Who cares about rural health care?

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The absence of physicians in the upazila and union health complexes has been a bone of contention for long. The matter has been highlighted again and again in the media and even raised in parliament. Subsequent governments have increased budgetary allocations for the health sector and there has been injection of funds from overseas too. There have been grants and donations, but the loans have to be repaid with interest.

The grants and donations are gifts from friendly states and agencies to the people of Bangladesh. These funds have been used to construct hospitals and health complexes. A lot is spent on infrastructure, maintenance, medicines and equipment. Many of the centres have ambulances. These hospitals and health centres require appropriate human resources to ensure the facilities are properly utilised. However, the lack of physicians, paramedics and other officials and employees hamper the provision of proper services.

The physicians are unwilling to serve in the villages. This is not a new problem and it has affected treatment at these health centres. The government has increased the number of physicians’ posts in the health complexes, but these vacancies are not filled in due time and the physicians often lobby to be transferred from the villages to the cities, to Dhaka in particular. The upazila and union health complexes in the country’s remote areas are in a mess.

The government has taken initiative to appoint physicians in two batches through BCS exams, but this will be of no use unless it is ensured that the physicians actually join their posts. Three years ago, 6000 physicians were appointed in one go, but many of them never actually served at their posts in the rural areas.

Many of the meritorious students who go on to become physicians, have studied at the government medical colleges for nominal fees at the taxpayers’ cost. Private medical colleges may be costly, but then secondary and higher secondary education costs are more or less on the government’s shoulders. And the physicians have a good pay packet and allowances. They are even allowed to take up private practice after office hours. They have social prestige. Everyone is dependent on physicians when it comes to health matters. They are a part of the society and they have an obligation to serve the people. We are distraught when they fail to do their duty. After all, the people have to pay the price.

There is the matter of the doctors preferring to serve in the cities, preferably Dhaka, rather than the villages. They use the excuse of ‘higher studies’ to stay away, or simply say it is not possible to live in the village. A recent investigative report published in a Bangla daily stated that there are only five physicians of the appointed 13 actually serving at the Lalkhai upazila health complex in Habiganj. There are 14 physicians serving in Golachipa upazila and union health complex of Patuakhali, against the allocated 39 posts. There are five doctors instead of the designated 25 at Gosairhat of Shariatpur. The report surveyed 50 upazilas. It indicated that, of physicians posted three years ago, 75 per cent had left their posts. The others are endeavouring to follow suit. Where are they going?

A look at Dhaka and the other bigger cities of the country will reveal that there is a high number of physicians appointed on deputation or on special appointment. Then there are those on higher education. Higher education is certainly required, but there have to be certain official procedures as to who will go on higher education and how. Had merit and seniority been the criteria, then it would have been all right. But it is all about lobbying and manipulation, and so rural health care is pitched into crises repeatedly.

Why do the physicians not want to stay at the upazila and union health complexes? It is said that the conditions are not livable. It is true that residential quarters have not been built for everyone. But if the doctors actually start staying there, the government can construct further quarters as needed. As it is, the physicians can live in those locations at a much lesser cost than the house rent allowances they receive. It is compulsory for those posted at the union level to live in those locations. Urbanisation at an upazila level is relatively developed nowadays and houses can be rented. The doctors can rent houses in many unions as well.

UNOs and AC (land) also live at the upazila level. Officers-in-charge of the police stations and constables live there too. Officials of other departments also stay there. So do some physicians. There are school and college teachers too. If everyone lives there, the community is enriched. There are markets and shops. Communications are improving. Mobile phone networks are available all over. Officials even live in the difficult terrain of the Sundarbans when posted there. So, living conditions cannot be used as an excuse to stay way. And it is the responsibility of the one appointed to any post, to carry out the duties assigned to that position.

What is the alternative? It can be said that since most of the BCS (health) cadre physicians are not willing to be posted to the upazilas and unions, doctors can be appointed from outside the cadre. At one time the district board would be in charge of health care at a thana level. The district board would appoint LMF doctors. They would be appointed and transferred within the district, The doctors would live there, on location, with their families. Their children would study in the local schools. Many of these physicians have climbed high in their careers at a national level.

If MBBS physicians are posted in this manner, their scope for promotion will be limited. Their appointments through BCS will shrink too. But if things continue as present, then a strong demand for such stringent measures may be made. So the physicians should be alert so that such a situation does not arise. Their organisation, Bangladesh Medical Association, can assist the government in taking a firm stand at the upazila and union level and in ensuring that the physicians remain at their posts for the specified span of time. However, that is not enough. The government and the directorate have to take an unbiased and stern stance.

It is obvious from media reports that the entire system is out of control. There is debate in the parliament too about physicians not staying at the upazila hospitals. It is rather surprising that the health and family planning state minister remarked, “The doctors are quite influential and expert at lobbying. They lobby and exert their influence to get transferred. Many use their clout to go for higher studies and training.” It is not understood as to whether their influence is stronger than that of the government. Such a weak statement is unacceptable. It is hoped that all concerned quarters pay due attention to the issue.

* Ali Imam Majumder is former cabinet secretary and can be reached at [email protected] This piece, originally published in Prothom Alo Bangla print edition, has been rewritten in English by Ayesha Kabir.