International Journal of Perceptions in Public Health Volume 1, Issue 1, December 2016, P 9-13 ISSN 2399-8164 www.ijpph.org
Commentary
Open Access
Practicing Pattern of Physicians in Bangladesh Amin Andalib1, S.M. Yasir Arafat2 1
2
Department of Surgery, Dhaka Medical College Hospital, Dhaka, Bangladesh Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
* Corresponding author: Amin Andalib, Department of Surgery, Dhaka Medical College Hospital, Dhaka, Bangladesh, Email:
[email protected] Citation: Andalib, A and Arafat, S.M. Y. (2016). Practicing Pattern of Physicians in Bangladesh. International Journal of Perceptions in Public Health, 1(1):9-13. Copyright © 2016 Amin Andalib and SM. Yasir Arafat. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited Received Date: October 10, 2016 Accepted Date: October 18, 2016 Published Date: November 20, 2016
Introduction Practicing medicine dates back as far as civilization and along with the change of its other aspects the pattern of medicine is also changing. The idea of a physician going to the home of a sick person is now replaced by the long waiting list of patients in the private chamber of a doctor. According to the theory of economy, like other individuals, doctors also aim to maximize their income, autonomy, professional ethics whereas theories of work motivation in Psychology give prominence to individual needs, values, personality and so on (Halvorsen, Steinert, and Aaraas, 2012). Though autonomy being a major reason for the growth of private practice, as private practitioners are much independent, self-employed and can be entrepreneur themselves, scope of handsome income in contrast to the fixed salary of public service is also a motivating factor (Halvorsen, Steinert, and Aaraas, 2012; Holte et al., 2015 and Russo et al., 2014). It is now suggested that, most countries with a low income have a large and expanding private medical sector, which is a significant source of providing care. Despite having a positive impact on the quality of health service for the poor, little is to be found statistically about the amount of health care delivered by the private practitioners in the poor countries (Uplekar, Pathania, and Raviglione, 2001 and Wang et al., 2013). Bangladesh has a higher rate of density as well as growth rate of population but still has achieved a steady and significant improvements in health-related aspects like life expectancy and child health (Bangladesh. Bureau of Statistics. Statistics and Informatics Division, 2014; Bangladesh health system review, 2015; Ahmed et al., 2011; Streatfield and Karar, 2009 and Arafat 2016). It has a pluralistic health system and public or Government sector and private © International Journal of Perceptions in Public Health
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International Journal of Perceptions in Public Health Volume 1, Issue 1, December 2016, P 9-13 ISSN 2399-8164 www.ijpph.org sector are the major contributors of health service (Bangladesh health system review, 2015). Though there is crisis for Human resource for health, the number of private practitioners is on the rise due to socioeconomic, behavioural and environmental factors (Ahmed et al., 2011). But there is lack of appropriate and helpful research to look into the pattern of practice of the doctors of Bangladesh. So, the authors aimed to look into the current situation of the pattern of practice of physicians in Bangladesh and to identify the determinants in light of the available resources. Methods Authors gained insight by talking directly with physicians from both the public and private sector. Authors also have insight from being attached with the healthcare sector for more than a decade and searched data bases for the related literatures. Overall Scenario Bangladesh, is a densely populated country having the population density much higher than any other mega country and a total population of around 160 million, which is also rising constantly, has acquired significant success in growth of Gross Domestic Product (GDP) and health related Millennium Development Goals (MDGs) (Streatfield and Karar, 2009 and Arafat 2016). Despite the crisis of health workforce as evident from only 7.7 formally qualified registered physicians per 10,000 population, the credit of the dramatic advance in health sector goes to the currently registered 82,500 physicians, who are giving relentless service both in public and private sectors (Ahmed et al., 2011 and Arafat 2016). The trend of private practice by the physicians in Bangladesh is on the rise along with the facilities including medical colleges, corporate based hospitals and clinics in the capital city as well as other divisions (Bangladesh health system review, 2015). Keeping pace with the increase in the number of hospitals and hospital beds, the number of private teaching institution is also increasing at a tremendous rate as evident from the fact that in 1996 there were no private medical colleges or any kind of teaching institutions but by the year 2015 there are 53 private medical colleges and 14 private dental colleges (Bangladesh health system review, 2015). Service Pattern Private sector health care providers having two main categories, firstly the organized sector which is both beneficial and non-beneficial, including qualified physicians of various disciplines and secondly the informal sector which consists of providers without any formal qualifications also known as traditional healers. The traditional healers are mostly dominating the rural areas whereas the former mostly is urban centric (Bangladesh health system review, 2015). There is also the trend of the physicians to go mostly to their respective villages once or twice weekly for chamber practices. Bangladesh is identified by the WHO as one of the 57 countries having critical shortage of health workforce and on top of that there is no structured referral system, hence the most convenient provider in terms of availability, accessibility and affordability is chosen by the patients (Bangladesh health system review, 2015 and Arafat, 2016). As there is a steady growth in GDP, per capita income is and the affluent individuals are choosing the qualified private physicians and facilities; few preferred to visit luxurious © International Journal of Perceptions in Public Health
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International Journal of Perceptions in Public Health Volume 1, Issue 1, December 2016, P 9-13 ISSN 2399-8164 www.ijpph.org hospitals in the capital city or to visit abroad famed institutions (Bangladesh. Bureau of Statistics. Statistics and Informatics Division, 2014 and Bangladesh health system review, 2015). Along with the tendency of the people, the opportunity of higher income, degree of autonomy and better chance of achieving individual needs, values, self-efficacy and goals are the motivating factors for the physicians to become more involved in the private practice (Halvorsen, Steinert, and Aaraas, 2012). Private vs Public The life of a Bangladeshi physician can be broadly discussed under two headings. The one before doing post-graduation and the one after completing it. The life of a graduated doctor goes mostly as a trainee for the post-graduation which can be private or as a employer of the government. Most of the private trainee doctors lead their life working without any payment as ‘Honorary Medical Officer’ in different government and autonomous hospitals. The others work in some private hospital with a fixed salary at a training post. Whereas the physicians employed by the government spend the first couple of years at a union level as a medical office and then does their training for the post-graduation at different government hospital, especially medical colleges. Both the private and public trainee doctors do job outside their training whether as a medical officer in a private clinic or as a general practitioner. After completion of the training and hopefully passing the post-graduation, the private physicians enter in the private hospitals or some of them does individual private practice. Whereas the government physicians get job in government institutes and at the same time does private practice outside the office time. Outside these, some doctors never go for the post-graduation and simply work as a private practitioner their whole life. Usual Daily Schedule The most ordinary day of a physician starts early in the morning. In the hospitals, the trainee doctors do the morning bed works and in the outpatient duties. In the public hospital, especially in the medical colleges, the senior doctor like as the professors spend their early morning in academic activities. After a certain period both the junior and senior doctors give around in respective wards. In both public and private hospitals, regular bed works are done mainly by the trainee doctors but for the both junior and senior, the daily schedule is very tight. Though the office time is up to 2`o clock in the afternoon, the works are hardly done, as in Bangladesh there are approximately 3.05 physicians for 10,000 people, and in some hospitals, a single doctor must see approximately 40-50 patients daily. After the office hour, the trainee doctor run off the private clinics where they spend mostly the rest of the day working as a medical officer. The same thing happens for the post-graduated senior physicians, who after their office hour goes straight to respective private chamber or to some private hospital to work as a private practitioner. As there is no structured referral system in Bangladesh (Bangladesh health system review, 2015 and Arafat ,2016), and the private practicing senior doctors are quite easily available, some private practitioners must see hundreds of patients the rest of the day working until dead hour of night. So, it is well understood that, though there are two well established sectors in Bangladesh, private and public, most of the physicians are playing the dual role from © International Journal of Perceptions in Public Health
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International Journal of Perceptions in Public Health Volume 1, Issue 1, December 2016, P 9-13 ISSN 2399-8164 www.ijpph.org being a public service provider in the morning to a private practitioner in the evening. This dual role playing by the physicians is the fuel of the nation’s healthcare engine. Leisure There is hardly any leisure period, specially in the life of the trainee doctors and to some extent for the senior doctors too. During the office hour, sometimes the doctors find no time even to take a meal, as there is no proper place or arrangement for the refreshments specially in the public hospitals. Even the senior doctors sometimes must buy and eat in their own rooms in between seeing patients. As the office time ends, so begins the next phase of running towards the chambers. Though the workplace changes the scenario remains the same, a leisure free hectic day of a physician. Some busy private practitioner who see patient up to late night, sometimes couldn’t even have proper meal with the family members. In the weekend, most of the physicians goes outside the capital sometimes to respective villages for the sake of private practice (Arafat & Ahmed 2016). Even in the national holidays, it is always found that some doctors, both trainee and senior, public and private, spending their holidays in the hospitals. Financial Facility In the public sector the salary of the physician is established under a pay scale granted by the Government ranging widely. As oppose to this fixed payment structure of the public sector the private sector promises a lot of verity. The income of a private practitioner depends on some variables like his field of expertise, experience, qualifications and sometimes by the popularity of the physician. Due to this, the trend of private practice if increasing. Pros and Cons Both public and private sector has its pros and cons, despite of that in the recent times the growth of private sector is quite astonishing. In the authors` opinion the major factor behind this is the financial flexibility of the private sector. Though the public service provides a fixed amount of money initially, which is a kind of a security for the medical graduates in a country like Bangladesh, but with the time the financial growth of the public sector is hindered by the hundreds of barriers like lack of good governance, bureaucratic red tapes, political influences, lack of infrastructures and more over the ever-growing urbanization. Moreover, the workplace security is also not satisfactory in the public healthcare facilities specially in the far-reaching healthcare centres, even in comparison to the condition of a country like Bangladesh where physicians and the patients go into a physical confrontation in difficult situations (Arafat, 2016). These factors are directly influencing and patronizing the growth of private sector and increasing the trend of private practice among the physicians. Conclusion Bangladesh, despite being a densely populated country, has achieved astonishing growth in health sector. Though physicians are playing vital role in the sector, there is scarcity of research in the sector to explore adequately as well as to identify and solve problems. This article will cast a light in this almost untouched domain of the practicing life of the physicians of Bangladesh. © International Journal of Perceptions in Public Health
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International Journal of Perceptions in Public Health Volume 1, Issue 1, December 2016, P 9-13 ISSN 2399-8164 www.ijpph.org References Ahmed, S.M., Hossain, M.A., RajaChowdhury, A.M. and Bhuiya, A.U. (2011) The health workforce crisis in Bangladesh: Shortage, inappropriate skill-mix and inequitable distribution. Human Resources for Health, 9(1). doi: 10.1186/1478-4491-9-3. Arafat, S.M.Y. & Ahmed, Z., (2016). Medical Representative in Bangladesh: a Job with Different Pattern. International Journal of Academic Research in Management and Business, 1(1), pp.47–51. Arafat, S.M.Y., 2016. Doctor Patient Relationship: an Untouched Issue in Bangladesh. International Journal of Psychiatry, 1(1), p.2. Bangladesh. Bureau of Statistics. Statistics and Informatics Division. (no date) Census of slum areas and floating population 2014. Bangladesh health system review (2015) Philippines: WHO Regional Office for the Western Pacific. Halvorsen, P.A., Steinert, S. and Aaraas, I.J. (2012). Remuneration and organization in general practice: Do GPs prefer private practice or salaried positions? Scandinavian Journal of Primary Health Care, 30(4), pp. 229–233. doi: 10.3109/02813432.2012.711191. Holte, J.H., Abelsen, B., Halvorsen, P.A. and Olsen, J.A. (2015). General practitioners altered preferences for private practice vs. Salaried positions: A consequence of proposed policy regulations? BMC Health Services Research, 15(1). Russo, G., de Sousa, B., Sidat, M., Ferrinho, P. and Dussault, G. (2014). Why do some physicians in Portuguese-speaking African countries work exclusively for the private sector? Findings from a mixed-methods study. Human Resources for Health, 12(1). Streatfield, P.K. and Karar, Z.A. (2009). Population challenges for Bangladesh in the coming decades. Journal of Health, Population and Nutrition, 26(3). Uplekar, M., Pathania, V. and Raviglione, M. (2001). Private practitioners and public health: Weak links in tuberculosis control. The Lancet, 358(9285), pp. 912–916. Wang, Y., Eggleston, K., Yu, Z. and Zhang, Q. (2013). Contracting with private providers for primary care services: Evidence from urban china. Health Economics Review, 3(1), p. 1
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