The Pandora’s box of health care

The first read “Faridpur newborn Galiba dies” and other, “Why hasn’t the Faridpur doctor been fired?” What we can gather from the newspapers is that Galiba’s mother went to a private health clinic in Faridpur. There was a delay in attending to her by the doctor, who eventually pronounced Galiba dead. However, she was still alive. Born at 23 weeks, she weighed only 700g. None of her internal organs, especially the lungs, had fully developed. It was also found that she contracted a number of infections during the time she was left unattended, after being declared dead.Medical leaders and their responsibilitiesLeaders in the medical sector who have limitless opportunities to lead the health sector in the right direction should have the courage to shoulder the blame for such malpractices that continue to occur in the country. However, contrary to owning up to their responsibility and failure, some very conveniently occupied the role of the plaintiff, jury and judge and decided to hang the alleged doctor, who should share only a small part of the blame for the death of poor Galiba. Proper and unbiased investigation would show that this has occurred principally due to failure of the healthcare system that has been presided over and championed by many, and the alleged doctor is merely a pawn in the game of medical care in Bangladesh. If a proper healthcare system had been developed, no one would need to show concerns over malpractice. If those who had led the health sector over the past few decades had done their job responsibly, there would be due process in any of these circumstances, and such due process would have raised a lot of issues.Resource management and quality assuranceFirst of all, workforce planning. Human resource planning is an essential component of any successful healthcare system, given the fact that two-thirds of the financial resources of the system is put aside for wages of healthcare professionals. Poorly planned human resource strategies create mismatch between demand and supply, and fall short in effectively utilising healthcare personnel, even if they are already trained, resulting in an unproductive, or at best under productive, work force. So in the absence of a properly formulated framework for workforce planning, is the current system of medical education and training appropriate and adequate? They very well know that it is not, but how do they plan to improve and make their doctors fit for purpose? There is a huge discrepancy between demand for health care in Bangladesh and supplying human capital with the appropriate expertise that will enable workers to satisfy the demand for healthcare. The number of appropriately qualified doctors, nurses and technicians, and corresponding skill sets and geographical distribution, is really worrying. We know Bangladesh has around 45,000 practicing doctors for a population of 160 million. According to WHO criteria, we are in need of a number of doctors ten times greater than what already exists. Government policy has focused on establishing new medical colleges, and Bangladesh now produces about 9000 doctors every year. Since 2010, out of a total of 45,000 practicing doctors in the country, 30,000 doctors have come out of these medical colleges, numbered at around 126, whereas in the UK, only 33 medical schools produce about 6500 medical graduates. Though the number of graduates produced in Bangladesh has increased exponentially, it is still not adequate for the demand for health care. Clinical governance, which is unheard of in Bangladesh's medical practice, is designed to ensure quality of patient care. This is the responsibility of the government, hospital authorities, doctors, nurses other health professionals, and is a powerful and comprehensive mechanism for ensuring that high standards of clinical care are maintained throughout a health system, and that quality of service is continuously improved. Clinical governance is composed of continued professional development, education and training, medical audits, clinical effectiveness, risk management, research and development, and openness.A framework for best practicesAnother important missing piece in Bangladesh is national healthcare frameworks. For example, the regulatory framework of healthcare in England is comprised of two main elements - regulation of the quality and safety of care offered by healthcare providers, currently undertaken by the Care Quality Commission, and regulation of the market in healthcare services, currently the responsibility of the department of health. Another framework, the UK NHS Outcomes Framework, alongside the Adult Social Care and Public Health Outcomes Frameworks, sits at the heart of the healthcare system, and provides a national overview of how well the National Health Service in the UK is performing. The national strategic framework to develop the healthcare support workforce, on the other hand, is a long-term strategy for workforce development, education and training. Many of the victims of medical negligence, particularly resulting in death, should be able to seek redress. However, the process in Bangladesh is long drawn, expensive, and non-cooperative, to both doctors and patients. Though health professionals should not be exempt from the criminal process and proper application of law is imperative to safeguard both patients and medical professionals, criminal law can be a very blunt instrument when applied to such a complex field as healthcare. The greatest tragedy in Bangladesh, for patients and for dedicated healthcare professionals, is the absence of ways to distinguish between system failure, individual error or frank negligence. This is due to the absence of national frameworks, of established processes of governance, both clinical and corporate, accountability and regulatory frameworks that help doctors to understand their strengths and weaknesses and ways to improve their care in order to fulfil the objectives that led them choosing a medical career - the noblest of professions. Instead of continuing to blame the victims of a faulty system that many healthcare professionals have themselves sponsored and established, they should engage in robust debate with politicians, lawmakers, healthcare management bodies such as the ministry and DG health, and healthcare professionals on development of various national healthcare frameworks. We also need to focus on workforce planning, clinical governance, medical negligence and litigations associated with provision of sub-standard health care in order to ensure patient safety, transparency and best practices, and safeguard the competent, dedicated and hardworking medical practitioners. Professor Raqibul Mohammad Anwar is a Colorectal Surgeon at Bart’s and The Royal London Hospital, Ambassador and Convener of Examinations, The Royal College of Surgeons of England, Colonel, UK Armed Forces (RAMC), and President and CEO of RAHETID (RA Hospital, Education and Training Institute Dhaka)