Nufel and I are to become first time parents in October. I am a late starter amongst my friends and now feel embarrassed that after several comments to my husband about my facebook turning into “mums net” I too am posting comments regarding “all things baby”. I have no doubt that this will continue as I bond and revel in my expanding bump. My blog is not a pregnancy blog but it is inevitable that my experiences as a Mum–in-the-making do now form part of my life in Bangladesh. I’m sure at least some of you will be interested to know how I negotiate my maternity oversees including my experiences with the Bangladesh private healthcare system (I am a product of the NHS or National Health Service which is a free for all universal health care service in the UK). In later posts I intend to discuss Bangladeshi perspectives on pregnancy and motherhood and developing our own identity as a mixed ‘Bangla-bideshi’ family.
Apollo Hospital Bashundhara, Dhaka
Our first obstetrics and gynecology appointment was at Apollo Hospital in January. It is one of several international standard hospitals located in Dhaka (others include United Hospital and The Square) and in terms of hygiene and healthcare is equivalent to the NHS hospitals I have had exposure to in England. My consultant took my full medical history, located baby-to-be on an ultra sound scan and ordered routine tests before sending us on our way. The only amusing event was the delighted reaction of the blood sampling technician upon learning that I was married to a Bangladeshi.
We have been back to Apollo for several check-ups now and overall my experiences have been positive. Some members of staff do not speak English but I anticipated that this would be the case and it does not concern me so long as I can communicate with my Doctor. Nufel seems to notice that as I am categorised as a ‘foreign patient’ I am treated with some extra care, attention and efficiency. I have heard receptionists relay to nursing staff that an ‘international patient’ is waiting to be seen so perhaps this is true. In general I have been given plenty of time during my appointments and feel I have received a good level of care and service.
Private Healthcare in Bangladesh
The obvious difference in seeking medical assistance in Bangladesh is the operation of a privately funded healthcare system. All appointments and interventions are, where appropriate, pre-booked and paid for in advance – usually at a designated departmental reception. Being completely unaware of the private medical fees charged worldwide the expenses we have incurred so far seem reasonable – just to give you an idea:
1,000TK/roughly £8.20 for an appointment with the consultant (including a basic scan)
2,200TK/roughly £18 for a full ultrasound scan (including 4D scan)
7,800TK/roughly £64 for a full blood testing/urine profile
The hospital offers a tour of the maternity unit combined with some antenatal sessions for 4,000TK/roughly £35 which we are yet to book and as it stands we don’t know the expected cost of delivery (naturally or via cesarean section) so my opinion could change!
The differing agendas of the Private and Public Medical Models
Although I do not have a medical background the differences in how care is delivered under the public and private medical models is readily identifiable. Under a privately funded system only those with financial security have access to the best level of healthcare either in Bangladesh or overseas in countries such as Singapore, Thailand or India which are renowned for their own particular specialisms. Patients willing to pay a premium for healthcare can also enjoy receiving medical intervention quickly where appointments or treatment can be accessed on the day or even on the spot if they can accommodate! Unlike the UK system which is blighted with imperfections – including queues at the local Doctors Surgery/Clinics and lengthy hospital waiting lists for routine procedures, under the private model healthcare is more readily accessible in Bangladesh.
On the down side subtle exploitation in the private system can mean that unnecessary care, attention and testing are provided which will conveniently exacerbate your medical bill! This method operates on a business based model whose agenda differs to that of a public healthcare regime financed through substantial taxation. In Bangladesh and worldwide more patients, more appointments, more testing and more admissions means more profit. This leaves vulnerable individuals in a position of potential exploitation where the frail and frightened could easily be talked into tests and perhaps treatment which may be nothing other than an indulgence or a “fishing expedition”.
In the UK I am told that women can expect a routine ultrasound during their 12th and 20th weeks of pregnancy. In Bangladesh, my consultant confirmed she wanted to see me monthly and then fortnightly from month eight. I was pleased to have to report with such regularity as it would provide me with more opportunities to check in with my baby. However, whether this number of appointments is clinically necessary is another matter altogether.
It is quite ironic that I used to work for an NHS hospital social work discharge team in the UK where hour by hour a multidisciplinary team of staff made impromptu arrangements to send medically fit patients home to make hospital beds available. We were often faced with annoyed relatives who wanted their family member to be discharged at a time convenient to them – “maybe at the weekend” or “when my sister gets back from holiday”. I wonder how many individuals would be quite so keen to delay discharge where a daily fee of say £150 is charged per person, per bed, per day. I also wonder how many individuals would miss their Doctor’s appointments if asked to pay a fee to secure their slot.
That said the publicly funded model with which I am more familiar has also been criticised. Beyond the potential abuse of services, waiting lists and difficulties securing Doctor appointments many are offended by the policy of treatment based on a “lottery postcode” – your address determining whether your local authority/primary care trust are willing to fund certain types of medical treatment. This has been the case particularly with cancer recovery and fertility services. Many are dissatisfied with the increased taxation required to fund free public healthcare and have often criticised the failing level of care in some parts of the UK (most recently with scandals surrounding MRSA and poor hygiene standards). I am not attempting to propose alternatives to the prevailing systems in my blog but the differences are telling and interesting to see played out in practice.
Healthcare for everyday people in Bangladesh
Large segments of the population in Bangladesh are deprived of a fundamental right: access to basic health care. The vast majority of Bangladeshi citizens rely on government hospitals to deliver medical attention and treatment at an affordable price tag. These hospitals are funded through minimal taxation subsidies and other sources. Amongst the Bangladeshi population government healthcare is perceived to be of a much lower quality standard where rudimentary expectations of cleanliness, skills and expertise are not met. Such institutions are frequently ill equipped and for those entering the system there is an informal expectation that tips are routinely paid to guarantee that a service will be done or an appointment time secured etc. Unlike the competition driven private sector these hospitals have no market incentive to motivate them to provide a higher quality of service so standards remain low.
An article I read about the service quality of public and private hospitals in Bangladesh by Syed Saad Andaleeb entitled “Public and private hospitals in Bangladesh: service quality and predictors of hospital choice” suggests that a number of strategies and incentives need to be applied to improve the quality of government healthcare services. He suggests that these hospitals should be subject to evaluation systems by patients about the quality of services provided and that the allocation of funding should be based on performance and/or ranking.
Like so much of Bangladesh the quality of life and indeed the quality of healthcare is based on one’s ability to pay. Unlike the operation of private healthcare systems elsewhere ie the USA there are no insurance schemes to fund either partially or fully treatment that is required. The reality is that urgent, ongoing medical treatment may require the release of life savings or the sale of land or property to honour payment.
Healthcare and our spending mentality
I recently discussed with Nufel the issue of payment for medical care in Bangladesh and with an open heart described how unnatural it felt to pay upfront for maternity services. My husband, having spent his formative years in Bangladesh thought this was amusing as this system is what he has grown up with no matter what the illness or condition.
Whilst I have indirectly contributed to the availability of healthcare in the UK through the taxation of my income many UK citizens will relate to the collective feeling that our healthcare system is “free” as the financial assistance we give to public services are deducted from our salary before we have a chance to spend it! Whilst we are contributing without the physical exchange of cash the mental process of “payment” is absent. The system is also designed to cover the expenditure of the unemployed, pensioners, children and those otherwise unable to contribute. As an NHS baby I cannot imagine not being able to access free treatment as and when I need it without a second thought as to how to pay for it. Inevitably in thinking about this situation more deeply it is inevitable that without the anxiety of healthcare fees and for that matter school fees (also paid for on a private basis in Bangladesh) UK citizens feel more confident in indulging their consumerist tendencies. I often tease my husband for being a saver and not a spender but as I have found this is a common trait in Bangladesh. Money is spent but the consumerism I was raised with in the UK is not to be found in Bangladesh. Not only are there fewer opportunities to spend in a developing nation but money tends to be instinctively saved for necessary expenses – such as for emergency medical intervention.
It will be interesting to see where the future of healthcare in the UK and Bangladesh is headed. If foreign media reports are to be believed it appears that in the UK we are also headed towards privatisation of not only our healthcare systems but also our vital social services. This transition had been discussed at least on paper at the time I left for Bangladesh last year but is yet to gather momentum. I will be interested to see how the change in healthcare provision affects our economy and whether we will follow the US insurance scheme pathway. In Bangladesh there are talks of a cheaper publicly funded healthcare scheme for poorer communities but again this is only at an embryonic stage. I suspect that in reality only by increased taxation rigorously monitored by the authorities that enough funding could be generated for this vital public service.