After informally interviewing about a dozen RMPs, the one question that kept nagging us was the quality of the treatment provided by rural Bangladesh’s most frequently consulted health practitioners. As we mentioned in our previous post on rural health practitioners, as of 2011, there were 130,000 RMPs operating in rural Bangladesh. So we thought that it was time to look into the training institutions that bestowed the RMP certifications. Within Gaibandha, we came across 5 such institutions that conferred three different types of certifications-
1. Rural medical Practitioners (RMP)
2. Local Medical Assistant and Family Planning (LMAFP)
The standard RMP certificate is a 6 month long course during which students are educated (for one month each) on six different areas. These areas include pathology, anatomy, surgery, OB-GYN, pharmacology and medicine. Understandably, there isn’t much, save the very basics, that can be taught on any of these topics within a month. The LMAFP on the other hand is a one year degree that deals with the same topics, albeit in slightly more depth, with an added course in dentistry.
The managers at these institutions assured us that RMPs and LMAFPs were not equipped to deal with any conditions except for the very basic of ailments such as fevers of unknown origins, common colds, sore throats, etc. The certificate does NOT grant them the ability to prescribe medication. While it trains them to deal with certain complex situations like child birth or severe injuries, it is always highly recommended that they refer such cases to doctors and intervene ONLY if there is no other alternative, as in the case of emergencies. Even in such cases, the RMP/LMAFP should only administer first aid and then refer to the nearest doctor.
However, our conversations with RMP/LMAFPs revealed that their views were radically different. In their eyes, their training and certification abled them to completely handle a wide range of ailments-one RMP went as far as to confess, and quite proudly at that, that he was quite capable of delivering children and had considerable experience in dealing with physical injuries (fractures, deep cuts, moderate burns, etc.) When asked as to his motivation for obtaining an RMP degree, he blatantly acknowledged that the RMP certificate was his safety net- if things went south, his certificate would protect him from the public’s out lash.
Of the three out of the five training institutions that we visited, two were NGO-based. These NGOs, with the approval of the government, were offering training and certification to address the acute shortage of doctors in rural areas. Granted, it was not the best solution, but it was a workable one. However, lack of proper monitoring has allowed the system to get completely out of hand. In fact the issue of accountability and transparency is so neglected that till now, we are still unsure of the government body that is actually responsible for overseeing the quality of training and monitoring the activities of the degree holders.
The case of the paramedic however, is thankfully much less confounding. The paramedic is trained under the Bangladesh Technical Education Board, with half his scores presented by the training institution and the other half presented from the Board itself. The average paramedic is trained in the areas of clinical medicine, pediatrics, surgery, gynecology and obstetrics, eye and ENT related problems, and first aid and bandaging. In addition to his coursework, the paramedic is also provided with and marked on extensive field activities.
During our conversation, it was also revealed that a large number of paramedics also choose to set up shop in rural areas, underserved through formal health care systems. Unfortunately, we did not have the good fortune of coming across any such personnel. However, the mere existence of such a situation, where a large number of trained paramedics choose to reside in rural areas despite the opportunity to migrate to urban centers, is remarkably fortunate. The way we see it, it provides an existing platform of semi-formal healthcare delivery in rural areas. The remaining challenges are to link them to formal sector healthcare providers, develop an adequate monitoring system, and empower them through training and technology to provide high quality health services at affordable prices.
Posted by Ahmed Abu Bakr