The Building Blocks of the Government Healthcare System

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With a doctor to patient ratio of approximately 1: 3500, Bangladesh faces significant challenges when it comes to providing its citizens with access to healthcare. The government has an extensive healthcare infrastructure, running along the geographical administrative lines, to create a hierarchy that provides primary healthcare and family planning services at the grassroot level and gradually escalates a patient up the chain to more sophisticated care at Upazila or District hospitals. According to the 2012 Health Bulletin by the Directorate Generate of Health Services (DGHS), there are 425 Upazila hospitals for 492 Upazilas and 3,710 union healthcare centers for 4,501 unions. The government healthcare system is universally free: patients get free consultation and medication. As Bangladesh does not have a national poverty classification system, such as the Below- the-Poverty-Line (BPL) card in India, the system does not differentiate between the rich and poor.

Each union of Bangladesh is divided into 9 wards, the smallest electoral constituency that elects its own ‘ward member’ or ‘union parishad member’. The building blocks of the government’s healthcare system also start at the ward level through the Community Clinics. The project calls itself a community driven project because the government pays for the construction of physical clinic while the community donates the land.

During a field visit to one of our projects in Gaibandha, the mPower team had an opportunity to visit a community clinic. The relatively new infrastructure meant that the clinic had been recently opened. It was staffed by a Health Assistant who informed us that patients mostly come for the free medication and when that runs out, he doesn’t have much to do – which was the situation now. He had send in his requirements a few weeks ago, but had not heard back. With a high school degree, the Health Assistant is not qualified to do anything more except dispense OTC medication and check basic health indicators such as body temperature, weight and blood pressure.

Determined to understand the next level of linkage, we made our way to the Union Health and Family Welfare Center (UHFWC). The lengthy title indicates the center provides both primary healthcare and family planning services. As we entered the dilapidated building, an angry cat hissed at us –annoyed at being disturbed from its slumber. All the rooms inside were locked; we began to wonder if we had come to the right place. As we getting ready to leave, a lonely figure emerged, and introduced himself as the pharmacist for the healthcare center. We were in the right place after all!

Although every UHFWC is supposed to be manned by a trained MBBS doctor along with a Sub-Assistant Community Medical Officer (SACMO) under him or her, the center had neither. As the pharmacist was speaking to us, an old lady walked in with her sick granddaughter. The pharmacist excused himself to help her. He was not only in charge of dispensing medicine, he explained – he also had to fill the shoes of a ‘doctor’. He was the only employee in this center; there was no one to even help clean the floors.

To be fair, the UNFWC at Gaibandha was a far cry from an UNFWC at Manikganj we had visited the previous week. The SACMO there hardly had any time to speak time to us as he was wrapping up a meeting of sales representatives from several reputed pharmaceutical companies. The smell of polao and fried chicken wafted in, courtesy of the corporate sector. The SACMO introduced us to the pharmacist, ordered his staff to bring us tea, and showed us the list of 30 patients he had already treated today. The only common thing between the two centers was the lack of the MBBS doctor. Even in a place like Manikganj – very close to Dhaka – the post of an MBBS doctor at the UNFWC remains vacant. Given the doctor patient ratio, filling the Upazila complexes is a tall task for the government let alone the union centers. To meet that gap, the 3-year diploma course to trains SACMOs was introduced. It is clear that this cadre of healthcare workers fulfill a critical need in providing professional healthcare to rural people.

For a country like Bangladesh, free healthcare is indeed an admirable and brave undertaking although how effective it is part of a much larger debate. The theme along the bottom tier of the government healthcare system is that it’s easy enough to construct the physical clinic, union centre, or hospital but the real task lies in keep it staffed and stocked. Why neither happens adequately is a million dollar question.
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Shammi Quddus

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