Stooping through the doorway to enter what can at best be called a one-room shack stocked with low end medicine, in the sleepy district of Gaibandha, I had my first ever meeting with a ‘Polli-Chikitshak’. For those of you who are less proficient in Bangla, ‘Polli’ is Bangla for village and ‘Chikitshak’ translates to healer/medic. These days however, they prefer to be known as RMPs, or Rural Medical Practitioners.
RMPs are the market’s solution to the failure of the state to ensure healthcare solutions in the rural areas of Bangladesh. The World Bank estimates the rural population to constitute approximately 72% of Bangladesh’s total population- that’s a whopping 111.4 million. For the large majority of these people, 130,000 RMPs (Estimated using (a)World Bank Data and (b)Ahmed et al. Human Resources for Health 2011 9:3 doi:10.1186/1478-4491-9-3) are the first stop for most health related problems.
When asked about the services he commonly provides, our RMP replied with the following list-
• Free diagnosis of basic ailments like fever, cough and the common cold
• Incisions and stitching when required
• Pushing Intravenous Saline
• Prescribing OTC drugs and low powered antibiotics
• Child delivery
He claimed that in addition to seeing patients at his shop, he also made house calls when called upon. In case the problem was too severe for him to diagnose or treat, he referred his patients to doctors and clinics, that he maintained liaisons with, in the nearest urban localities.
Within a 3 kilometer radius, there were about 8 RMPs, sitting in their medicine shops and none of them seemed to be doing too well, save one. He sat in a shop about twenty paces away from the RMP I talked to first. Sitting there with his stethoscope around his neck and blood pressure machine in hand, he was attending to a remarkably long line of customers. While the first RMP had a rundown shop with zero traffic, I had to wait about twenty minutes to get a chance to talk to the second. On talking to him I learned that he had recently renovated his shop- business was booming!
During our conversation I learned that he had invested about BDT. 8000 for obtaining the RMP certification- and this was about 5 years ago. Since then, he informed, the cost of obtaining an RMP degree has almost doubled. And yet, the number of RMPs coming out of such institutions is remarkably high.
Government regulation in Bangladesh, especially in the area of healthcare is frighteningly weak. Even in the major cities, one can find a large number of pharmacies selling drugs without the proper certification. There are still a large number of rural healthcare providers that ‘treat’ patients with no formal training or education. The certification itself therefore is by no means mandatory. And the real training, for the majority of informal health practitioners in rural areas has always been some form of apprenticeship.
It seems to me that the RMP certification, when it first started out, ended up as a fantastic way to build one’s own brand as a rural health practitioner. It must have been great to be able to say ‘I am the only person in a 10 mile radius that has actually been taught to deal with your ailments by a real doctor!’ Understandably, demand for RMP certification must have sky-rocketed, spurring countless degree disseminating organizations to sprout up in all corners of Bangladesh. Today however, the RMP certification seems to be the norm- a basic must have, in order to survive in the market.
It turns out that most of the RMPs in that area had received training from the same institution. Yet, only one seemed to be completely dominating the market. So how is he monopolizing his market? I am guessing that his show of technical equipment had something to do with it.
Posted by Ahmed Abu Bakr