Sure Care: A platform to connect rural doctors to Bangladesh's rich medical diaspora

Rashida was a heart patient who died in a hospital in the capital. She was shifted to Dhaka in a critical stage, because the doctors in her hometown didn't know how to help her, while the hospitals were not properly equipped to support a patient like her.  

While she suffered, her husband sold off their property, one by one, to pay the bills at the hospitals. He would sell it all, but his wife died before he could turn penniless.  

Rashida's story is tragic but much too common. In the absence of proper healthcare in rural areas and stupendous healthcare costs in the capital, heart patients who require urgent attention find themselves in extremely distraught situations. 

However, just as this phenomenon is true, it is also true that Bangladesh has a large pool of expert heart specialists, both inside and outside the country. 

And at the behest of some Bangladesh-origin doctors who are currently practising in countries like the United States and the United Kingdom, a platform called Sure Care has emerged to address these challenges, along with an intention to ensure 'accountable healthcare' in Bangladesh's healthcare system. 

Sure Care, once launched officially, will be a digital consortium of expert doctors based in Bangladesh and all over the world. It will be present in different tiers across the country, with a key focus on rural Bangladesh, where access to proper care is challenging. 

When local doctors, in remote areas for example, struggle to understand something while treating heart patients, Sure Care's consortium of expert doctors from all around the world will come to their help. That consortium will be made available through an app that Sure Care developed to provide digital health care. 

What makes this initiative different is the consortium of resident and non-resident doctors behind this, their special focus on heart treatments (they will address a myriad of other diseases as well), and the plan to provide loans to patients in need, so that no family has to descend to abject poverty by shouldering the weight of the current out-of-pocket medical billing system.  

Oversight and accountable healthcare

Dr Chowdhury H Ahsan, a Bangladeshi-American doctor who is Chief of Medicine at University Medical Center, Las Vegas, is one of the architects of this platform. He is also the Governor of the Nevada Chapter of the American College of Cardiology.

Explaining the idea of accountable healthcare, he said, "In garments, the buyers and sellers both know what they are buying and selling. You know you want a red dress with three buttons. Both parties are aware. But this does not happen in the health sector. The provider (doctor) knows what he is providing, but the consumers (patients) are not aware." 

"Suppose you take your father to a doctor. He says you need a cataract operation. But do you really need that operation? Or is the operation taking place because the doctor wants it? You don't know." 

Dr Ahsan went on to explain how when it comes to heart treatment, not all patients require an angiogram. 

"What kind of nonsense is this? All blockages are not equal. Is this left main artery blockage or blockage of a branch of it… I know this because this is my subject. But the consumers (patients) don't know this. What are you giving the consumers? Fear," Dr Ahsan said.  

As the discussion delved into more complicated medical discourse, Dr Ahsan pulled back, and said, "I am not trying to overwhelm you in this discussion, I am simply saying that whether an expensive device or therapy is required depends on the clinical context, patients' presentation, underlined diseases etc." 

"What does it mean? It means if there is no oversight here, as a human being, my tendency will be to overcharge the patients. 

"Nobody is a saint. I work here. I am not a saint here. But since there is regulation and oversight here, I have fear. This is a rational fear. Because if I don't ensure the appropriate use of the stent, the insurance company will refuse to cover it. And if it is covered by the government, and if they find I overcharge the government inappropriately, in the second-year review, the government will not only ask for the money back, they will ask for the interest, and also, may send me to jail. These two are extreme examples of unregulated and fully regulated care," he explained. 

However, he said, if we want to go to fully regulated care in Bangladesh, it is not possible. It would be impossible to enforce oversight to this degree. 

"If we have to work in Bangladesh, it has to be in collaboration. We cannot just go and say 'don't overuse'. What we can do is suggest that 'what you prescribed could have been done without'," Dr Ahsan said. 

That is where the Sure Care collaboration comes into effect. 

Dr Ahsan's brainchild will be a collaboration of the best local and international doctors, where a doctor from remote Bangladesh will have access to prompt suggestions from top-class doctors in the US or UK, or any other place, and through the pool of a network of doctors, there will be an effort to minimise the cost of treatment for the patient. 

Easing the burden of the out-of-pocket system 

"My experience in Bangladesh is that more than 99% of the healthcare costs are out of pocket. Whereas here [in the United States], insurance or a third party pays the healthcare cost," Dr Ahsan said. The insurance system that covers such expenses in the United States never developed in Bangladesh. 

"First of all, in Bangladesh, this is tough to afford. Secondly, it is not in our psyche to pay insurance premiums each month," he told The Business Standard. "So, I had it in mind that an alternative system needs to be developed where the patients are empowered… a system where they will have the medical records [stored]." 

What would be the alternative? Health loans! 

The banks would pay the bills of Sure Care's member patients and the patients would pay them gradually. This would prevent people from abruptly falling below the line of poverty as a result of paying off massive medical bills all at once. 

Dr Ahsan, during his last trip to Bangladesh, tried to convince some banks to get on board with a health equity line of credit. Did you convince anyone? He laughed and answered, "It is not easy in Bangladesh to get someone in the field."

There is indeed a risk factor in the loan payment, but on that, Dr Ahsan is confident that people will pay the loans once the service is taken because "it is mostly the super-rich who default on loans here, not the middle-class or poor." 

"Besides, I took it philosophically that even if no one stands by our side, even if the project doesn't stand on its feet, at least I am injecting these ideas that there should be an oversight and accountability," he added. 

Reaching the most vulnerable people 

The platform has on-boarded over 70 non-resident and resident doctors, and partnered with associations like Diabetics Associations of Bangladesh, Citi Health etc. 

In an event in November at the Pan Pacific where World Heart Federation's president-elect Professor Jagat Narula attended as a guest of honour, Diabetic Association's Secretary General Sayef Uddin said they have 90 affiliated associations spread across the country, trained over 20,000 physicians on diabetic care, established a network of laboratory system in districts and sub-districts so that patients need not come to Dhaka. 

Sure Care considers such a strong partnership a positive start. So when Sure Care talks about its intention and plans of bridging doctors and patients, it doesn't sound impossible, given the role the infrastructure of their partner organisation could play in realising that. 

 "Suppose there is a small centre of ours in Khoksa, or Ukhia. Suppose a patient comes with chest pain there. Now chest pain can occur for many reasons. The local doctor assigns an ECG, and the point of care does some tests. If there are dynamic changes in ECG, and risk factors of heart attack, then we have to prove that he or she already had a heart attack, or an attack is impending, or at high risk. 

"Now the young doctors in the remote areas may not be confident enough about what to do. They may not have the necessary experience. So if the ECG is uploaded on the app, it will come to us, or to our doctors as a message." 

"Our concept is if we can build a network where we can give our members an oversight, they will at least know that people are behind them, and they will be able to make proper use of healthcare… We have a pool of experts locally and overseas. Whenever one of the doctors takes note, the others will see the responses that… for example, Dr Aziz from Atlanta, or Rafik Ahmed from Baltimore, or Hafeez, or myself, has responded from Las Vegas." 

"It means one of the experts is already on the case. He will dial up the local doctors," Dr Ahsan said. 

"He will check all the issues with the local doctors. He will advise on whether the patient needs to move to bigger care facilities in the capital, for example, or will address the issue based on their financial capacities. It will reduce costs, because the patient will not have to go to hospitals in cities, if avoidable." 

The care will be conducted in three tiers. Tier1 would be in the remote areas, where there is no access to healthcare. Tier2 would be in the district levels, whereas Tier3 would be in the divisional cities, where members would get discounted prices. 

How would you ensure doctors in rural areas? "It is a fact that our doctors don't want to go to remote areas. But we have seen, among our junior doctors, some want to stay where their homes are… the second option is we provide incentives under this programme," Ahsan said. 

The platform is still in the 'proof of concept' stage. There is no funding yet as the app they developed was self-financed by the founding president himself, and point-of-care services are provided by the Diabetics Association.

"Our government rightfully identified five non-communicable diseases – cardiovascular, stroke neurological, COPD, Renal, diabetic and diabetic complications. - as diseases that will have a significant impact. We want to address these diseases. We are highlighting cardiovascular on Sure Care. But we will take care of other disciplines as well," he added.  

"We cannot and we are not taking on the whole care. Because we cannot simply afford it. But at least we can say that we are here to help," Dr Ahsan said.