Doc, Quality Delivery & Experimentation

Increased health spending raises the number of caregivers.
Does it raise the quality of service delivery at the health centers?
In the face of threat tank, APC get NBC suit.
Health facilities need the same to stand resolute.
Bring back the bygone era enterprising class,
To instill values of experimentation among the mass.

1.

During this lockdown, I finished reading “Dhire Bohe Buriganga"( Gently Flows The Buriganga), the memoir of veteran journalist, political commentator and lyricist Abdul Gaffar Chowdhury. He is known to Bangladeshis and the world as the lyricist of Ekushey anthem written after the shooting incident of language movement. The book is unputdownable and packed with anecdotes unraveling the times of late 40s, Pakistan , infant stages of Bangladesh and its early years of democratic period. This gentleman has strong eyes to see subtle social changes and brought to fore many unpleasant truths. Everyone should read it.

From this book, I came to learn that prior to the tumultuous years of partition in the late 40s Savar, a countryside on the outskirts of Dhaka , housed a class of “Kabiraj” or traditional healers whose herbal medicines earned them reputation across India. The violent partition severely weakened the traditional medical practices. I also met some of them during my childhood. Unlike the present ones who promised to cure cancer and AIDS, my childhood “Kabiraj” sold medicines to cure fever, sore throat, headache, back pain, acidity, attention deficit. And they also had tonics to build a strong body, to increase memory power. The medicines were prepared based on some formula. Some of the formula books were printed and published in Kolkata, maybe by those migrated “Kabiraj”. These formula based medicines had great demand. I was specially attracted to one particular type called “Chawanprash”, a sticky mixture that promises good health. It tasted really good. In my native village in Chittagong, neighbor of my paternal grandfather practiced this kind of herbal medicine based on the formula book printed in Kolkata. They spent nights and days with their ingredients to prepare those mixtures. They made it really good as those were sold thousands of examples as far as Akiyab in Myanmar. If they had a good season, “Guda Dada"(Young Grandfather), as I used to call the neighbor, took me to have breakfast in the village bazaar. We ordered molten dalda (made of animal fat )draped parathas and downgraded version of Havshi halwa. I preferred to have my parathas dipped into thick milk tea where the dalda floated like “premer mora jole dobe na"(unsuccessful lover’s body never drowns) and refused to settle at the bottom of tea cup.

Dalda, another example of colonial rule, destroyed the market of local mustard oil and ghee(clarified butter made of cow milk). Gaffar Chowdhury’s book offered an account of it.

The point is prior to Pakistan period, we had these vibrant enterprising classes of professionals who experimented with local herbs and made traditional medicines. Though after Pakistan came into being, Kundeshwari, Sadhana, Hamdard, AP did remarkably well but turbulent time of liberation war broke that ecosystem. The glorious days of herbal medicine never returned. Research and experimentation not only in herbal medicine but in the health sector in general are conspicuously absent.

2.

Govt has taken plan to increase its health spending manifold in the next budget. Now it is time to see how it will spend this money. Coronavirus unveiled that many of our government health facilities do not have enough ICUs and specialized beds in the ICU across the country. This pandemic may be over in future but it proved how vulnerable and less equipped our health system is. We spend more on APC, Tanks and defense facilities to make them NBC(Nuclear, Biological and Chemical) compliant. Time has come to replicate the process in health sector as threat of another pandemic or chemical or incendiary disaster looms large. We need to build NBC compliant ICUs, doctor’s chamber, patient’s ward across the health facilities of Bangladesh. Most importantly, we have to train and churn out health providers. I tried to build a model with data available in BER2018, Henley Nationality Index and Odhikar to see what influences producing doctors in Bangladesh. The period chosen was 2006-2017. For constructing the perfect model I chose Leamer’s extreme bound analysis (EBA) approach. I picked up number of registered doctors (Doc), number of beds in government hospitals and dispensaries(Bed), number of medical colleges(Med), number of dental colleges(Den), ADP spending on health, population and family welfare (ADP) and victims of political violence(Pol). The idea was that with number of increased hospital beds we need more doctors. Number of Medical colleges obviously influences churning out doctors. So does the number of dental colleges. Increasing health expenditure could also play role a role in delivering health professionals. I was eager to see whether governance could shape churning out doctors. A lagged variable was chosen in this regard as political turbulence this year could delay graduation of doctors in future. However, I treated this variable as a doubtful one and considered Bed and Med as free.

First, I regressed Doc on Bed. Then I regressed Doc on Bed and Med. After that I regressed Doc on Bed, Med and Den. Later I regressed Doc on Bed, Med, Den and ADP. Then Doc on Bed, Med, Den, ADP and Pol(1-period lag). Subsequent stages of regression increased both the R² and Adj R². We have five coefficient estimates for Bed, 4 for Med , 3 estimates for Den and 2 for ADP. The coefficient of Bed oscillated between 0.13 and 0.377. That of Med varied between -0.186 and 4.4. The coefficient of Den ranged between -0.2 and 43.56. The coefficient of ADP moved between 10.9 and 11.38.

I put my trust on Bed, Med and ADP as inclusion of other variables did not produce fragile estimates of their coefficients. I also noticed that inclusion of Pol(lagged) variable yielded wrong sign for Med variable which is contrary to the conviction that increasing number of medical colleges produces more doctors. So I went for other variable to measure the governance. I went for Kälin- Kochenov Quality of Nationality Index (QNI). QNI ranks qualities of nationalities. Each nationality receives an aggregate score based on economic strength, human development, ease of travel, political stability and overseas employment opportunities for citizens. So I thought QNI could be a better measure for governance. But data were available for 2011-2018. So I ran the regression for this period. After the regression, I found that Med produced opposite sign. So I discarded this variable too and my attempt to see role of governance in making doctors turned out to be damp squib.

And I finally rested my trust on the following model:

Doc_t = a + b Bed_t + c Med_t + d ADP_t

The result was:

Doc_t = 20088.07 + 0.16 Bed_t + 0.37 Med_t + 9.87ADP_t
(t = 3.86, p=0.00 , se=5194.24) (t=2.25, p=0.05, se=0.069) (t=0.16, p=0.87, se=2.35) (t=2.54, p=0.034, se=3.88)
(F=49.33, p=0.00)

The model fit well. However intercept demonstrated a huge standard error and coefficient for Med turned out to be insignificant. It appeared ADP expenditures on health and number of hospital beds in govt hospitals play the big role on the number of registered doctors. In my model, an increase in 1 crore taka in ADP on health led to churning out around 10 registered doctors every year in the given period. Though Bed turned out to be significant, its coefficient is less than one.

3.

Increasing health expenditures may lead to raise the number of healthcare provider. But I do not know whether it is enough to raise the quality of service delivery. Abdul Gaffar Chowdhury in that memoir shared an anecdote of service delivery at Dhaka Medical College Hospital in 1953. In the general patient ward, paratyphoid patient Gaffar was staying few more days to get cured. As in those days, the patients who managed to buy medication for paratyphoid had better chance of survival. Those who could not mange to buy medicine were succumbed to death. Medical authority could not do more. A well-to-do leukemia patient was also admitted to the same ward. He did not know his days were numbered. One day the patient died. Relatives came and engaged in an altercation with the medical staff as the naked dead body was draped in white bed cover and his silk Punjabi, moneybag, golden necklace were missing. 67 years later one may still call into question the improvement of service delivery in our health facilities. Increase in health spending may increase the number of healthcare providers, but whether it may ensure quality service delivery and spur research activities in the health sector is a subject of another scrutiny.