Financial impact of standardised emergency care in Bangladesh: a patient's view

It may very well be that the Bangladeshi public, in general, has a false sense of security when it comes to the consumption of Emergency Medical Care. After all, at least in the urban setup, signposted emergency departments abound and previous rulings by the High Court have mandated that hospitals, clinics and medical practitioners provide emergency medical services to every patient when brought to them. The reality, unfortunately, is grim, especially with the phenomenon of private health facilities refusing to treat such patients, for one reason or another. Much of this boils down to the absence of any structured Emergency Care or Emergency Medicine training in Bangladesh's medical education paradigm. Whereas neighbouring India, Pakistan, Sri Lanka, Nepal and even Bhutan have been producing specially trained Emergency Physicians since the early 2010s, we as a nation, lack both a curriculum and a career path for health care professionals in this field.

Now, the powers that be may reckon that setting up a new medical specialism, and all the costs it entails, may not make much fiscal sense; after all, the healthcare system has been trudging along for the last fifty odd years without Emergency Care. However, the value of Emergency Care is well established across numerous healthcare systems worldwide with organisations like the International Federation of Emergency Medicine and the World Health Organization advocating for it.

This article takes a dive into the microeconomics of the effect of Emergency Care, and to do that it looks at two contrasting scenarios of a patient. The first is a typical patient journey through the current healthcare system in Bangladesh and the second is the same journey with an embedded Emergency Care system in place.

SCENARIO A: Mr Chowdhury is 58 years old and works in a clerical position in a bank in Dhaka city. At 2 pm he notices that his left arm feels week but does not think much of it. However, when a colleague comes to talk to him, it is obvious that he has difficulty forming words and speaking. His colleague is immediately aware that something is wrong and offers Mr Chowdhury a sugary drink. Mr Chowdhury tries to drink but is having severe difficulty swallowing the fluid and almost chokes while doing so. With concerns over Mr Chowdhury's health rising, his colleagues quickly rush him to the diagnostic centre across the street where they know that doctors are present. However, they get turned away by guards at the gate saying that the diagnostic centre does not have any emergency unit, and they must go to the nearest one.

Transport is required to take Mr Chowdhury, who is now having difficulty walking on his left leg, and they take him to the nearest facility with an emergency room. He gets seen more or less on arrival, given the nature of his presentation in the near empty emergency room, has his blood sugar measured, and after it comes back normal his colleagues are informed that this is likely to be a stroke and he needs to have a CT-scan of his brain. Unfortunately, the health facility they are at, does not have any CT capabilities and therefore they are forced to move again with new transport.

They are advised by staff to take Mr Chowdhury to either Dhaka Medical College or the National Institute of Neurosciences (NINS). Being more familiar with Dhaka Medical College, they opt for it, but the traffic causes significant delays. When they make their way to the emergency department counter through the crowd, they are informed that the emergency scanner is out of commission and the perennial bed crisis has not resolved, so they would have to make some space for Mr Chowdhury on the floor. They are suggested to take Mr Chowdhury to the aforementioned NINS Hospital, but by the time they arrive there it is 9 pm. A CT scan is done, and it shows a blood clot in the blood vessel supplying the brain that has caused a stroke. His colleagues are informed that if he had arrived by 6 pm, there was a possibility of treating the stroke by dissolving the blood clot, but now he would need admission and likely long-term rehabilitation. Figure 1, below, shows the impact of cost across time for this scenario.

SCENARIO B: Upon finding Mr Chowdhury slurring his speech and then unable to drink, his colleague calls the emergency hotline 999. After explaining the situation, an ambulance with a paramedic is deployed. It takes an hour for the ambulance to reach Mr Chowdhury given the situation of the city traffic, but after some preliminary tests by the paramedics and the phone calls, the ambulance takes Mr Chowdhury to NINS where he receives thrombolytic treatment for the clot, followed by an uneventful hospital stay for one week and minimal rehabilitation requirements. Figure 2, below, shows the impact of cost across time for this scenario.

It is recognised that costs for Emergency care are higher than other primary care services such as out-patient services and urgent care services. Despite this, patients are willing to pay, even in out-of-pocket health economies like Bangladesh, for emergency medical services when appropriately informed. On the other hand, a price cannot be put on the uncertainty and the aggravation that patients and their attendants have to face when no clear and definitive treatment plan is made available.

Furthermore, not only do hospital admissions account for a high percentage of patient care costs, but they also take up considerable man-hours for the patients attendants who would otherwise be employed elsewhere. Appropriate and timely emergency care allows for a shorter length of stay for patients, and this is especially true for time-critical diseases like strokes, heart attacks and sepsis. Not only does Emergency Medicine decrease patient mortality across healthcare systems, it also decreases patient morbidity.

In the scenarios above, the absence of emergency care services resulted in an ischaemic stroke to mature and this required long term medication and physiotherapy for the patient to make a recovery as close to initial baseline as possible. Again, rehabilitation sessions are associated with a loss of working hours not only for the patient but the attendant as well.

The detrimental impact of the lack of Emergency Medicine in Bangladesh cannot be overstated. How often do we find news stories of people dying in road traffic collisions relegated to the inside pages of the national dailies? We have been desensitised to these unfortunate and preventable deaths and we only take notice when the death toll arbitrarily strikes our collective consciousness. If we are comfortable with ten preventable deaths today, it is more than likely that we will be comfortable with a hundred deaths in the near future. We, as a nation, need to urgently introduce Emergency care as a speciality and a career path before its lack impacts each of us a little too close to home.

Dr Mir Saaduddin Ahmad is a specialist in international emergency medical care working with the ZABS Foundation in Bangladesh and Doctors Worldwide in the UK; he is also a consultant in emergency medicine in the NHS, based in London.  dr.msahmad@gmail.com