The health programs director leafed through the monitoring tool, a checklist that details the key components of family planning counseling. Providers themselves will use the tool as a point of reference during patient treatment. Periodically, other field co-workers will use the checklist to check the quality of care given to patients.
“I have four hours during a clinic. If I have 50 patients, I only have four to five minutes to give to each patient,” he said. “And I usually have more than 50 patients.”
He stopped there. The tacit question–How can I expect my healthcare providers to do all this with each patient?–hung in the air. Anxiety about the trade-off between quality and quantity exists on a whole different level here in Bangladesh.
Burcu and staff of the Emirates Friendship Hospital
This summer, I am working with an NGO called Friendship, which provides health care – through a hospital boat, satellite clinics, and community health workers – to impoverished island communities in the riverine north of Bangladesh. My internship entails helping to start a monitoring system for our health services to ensure the same standard of care across our entire coverage area. Monitoring has the potential to ensure that patients don’t fall through the cracks, that we do a comprehensive job with each, and we celebrate good practice. When patients do fall through the cracks, the tools act as a built-in feedback system to identify room for improvement. But this all requires a bit more time and focus, plus a system that will value, and not fear, feedback.
Two months later, when the same director was advocating for the use of such tools to his field staff, someone asked, “But sir, if we provide all this quality, won’t we lose our patients?”
At UNC’s public health school, many of my lectures and conversations revolve around the three pillars of cost, quality and efficiency. These words have shaped my episteme of public health. They play a pivotal part in how I think successful interventions and programs should be designed and developed.
Little could have prepared me for the task of interning in one of the most resource-poor settings in the world and the complexity behind the reality. My practicum has instigated a much-needed, intentional evaluation and deconstruction of these words and what they mean for different people. Whereas in the United States, our debates revolve around “getting our money’s worth,” “ensuring the health care continuum,” and “effective use;” in Bangladesh, NGOs face the monstrous task of transforming an entire system where millions can’t even envisage a life with the most basic rights and needs, let alone equitable, dignified and quality health care.
The streets of Gaibandha, Bangladesh, near the Friendship Field Office, are teeming with people
Obviously, distinctions abound between these two healthcare systems. Most of these come from both countries falling on opposing sides of the Great Epi Divide. Stunting, for instance, is still common among Bangladeshi children, and the probability of dying between 15 and 60 years of age is six and a half times higher in Bangladesh versus the States. And though Bangladesh faces the unique pressure of its dense population, the United States uses about four times more of its GDP on health, percentage-wise.
However, my experience has involved finding far more commonalities than differences. Both countries share the same familial problems: health care access is limited due to financial constraints, and governmental bureaucracy or special interests inhibit practical application of research. Uneven progress in treatment and care is distressingly common. Both suffer from a limited health care workforce and sub-par social policies that economically and politically damage governmental bodies. These are all connected to global forces that enmesh the impoverished and affect health in broadly similar ways. The most recognizable symptom: sick people left untreated.
Perhaps the most significant and encouraging similarity that I’ve encountered is that both systems share an immense potential for transformation. Why? Organizations might not be staying true to the buzzwords they claim, but on an individual basis, a values-based approach is widely followed. My Bengali friends want to reflect, they want to improve, and they want to build consensus around change. This change in organizations, hospitals, and in communities might not be linear or fast, but it has the power to repaint the picture of health in Bangladesh.
Debates among health NGOs are starting to leave room for the ideals of cost, quality and efficiency to be solidly planted in the larger themes of social justice and equity. Health for all, (not just for the rich, or for the most patients), is no longer a slogan, but a sought reality that transcends borders.
“But sir, if we provide all this quality, won’t we lose our patients?” The director admitted that yes, it would take extra time and effort to ensure quality. “But in the end, the answer is no. They’ll get better treatment and be healthier. Besides, all of our patients deserve the best we can give them.”
- Burcu
[Burcu Bozkurt is a senior majoring in health policy and management at the UNC Gillings School of Global Public Health. With support from the Carolina Undergraduate Health Fellowship and the Mahatma Gandhi Fellowship, she worked this summer in Bangladesh, at the NGO Friendship. To read more about her experiences, visit her blog, burcuatfriendship.wordpress.com]
