Revitalising general practice in Bangladesh: complementing ‘the Bangladesh Paradox’

HEALTH CARE IN BANGLADESH

Bangladesh is one of the signee countries of the Alma-Ata Declaration of 1978, which adopted a broader vision of expanding primary health care to the grassroots level of the nation.¹ Enormous efforts were made to establish health facilities at a community level by 1985,¹ resulting in a significant improvement in population health indicators despite the socioeconomic challenges, thus coining the term ‘the Bangladesh Paradox’.² This phenomenon refers to how direct health interventions can yield high population health outcomes in the context of positive social determinants including gender equity and education, and overcome the impacts of natural disasters and a strong presence of negative determinants such as poverty, low gross domestic products, and income inequality.

Although these successes describe one part of the overall picture of health care in Bangladesh, the country continues to struggle with delivering comprehensive health care at the community level. There are over 10 000 community clinics that could be delivering optimal primary care but more than three-quarters of physician positions currently lie vacant. This results in a limited service delivery for Bangladesh.^1,3

We have arrived at this scenario for several reasons. First, the inefficiency of the referral system has made access to specialists easier for the richer quantile of the population, leaving the poor with minimal access.⁴ Second, informal providers known as quacks (traditional and faith healers) seized the opportunity and created localised markets of non-standardised health services. Such practitioners are located mostly in the rural areas where there is a substantial shortage of a health workforce. Third, private institutions have expanded in urban areas delivering healthcare services at a higher price, which is simply not affordable to most of the people in the country.

Moreover, a substantial lack of availability and accessibility to GPs have given rise to people taking antibiotics and steroids in potentially inappropriate and hazardous ways via an informal provider, thus affecting the health of the general population to a greater extent.⁵ Therefore, actively not supporting, respecting, and developing the role of GPs within the health system has resulted in a substantial gap in the delivery of health services and thus compromised the fundamental health rights of the citizens of Bangladesh.

WHAT NEEDS TO CHANGE?

Revitalising the cadre of GPs is required to overcome this situation. Although the number of medical graduates has improved in the last few decades, the number is still inadequate to deliver health services to the entire population.⁶ Moreover, there is a maldistribution of physicians in urban areas that affects the health services at rural areas.⁶

In addition to increasing the number of medical schools and seats, other professional challenges for GPs include a lack of national guidelines in clinical practice, the absence of a well-established referral system, lack of essential medications and trained human resources to deliver primary care, and lack of awareness about health and health services. All these issues must be urgently addressed for the health service to improve.⁷

Specific policies to promote equitable and demand-driven recruitment and deployment of GPs and allied human resources at the community level are required. Revising existing incentivisation strategies at public and private healthcare facilities and improvising the infrastructures can help retain GPs in rural areas.

Workplace violence is also highly prevalent in the context of resource-constrained facilities. Ensuring an optimal supply of essential medications and instruments and increasing legal measures can help minimise public anger and subsequent violence at community health facilities. Furthermore, key stakeholders and policymakers should be made aware of the importance of delivering health services in a holistic manner, something just not possible without an enabling environment for GPs.

Last but not least, the building blocks of the health system of Bangladesh should be strengthened to minimise the ongoing challenges for GPs and maximise the collective efforts of all to deliver health care as well as ensure there is universal health coverage for future generations.