Public Health & Village Doctors in Bangladesh
Bangladesh is one of the most thickly populated countries in the world with a population of over 1.5 million (World Health Organization, 2017) and 75% of its population lives in rural regions (Iqbal, Hanifi and Bhuiya, 2008). These people are always suffering from unsafe food, lack of hygiene, poor environmental sanitation, inaccessibility to qualified doctors, etc., leading to one of the major public health concerns in the country — disease burden. Inefficient governance of health providers and facilities by the government has increased this burden further, as much as it has increasingly led to the non-professional practice of village doctors or palli chikitshaks. Through a literature review of journals, working papers and other articles, this study attempts to explore if the ineffective public health system is indeed a primary contributor to the growth of village doctors in rural Bangladesh.
To conduct the study, published works were identified from the ScienceDirect, BioMed Central, National Center for Biotechnology Information, ResearchGate, Wiley Online Library, Oxford Academic and Google Scholar databases for a period from 1983 to current. This wide time range is deliberately chosen in order to understand for how long the informal medical practice has been existent in Bangladesh even after several public health system improvement initiatives.
The main search terms used were ‘village doctors’, ‘palli chikitshak’, ‘Bangladesh’ and ‘rural medical practitioners’. The modifiers used were health workforce crisis in Bangladesh, role of rural medical practitioners, public health in Bangladesh, village doctors practice in Bangladesh, rural health in Bangladesh, informal healthcare in Bangladesh, palli chikitshak contributions in rural Bangladesh, etc. The search yielded many articles; however, about 20-25 references were shortlisted after glancing through the abstracts and introductions of all articles. Only those which provided substantial insights on the village doctors of Bangladesh were considered, irrespective of the research perspective in them. The articles which had only discussed village doctors tangentially in the context of a different research agenda were excluded from this literature review. For example, self-care is a dominant practice in rural Bangladesh, but it is not directly relevant to this study. Hence, such resources were excluded from study and were only used as background information to help understand the context. General reports on Bangladesh health status were also helpful as background information to this study.
Literature Review: Findings and Discussion
The literature review is ordered in the following sub-sections to analyse the impacts of public health systems on the growth of village doctors better.
Many research (Rahman, Ashaduzzaman and Rahman, 2005; Bangladesh health watch report 2009, 2010; Muhammad et al., 2017) indicate that the public health situation has improved in Bangladesh over the past few decades, but they also mention that Bangladesh is still one of those countries facing acute health challenges that is not fully tackled yet. Constitutionally, the Bangladesh government is committed to providing basic medical facilities to all citizens, irrespective of economic or regional differences (Islam and Ullah, 2009). However, Ahmad (2003) describes the current public health situation of Bangladesh as “far from satisfactory” (p.2). Bangladesh is still one of the top countries plagued by child malnutrition, maternal mortality, communicable diseases like tuberculosis, unsafe food-related diseases like diarrhoea and even non-communicable diseases like cancer and diabetes and many more, notes Muhammad et al. (2017). Large number of people in rural Bangladesh are unable to access primary healthcare due to social, political, economic and other reasons.
Although there is a traditional healthcare system in Bangladesh, most of the medical practice in the country, especially in the rural areas, is informal (El-Saharty et al., 2013). This informal healthcare includes unregistered drug vendors, traditional healers and the village doctors or the palli chikitshaks. According to these authors, about 94% of the health workforce comprises these unqualified and unprofessional providers. According to the study by Ahmed et al. (2011), there are only 2.5 qualified healthcare professionals in every 10,000 people, which is the lowest prevalence rate in entire Asia. Naturally therefore, most Bangladeshis reach out to informal providers when faced with a health issue. Mahmood et al (2010) studied responses of a cohort of Bangladeshis and found that 65% of the diseased consult a village doctor in rural regions. The graph to the right explains their findings. Even Roy (1997) presents similar findings. He mentions that rural Bangladesh is massively short of registered physicians, prompting villagers to consult local healers and quacks to sort their health issues. The village doctors provide them with a prescription and also have been found to offer medications themselves. However, Rasu et al. (2014) mentions that this informal practice mostly remains unregulated and unsupervised in the country, with no one to check the quality or accuracy of prescribed drugs. Many studies have also shown these palli chikitshaks’ incorrect diagnosis and prescription giving, especially when it is done by the doctors’ assistants and paramedics (Wahed, Rasheed and Bhuiya 2012; Wahed et al. 2009; Bloom et al. 2009; Wahed, 2009; Alam et al., 2015). The public health risks are undoubtedly high, but the need to identify the shortage of healthcare resources in rural areas of Bangladesh is even higher. It is important to understand why the informal village doctors practice is steadily increasing, in spite of ongoing emphasis on public health systems, staffed by qualified and trained physicians.
There can be many reasons that contribute to the continued growth of unqualified village doctors in rural Bangladesh.
Poor governance is one of them. The Bangladesh health watch report (2009) notes that the statutory and regulatory bodies formed to create qualified healthcare providers did not function as expected due to poor governance at the centre. Ahmad (2003) has discussed the need for decentralisation in the Bangladesh health situation context. He feels that decentralisation leads to better governance and also enhances participation at local levels, thus increasing monitoring and supervision and finally improving the entire healthcare system. Muhammad et al. (2017) also consider lack of democratic functioning and too much loose governance by the central government leads to poor health outcomes.
Poverty, inequality and lack of awareness:
Ahmed, Hossain and Raja Chowdhury (2009) found that rural Bangladeshis sought the palli chikitshaks because (a) they were unaware of the services available to them (like the satellite clinics), or (b) they were generally uninformed about diseases and their impacts, or (c) the village doctors were cheaper and faster-to-reach than other doctors in the area. The general lack of awareness about health facilities have also been highlighted by Islam and Ullah (2009) in their study. And these authors rightfully connect their lack of awareness/knowledge to poor campaigns by the healthcare authorities, the government. They also feel that lack of awareness can stem from social inequalities where the poor often remain deprived of vital information and healthcare access is a privilege of the elites. Low literacy levels leaves no scope for better living. As Muhammad et al. (2017) concludes, unsanitary living conditions and severe poverty also lead to health issues which increases their need for doctors. Either they cannot afford visiting qualified doctors financially or they are too far from them, whereas village doctors are always available at walking distances. That perhaps also explains why a majority of patients walk to their doctors in rural Bangladesh, as observe Iqbal, Hanifi and Bhuiya (2008).
The village doctors’ fees are lesser and more affordable for the poverty-stricken rural population. Also, their fees could be deferred (Wahed, Rasheed and Bhuiya 2012; Wahed et al. 2009; Bloom et al. 2009; Ahmed, Hossain and Raja Chowdhury, 2009; Wahed, 2009). This could well be a good reason for the growth in the number of palli chikitshaks. Additionally, the illiterate population had no way to know even if they were prescribed incorrect medicines or dosages. The fact that these patients would never challenge or blame the village doctors further fans the growth of the latter (Ahmed, Hossain and Raja Chowdhury, 2009). This again indicates lack of proper governance and coordination from the centre.
Shortage of public health practitioners:
Other researchers like Ahmed et. al. (2011), Ahmed, Hossain and Raja Chowdhury (2009), and Mahmood et al. (2010) feel that the Bangladesh health situation is a result of its health workforce crisis. As per a nationwide survey in 2007, Bangladesh needs 60,000 doctors and 280,000 nurses, which is way too big a gap for the government to fill soon (Mahmood, et al., 2010). That is probably why the government has been passively supporting the growth of the informal doctors as that may be the only way to address the disease burden plaguing the country for decades. The country has started using the palli chikitshaks to their advantage, whereby their importance in harnessing the spread of diseases and providing primary healthcare, in keeping with the Millennium Development Goals, is acknowledged (World Bank, 2003; Ahmed, 2005; Cockcroft et al., 2007; Ahmed, Hossain and Raja Chowdhury, 2009). Bhardwaj and Paul’s (1986) study discusses the advantages of having the village doctors nearby in saving lives. The authors note the positive aspects of medical pluralism in health resource-poor Bangladesh — how village doctors can be a solution to primary healthcare in rural Bangladesh. Parr et al.’s (2012) study also notes the importance of informal doctors in overcoming the public health challenges in Bangladesh. The authors acknowledge that untrained doctors can lead to harm and therefore, they recommend proper training and supervision before they engage in healthcare. Evidently, many research are in support of a pluralistic healthcare system in Bangladesh. But there are also counter-arguments like the one put forward by Feldman (1983). This author concluded that deploying the private palli chikitshaks in remote areas of Bangladesh would only create a rural elite, pushing the extremely poor to farther margins. Both the perspectives are true and can perhaps be bridged with a decentralised healthcare system with better supervision and control at the local levels.
Chaudhury and Hammer’s (2004) study explains the shortage of qualified healthcare professionals in the remote areas of Bangladesh with fresh perspectives. They made sudden visits to health clinics and found an alarming rate of absenteeism among public health practitioners. Rahman, Ashaduzzaman and Rahman (2005) also note the prevalence of these ghost doctors in Bangladesh who do not report to duty, taking advantage of poor monitoring and supervision by the Ministry of Health.
One of the most effective solutions to the Bangladesh rural situation seem to be in formalising the informal practitioners. This could be done by ramping up training levels of the village doctors before they start practice and ensuring that they comply to health policies and standards while prescribing medication to patients. Although some do undertake short trainings on common illnesses from private institutions, only a small percentage undertake the government-sponsored palli chikitshak training programme (Ahmed et al., 2011). This issue can be tackled with more awareness, incentive and governmental monitoring.
Ahmed, Hossain & Raja Chowdhury (2009), Rasu et al. (2014) and El-Saharty, et al. (2015) — all of them recommend integration of the village doctors within the formal system for better healthcare delivery. El-Saharty, et al., in particular, observe that disease-specific short courses can help in targeted outreach and improved diagnosis and treatment. Alam et al. (2015) actually find that the informal doctors or palli chikitshaks are capable of much improved healthcare service after brief educational courses. If rightly trained, feel Mahmood et al. (2010), these village doctors hold immense potential for improving Bangladesh’s public health scenario. However, as mentioned earlier, medical pluralism must be actively managed (Ahmed et al., 2013). Parallely, the government should also raise awareness, particularly among the rural population, about the existing healthcare facilities (Roy, 1997). Apart from these, some researchers like Rahman, Ashaduzzaman and Rahman (2005) recommend slightly different solutions such as decentralisation because they feel that empowering local authorities for monitoring and supervision of informal practices can lead to better health outcomes. The centre should only focus on health policies and standardisations.
Study of the various perspectives offered in the extensive literature review above fairly indicates that the public health situation (resource scarcity, absenteeism, lack of governance, centralisation, inaccessible medical facilities, etc.) is actively prompting the growth of the village doctors in rural Bangladesh. Closing the gap between desired and actual number of qualified medical practitioners seems unlikely in the near future. Hence, the only solution lies in better governance, more public awareness and decentralisation. The Bangladesh government must tap into the huge potential of the informal workforce practicing unorganised, non-standardised, private healthcare in the rural areas and convert them into trained and informed providers delivering consistent healthcare to all.
Ahmad, A. (2003). Provision of Primary Health Care in Bangladesh: An Institutional Analysis. In: Development Research at Lund University. Sweden: SASNET, Lund University, p.2.
Ahmed S.M. (2005). Exploring health-seeking behaviour of disadvantaged populations in rural Bangladesh. PhD Thesis. Stockholm: Karolinska Institutet.