Is contracting-out medical services feasible?

Shahiduzzaman Khan Bangladesh has made some good progress in healthcare services by setting up some state-of-the-art hospitals with modern equipment and technologies in the capital city. A large number of patients have stopped going abroad for treatment and for that matter, foreign exchange components worth about Tk 120 billion are being saved annually. But the fact remains that the country's overall healthcare services have deteriorated. Capacity constraints in the public hospitals are prohibiting a lot of patients from getting fair treatment. Despite serious limitations, most of the public hospitals are offering emergency services, but the quality of treatment is not at all satisfactory. They can hardly cope with the ever-rising demand for treatment. Doctors and nurses seldom take care of the patients in most of the public and private hospitals. Free medicare facilities and medicines are rarely available. According to reports, a section of dishonest public hospital officials influence patients to get admitted into private clinics citing better treatment. Private clinics offer a slice of their income to these touts. Medicare services in public hospitals beggar description. Poor people have no alternative other than going to these hospitals. It is hard to get services there. Specialist physicians are mostly busy with their private practices. Even on-duty doctors leave hospital premises to visit patients in private clinics. Unfortunately, specialist physicians in Bangladesh are very few in number. So a specialist physician, after hisher duty at the public hospitals, visits at least 50 patients a day at his own private clinic. How can he do justice when he usually gives only five minutes per patient? He has little time to go through the patient's history to diagnose his disease. In most developed and developing countries, at least 30 minutes and beyond are generally earmarked for one patient. Doctors there visit only 20 patients a day. Private practice for a public hospital doctor is strictly prohibited. Poor doctor-patient communication in fact hinder correct diagnosis. Many doctors in Bangladesh are reluctant to improve such communication which is one of the key elements of treatment. Although Bangladeshi physicians have proved their worth in treating diseases abroad, they give little importance on good doctor-patient relations. Patients, after all, are not cars or televisions, which can be fixed with a 'tune-up'. They are living human beings whose humanity must be respected if treatment is to succeed. They are also reluctant to share any information about their condition, and have little authority to decide their own treatment. The result is poor health outcomes for the patients. Studies have shown that, of all the risks that poor households are facing, health risks probably pose the greatest threat to their lives and livelihoods in Bangladesh. Unfortunately, the health system is frequently ineffective in reaching the poor, generates less benefit for the poor than the rich, and imposes repressive cost burdens on poor households. The consistently inequitable nature of health systems limits the access to healthcare by the poor who need it the most. Concern was raised recently about attaining the health-related Millennium Development Goals (MDGs) in low-income countries like Bangladesh without improving the ability of health systems to reach the poor effectively. The poor and disadvantaged households with only a few assets are likely to struggle to meet even small extra-budgetary expenses Thus, improving the ability of the health system to reach the poordisadvantaged populations is essential to mitigate the income-erosion effect of ill-health and poverty alleviation in Bangladesh. The US-based healthcare companies are now outsourcing their healthcare services overseas either through joint venture initiative or opening their own state-of-the-art hospital facilities. The objectives are to provide comparable healthcare services to their own patients as well as to the international communities at a reasonable cost. Bangladesh should develop clear strategies to motivate these potential healthcare companies to expand their services in Bangladesh. It will not only create thousands of new jobs but also provide better treatment opportunity to the local people. It is essential for the government to revise the curriculum in medical, nursing and pharmacy schools that train healthcare professionals, so that they are trained according to the new international paradigm. Business schools should be encouraged to develop executive training programmers in healthcare, which will effectively reduce the talent gap for leadership in this area. The government should also develop and implement international standard examination by which doctors, nurses and pharmacists are qualified for employment in the Joint Commission International (JCI) accredited organisations. Local hospitals need to be encouraged to evaluate their services by JCI and meet their compliances. Partnerships between the western and local hospitals should be developed to devise newer ways to deliver healthcare. The government may appoint a commission, which can make recommendations for the healthcare system and monitor performance. Very recently, the World Bank (WB) asked the Bangladesh government to contract out some of the medical services to the private sector 'at certain levels.' The WB recommendation followed a study on the state of affairs relating to the country's medical services. The study found a state of anarchy prevailing in the sector. Common people, especially the poor ones, are not getting medicare services at all. Despite infrastructures at the upazila and union levels there are no medicines and no services available. The physicians posted at the upazila level are seen absent from their places of work and most of them prefer to stay in the cities and towns. They are involved in practice at private nursing homes and hospitals. Nurses are seldom seen at the upazila level hospitals, said the study. The World Bank advised the government for contracting out medical services to the non-government organisations (NGOs), private institutions of fame etc. Such contracting-out should be based on win-win situation. The private sector organisations must be chosen from among the lists of transparent and accountable firms and organisations. At the initial stage, the government may go for contracting out union and upazila level medical services which is all-important for ensuring bare minimum services to the needy ones at grassroots level. Then it may consider bigger public sector organisations in cities and towns to open up. In this context, the government may even go one step ahead. It may consider transferring the management and operation of the large health sector entities to famous overseas medical services groups and firms. The large entities might include Suhrawardy Hospital, Hospital for the Handicapped and Disabled, National Heart Diseases Institute Hospital, Eye Hospital etc. In the wake of chronic mismanagement, negligence and widespread corruption in these organisations, it is necessary that there should be an effective mechanism to streamline the activities of such ailing organisations. szkhan@dhaka.net