The government of Bangladesh has been building tertiary care hospitals to meet the complex and critical healthcare needs of the population. With growing health awareness, higher income levels and literacy rates in general, and increasing life expectancy in particular, people in Bangladesh are in need of accessing healthcare services, and they are getting it more often in institutional settings. In addition, the epidemiological transition of disease in the country is reflected in the higher prevalence of non-communicable diseases (NCD); these health conditions usually need more frequent medical care encounters and sustained attention from healthcare professionals. Also, cases of injuries and accidents are on the rise and many of these need receiving care at secondary or tertiary-level hospitals. These specialised or referral hospitals mostly deal with severe, life-threatening health conditions that need urgent care and the attention of specialist doctors and other healthcare professionals.
In the list of primary, secondary, and tertiary level hospitals, available at the government website (http://hospitaldghs.gov.bd/list-of-2ndary-tertiary-level-hospital/), there are 25 tertiary level hospitals in Bangladesh. Out of these, 9 are located in Dhaka city alone though Dhaka has a population of not more than 1/8 of the whole country. Looking at the current geographic distribution of these hospitals does not give the impression that the government has followed a clearly developed and evidence-based policy or plan to build these hospitals.
Private hospitals quite understandably locate themselves where affluent and high-literacy people live and cluster. Looking at the locations of the top few elite, private, and large tertiary-care hospitals in Dhaka makes it obvious what their catchment areas are and why is this so. Among the tops, Labaid is in Dhanmondi, United is in Gulshan, Evercare is in Bashundhara, and Square is in Panthapath.
However, public healthcare facilities must address the need of all people irrespective of their wealth, income, occupation, education, location, ethnicity, and social class. The country has an obligation to reduce all inequalities in healthcare access. One of these arises from the geographic barrier to reaching the hospitals.
Bangladesh is a highly populous country where disease distribution varies by region. Several research studies show that injuries and diseases afflict people living in different regions differently; the incidence, prevalence, and severity of diseases vary by region. For example, snakebites are more frequent in flooded and jungle areas; malaria is more common in the hilly districts whereas leprosy is prevalent in the far-northern areas. A mapping of the incidence and prevalence of health conditions by geographic location would help create profiling of health conditions and uncover the pockets of vulnerable populations in regions where the needs are more acute and higher.
Also, population density is not the same across the country and all parts of the country are not well-connected yet through road and rail networks. Also, a large segment of the population depends on water transport. To make matters worse, vast areas of the low-lying parts of the country go underwater during the rainy season making it very difficult for patients and their caregivers to travel to the capital Dhaka where many of these specialised hospitals are located. Districts vary by population, area, income, and literacy rates. Meherpur has an area of 752 square kilometers (skm) whereas Chattogram has an area of 5,282 skm. In terms of population, Bandarban has a population size of 481,109 whereas Dhaka has a population of 14,734,025. More than likely, these socio-demographic and geographic factors have not been considered in planning and building referral health facilities.
Many major public hospitals have been built in Dhaka, a city that is somewhat centrally situated in the country and has the highest population size and density. However, the real reason may have been the powerful and wealthy social class who wanted to make healthcare services more accessible and convenient for them. Sadly, the middle and upper-income groups have started seeking medical care overseas or seek care at the elite private hospitals leaving the centrally located public hospitals to serve the rural and remote people who have to come to Dhaka. Also, the urban poor in Dhaka still receive care from public hospitals. All this created access barriers and further escalated health disparity.
If the residents of Banglabandha need to come to seek care at the nearest tertiary-care hospital-- Abdur Rahim Medical College, Dinajpur, it will take them about 3.30-4 hours if they travel by car. By using public transport, it will be several hours more to travel. If the exact access to medical care takes a few hours and the patient is released on the same day, they will still have to stay that night there and will have to pay for accommodation and meals. Patients are accompanied by more than one caregiver, relative, or friend and this doubles or triples the costs incurred. Looking at the map, a tertiary care hospital located in Nilphamari or Thakurgaon would be more centrally located for the people of that far north region to travel to access care. Rangpur already has a Medical College Hospital and it is easily accessible from several upazilas of Dinajpur. Rangpur Medical College Hospital is only about 2 hours away (driving distance) from M Abdur Rahim Medical College, Dinajpur.
The government needs to identify the medically underserved regions of the country and create an epidemiological profile of disease by region. Then, after incorporating the area and population size of the districts, policymakers should identify the needs and then plan for health facility building. Using simple tools like Google Maps, estimating distance and time to travel has become quite easy. Creating a decision algorithm after consulting with the experts will help in this. The government needs to stop building specialised hospitals randomly.
Hasnat M Alamgir is a Professor and Head of Public Health at the State University of Bangladesh. wasiahmed.bd@gmail.com
Where should Bangladesh build its next tertiary-care hospital?
Hasnat M Alamgir | Published: June 24, 2023 21:06:26
Where should Bangladesh build its next tertiary-care hospital?
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