked why he called this a good experience, Saiful stated the following: ‘I had thought that things might get critical. But thankfully I was able to save my father and deal with the matter without having to pay too much’. When asked to describe a ‘bad’ healthcare experience, Saiful said that he had never had a bad healthcare experience.
Our second story is that of a Mr. Nurul Amin. Nurul is a teacher at the local madrasa (school) and teaches a group of students privately in the afternoon. With a monthly household income of Tk. 25,000, Nurul is arguably in the upper economic class of rural Bangladesh. His ‘good’ healthcare experience was when his wife underwent a surgery for ligation, based on the advice of the FWA -Family Planning and Welfare Assistant(a government health worker). The procedure required that he accompany his wife to two separate government health complexes (at the sub-district and district levels), spend Tk. 5000 and take about a month off from work. In his words, Nururl was happy with this experience because ‘the major cost of the surgical procedure was borne by the government.’ This experience also made him feel that government hospitals/health centers were quite efficient.
However, his ‘bad’ healthcare experience also took place at government health centers. This narration featured his cousin who was suffering from serious breathing problems. As a first response, Nuru visited his local RMP who was unable to help at all. He then took his cousin to the sub-district level health complex before going to the district level hospital. Unable to find a vacant bed, he and his cousin had to sleep on the floor for three days! He also had tremendous difficulty arranging an ambulance. Eventually, his cousin died in the ambulance en route to Dhaka. When asked as to why Nurul thought this was a bad experience, he enumerated the following three points:
(a) The hassle he had to face in seeking treatment because of a lack of knowledge as to where to go.
(b) Having to sleep on the floor in a hospital.
(c) The problems with arranging an ambulance.
Nurul later lamented that his cousin would probably have been alive today if he had known where to go and if he had been able to arrange for transport in time.
Our third account comes from an Atiqur Rahman. When asked about a good healthcare experience, he told us of a time when he dislocated his jaw. In severe pain, he went his trusted RMP, only to receive a pain killer and a referral to a surgeon. Tossing and turning through a painful and sleepless night Atiqur left to meet the surgeon at first light. According to the surgeon, a surgery was the only solution to his problem. Apparently, he had dealt with a number of such cases and there was no alternative to a surgical procedure.
Atiqur was reluctant to undergo a surgical procedure and ended up calling a friend of his, who happened to be a doctor at Dhaka Medical College. His friend took him straight to Dhaka Medical College and after an X-ray decided that he might be able to put things right without a surgery. Using what Atiqur described as a ‘massager like device’, his friend was able to position the lower jaw back into its socket, relieving Atiqur of his pain and his need for surgery. Atiqur recalls that another doctor present during the procedure congratulated Atiqur, pointing out a nearby patient who would be requiring surgery for the same albeit more severe problem. Atiqur’s reasoning for calling this a good experience was that he was able to avoid what at the time seemed like an absolutely necessary surgery. Like Saiful, Atiqur too claimed to never have had bad healthcare experience.
Among these, and the other collected stories, certain themes seem to run through all of them. Firstly, most people, if not all, rush to their local RMP for any sort of ailment, seeking either treatment or advice. Even if they know a qualified doctor personally, the first choice in case of any health related problem is always the RMP. What we initially assumed to be the result of inaccessibility to qualified doctors seems to now be a matter of perception- RMPs are NOT the first choice because they are the only choice. RMPs are the first choice because they are actually perceived as qualified, effective (in certain cases more so than an MBBS doctor), and trustworthy health care providers that just happen to be close by.
Interestingly, the second theme running through all our interactions was the seemingly unanimous want for the presence of an MBBS doctor at the community level. In fact, even local RMPs felt that local healthcare would drastically improve if an MBBS doctor was present at the local level, at the government health centers/community clinics. The finding is rather contradictory since we clearly saw that people preferred to go to RMPs even in the presence of MBBS doctors. In case RMPs were unable to resolve the issue, people were completely confident in the RMPs referral, even if the RMP referred them to distant locations despite the availability of a nearby MBBS doctor. Perhaps, the want is the presence of a nearby MBBS doctor that is accepted by the local RMP.
Lastly, a surprisingly large number of people actually claimed to not ever having had an experience that they would call ‘bad’. In fact, for one of our interviewees, an experience where he was referred to four different institutes, where he spent an inordinate amount of time waiting for the doctor and where he spent double his monthly household income (mostly on travelling from one place to the next because of the institutes lack of capacity to treat his condition) was termed a ‘good’ experience. It turns out that people in rural areas naturally associate seeking healthcare with hassle. Unavailable doctors, multiple referrals and unnecessary expenditures due to information gaps are expected, and even accepted as ‘just the way it is’.
Undoubtedly, rural perceptions about healthcare and health experiences are radically different from the typical perceptions in urban settings. What captures my imagination is the effort required to change them.
Posted by Ahmed AbuBakr