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The quality of services provided currently in general by both the public and private healthcare facilities in Bangladesh is certainly not beyond questions. This has been a cause for concern even at the policy level. High level deliberations have failed to create a consensus on how to develop a feasible regulatory mechanism or framework or more specifically create a set of standards or benchmark parameters to adhere to.
Sadly, many of our health facilities-- even those in operation in the critical care sector still remain unregulated, unmanaged and have been left unaccountable for what services they provide for. Some of these are not even duly registered with the government or have been operating with forged documents or well beyond the expiry date. How do we know that the services they offer and equipment they use are documented, catalogued and the quality of those ensured or the human resources they employ are duly qualified or credentialed?
To comprehend the extent of how convoluted this conundrum has been may be exemplified by the simple fact that a few such unregistered facilities received high level government contracts for Covid-related tests and treatments during the pandemic when the citizenry really expected that finally or at least once there would be a rising of moral renaissance among all quarters in Bangladesh during the critical period of the pandemic.
The inefficiency and faulty or intrinsic mismanagement of many of these facilities became evident during this pandemic when disgraceful incidents of conducting false tests and supplying fake or low quality Personal Protective Equipment (PPE) for healthcare workers were exposed. Now the point is, has our healthcare service improved afterwards?
Asking for needless diagnostic and pathological tests, prescription of unnecessary medicines, performing avoidable procedures including caesarians, and forcing patients to stay at the hospital particularly in its high-resource intensity units such as ICU/CCU are few of the many issues that have been raised repeatedly by many care recipients and these are not unknown to the government regulators. These have eroded the confidence of majority of the citizens in health professionals and the health care service delivery system in the country.
Other common health service quality issues in the hospitals that often come to the media and create public uproar include 1) poor behavior of the healthcare professionals and hospital staff or their inattentiveness or indifferent attitude towards patients 2) very short visit time allocated for patients 2) malfunctioning, poorly maintained, unavailable or obsolete machines and equipment 3) incomplete, fragmented or disorganised provisions of basic or essential healthcare services 3) poor or no ambulance service 4) unlicensed hospital staff such as ayas (helping hands), cleaners and ward boys offering critical patient care service or providing medical advice 5) unwanted presence and influence of middlemen (dalals) who prey on unsuspecting patients to redirect them to inferior and unregistered private facilities 6) a working and patient care environment that is unhygienic (e.g., dirty washrooms and poor quality food at canteen) 7) allegations of incorrect diagnosis and continuation of erroneous treatment regimen 8) no timely referral 8) charging of exorbitant fees by most private hospitals 8) very long wait time and delays in crowded emergency rooms and outpatient counters 9) more patients admitted compared to seat capacity.
Monitoring and surveillance of healthcare sector is crucial because of people's ultimate dependence on and use of it and they need it the most during critical life-threatening situations and moments. Many well-off patients simply stopped seeking healthcare in Bangladesh and even for regular checkups and health conditions that require simple interventions, they fly overseas, costing the country millions of dollars. Therefore, it also makes an economic case for improving the quality of healthcare services in Bangladesh. Thus the healthcare industry has to earn the confidence of the high-paying patients to get them back on its premises.
A key notion to create, maintain and deliver quality healthcare service is "health outcome" and the World Health Organization (WHO) defines a health outcome measure as a "change in the health of an individual, group of people, or population that is attributable to an intervention or series of interventions." These outcome measures are commonly collated and reported to the government, large payers, insurance providers and quality reporting organisations on regular intervals as well as to the general public via website, social media and annual reports.
Health outcome measures are poorly defined, developed, understood, standardised, implemented, reported and promoted here in absence of a government-mandated functional regulatory mechanism (e.g., for a lack of understanding, resource support or expertise, or simply due to careless attitude). Those are made worse on account of a poorly organised, weak and small health insurance market, an absence of standardisation or accreditation bodies and miss-directed or unfocused priorities of the health professionals' associations.
A first step to create a quality culture in the healthcare industry may be to put in place a set of health outcome measures which will be reported by all large facilities. With several world class and large hospitals now operating in Bangladesh and several others in the pipeline, it may be time for these facilities to create a set of common health outcome measures for the sake of creating and maintaining their own reputation, quality assurance and marketing efforts. They must make these indicators available to the general public who can assess the quality of the services provided. The government can learn this self-certification process and be informed on these evaluation measures and efforts.
The healthcare industry in collaboration with professional associations or healthcare research and oversight bodies such as the Bangladesh Medical Association, Bangladesh Medical Research Council, Bangladesh Nursing and Midwifery Council, Nurses' Association, researchers with expertise and interest in health service quality or hospital administration, patient safety and rights advocates and public health associations need to initiate immediate discussions on improving service quality. This will help them gain people's confidence and trust leading to creation of a fair, open and competitive market.
Dr. Hasnat M Alamgir is a Professor of Public Health.