'Healthcare will soon emerge from 17 years of darkness'

This excerpt is from 'Zero Sum Game', a talk show hosted by Shakhawat Liton, Executive Editor of The Business Standard. The guest for this episode was Dr SM Ziauddin Hyder, Special Assistant to the Prime Minister on Health and a former World Bank health specialist. Six months into the government formed following February's election, he set out the new government's health roadmap and the commitment to transform the sector into a prevention-centred health system. 

Infograph: TBS

How would you describe Bangladesh's health sector in one word?

A single word is difficult. The manifesto puts the political economy of it plainly: health is a fundamental right, not a favour, and the sector has been long crippled by neglect, political interference and a deficit of accountability. Some 72% of health spending comes straight out of people's own pockets, so illness itself remains one of the main causes of poverty.

Infograph: TBS

Ordinary Bangladeshis and professionals from various fields consider the way health has been treated in this manifesto to be one of the best health-sector manifestos in the Bangladeshi context. We are now moving ahead with implementing these plans. We hope to soon leave behind the darkness of the past 17 years and improve the poor state of healthcare — much of which still remains in many parts of the country.

What has grown between the public and the system is a relationship of distrust. A person walking into a hospital, private or public, assumes from the outset that they will not receive care worth their money, and that they will encounter negligence, harassment and touts. That is why lakhs of Bangladeshis go abroad for treatment every year, and roughly $7 billion to $9 billion in hard-earned foreign currency leaves the country with them.

What is the fundamental change you are trying to make?

We want a transformation that builds a prevention-centred health system in Bangladesh. That is why, as you saw in our manifesto, the Prime Minister has said many times that, to take healthcare to people's doorsteps, we will recruit 100,000 new community health workers alongside our existing staff, so that every household is visited by a health worker at least once every three months.

On each visit, every adult member of the family will have their blood pressure and blood sugar measured, along with a quick mental health screening. Any married woman of reproductive age will be checked for pregnancy; eligible couples will be counselled on family planning and given the supplies they need; and young children's nutrition, height and weight will be monitored. Where a child or expectant mother is due for a vaccination, they will be told where and when to get it.

It is, in short, a package of preventive healthcare delivered to every family once every three months, so that anyone at risk of disease is identified at the earliest possible stage.

Every citizen will also have a health card. Through it, anyone found to be at risk or already ill will be referred to the nearest primary healthcare centre — and that referral means the person has entered our health system. If the centre can treat them, it will; if not, it will refer them onwards.

What we want is something that has never existed in Bangladesh in the nearly 56 years since independence: a comprehensive primary healthcare centre in every rural union, and one in every ward of each municipality and city corporation.

Under each centre, there will be three health and wellbeing hubs — we will convert the existing community clinics into these — which will house the community health workers, their base and their equipment. Each hub will have three community health and wellbeing workers, so there will be nine workers in each union or city ward, taking healthcare to people's doorsteps.

The primary healthcare centre itself will have everything needed to deliver primary care: two SACMOs — diploma-qualified health professionals — a nurse and two midwives, so that no one with a normal pregnancy has to leave the union to give birth. Everyone will be able to come to this centre for a normal delivery.

There will be an aya to assist with deliveries, a small pharmacy stocking primary-care medicines, and a small diagnostic lab for very basic tests such as haemoglobin. Those who can be treated there will be treated there; those needing higher-level care can be referred, via the health card, to the upazila health complex and, if necessary, to the district sadar hospital, a medical college hospital or a specialised hospital for more intensive treatment.

And the structure that receives them?

Every citizen will have a health card, and through it, anyone found to be at risk will be referred into the system, to the nearest primary healthcare centre. We will build a comprehensive primary healthcare centre in every rural union and every urban ward. This is something that has not happened in the 56 years since independence.

Under each centre, there will be three health and wellbeing hubs, created by converting the existing community clinics. Each hub will have three community health and wellbeing workers, so there will be nine workers in each union or ward. The centre itself will have two diploma-qualified sub-assistant community medical officers, a nurse, two midwives and a helper, so that normal deliveries can take place within the union, along with a small pharmacy and a small diagnostic lab.

From there, the health card will enable a patient to be referred upwards — to the upazila health complex, the district hospital and, if needed, a medical college or specialised hospital.

Do you have the workforce for this?

At the front line today, we have three kinds of workers — health assistants, family welfare assistants and community health-care providers. Each works under a different directorate, with no coordination between them, so some homes are visited by all three while more remote ones are visited by none. We are merging the three into a single new cadre, the community health and wellbeing worker.

We have about 41,000 to 42,000 of these staff now; adding 100,000 new posts would bring the total to roughly 140,000, enough to deliver that preventive package to every household every three months. Recruitment to fill the existing vacancies has begun, and the creation of the new posts is well advanced.

None of this is free. How are the funds being allocated?

Our commitment is to raise the health budget to 5% of GDP in phases. Historically, it has stayed below 1%, while many countries spend 8%, 10% or 12%. For the first time, this year we have raised the health budget by around 37% — an increase that few developing countries have managed in a single year. The government led by Tarique Rahman does not just plan; we believe in implementation, and we have begun with the budget.

Our country has done a few things well. Take our immunisation programme or our family-planning programme; both have been praised in various countries around the world. We did that work very well.

In my own experience, I have worked in a number of countries — mainly in Africa, across several African countries, then in East Asia, in Cambodia, Vietnam, Laos and Indonesia, and in South Asia, in Pakistan and Sri Lanka. If I were to sum it up, what our health sector suffers from is disorder and a lack of efficiency. 

We have fine experts, fine doctors, and individually excellent nurses and medical technologists — but organising them into a single, coordinated force to achieve better outcomes takes political commitment and leadership. In the past, we have seen that fall short in many places.

If you look at the Covid-19 period, you will remember that in the early days our health sector was thrown into complete disarray. More people died of non-Covid causes than from reported Covid deaths — those who had a heart attack or a stroke, or fell ill in other ways, went to hospital and could not get care. 

As a result, they died or suffered greatly. That was when we saw another thing clearly: if a country's health sector does not run properly, if it is disrupted, the gains made in every other sector are lost too. The other sectors cannot hold up.

What have you actually legislated in these first months?

Within the first 180 days we have drafted three legal frameworks. 

The first protects health workers, doctors and patients alike, because violence in hospitals has become a serious problem. 

The second is to prevent unnecessary caesarean sections. In urban private hospitals a normal delivery is now almost unheard of, on the false belief that a caesarean is safer. 

The third replaces the 1982 ordinance that still governs private hospitals, written when the private sector was small; today it delivers 60% to 70% of urban healthcare, so it must be regulated to provide quality care at an affordable cost. All three drafts are close to done and should reach parliament soon.

Have any structural changes already been made?

Yes — urban healthcare. Since independence it had been left with the Ministry of Local Government, and for want of coordination with the health ministry it kept falling between the cracks. Soon after taking charge we decided to transfer urban healthcare fully to the health ministry. 

I think it is a landmark step; it will do a great deal to enrich care in the towns and cities.

You have worked as a health specialist abroad. What pressures are coming that we are not ready for?

Two, above all. 

One is an aging population — longevity is rising, but we must make it healthy and turn our elderly from dependents into a productive population, what is called the longevity dividend, which means strengthening geriatric care from the primary level up. 

The other is climate change, which is shifting our disease pattern: non-communicable diseases —  stroke, hypertension, diabetes, cancer, road accidents — now account for 71% of all deaths. Yet pre-hospital emergency care is almost non-existent here. 

In Thailand you dial one number, an ambulance suited to your condition arrives, a skilled paramedic begins treatment on the way and takes you to the right hospital. Build that, and we could cut deaths from stroke, heart attack and road accidents very significantly.

Do we have the skilled people for all this?

Not yet, and this is where medical education has to change. Our curriculum is old and content-based; the countries doing well have moved to competency-based and community-based education, and we must follow. 

The MBBS curriculum is reasonably good, but for nurses, midwives, medical technologists and pathologists it is very poor and has been neglected. So we are updating curricula to global standards, investing in faculty and modern, simulation-based teaching, strengthening the regulatory councils, and looking at a national exit examination for graduates. 

In this year's development programme we have taken projects to strengthen the medical, dental and nursing councils and the Medical Research Council, and we went to the Philippines to study how they train and regulate their nurses. None of this is a one-year or two-year task; what it most needs is political will — and for the first time we have a prime minister who has placed health at the very top of his list.

Two immediate worries — the measles deaths, and dengue ahead. What is the government thinking to improve the situation? 

On measles, let me be precise, because the figures have been confused. The roughly 1,000 deaths being cited are suspected cases, deaths with measles-like symptoms; confirmed measles deaths are around 99 or 100, and the others may have died of pneumonia or the like. 

In one of the fastest campaigns anywhere, within four weeks we vaccinated children from six months to five years with close to full coverage; when about four million were found to have been missed, we launched a crash programme, and our national immunisation advisory group is now considering whether to extend the age range. 

On dengue, we are moving to a community-based prevention programme, because neither the municipality nor the government can do it alone — a single bottle cap of standing water on a rooftop breeds the mosquito. It needs an all-out effort and a change in everyone's behaviour; manage that, and we can be free of it, and if we fail, the suffering will simply carry on.