The health care provision in Bangladesh has undergone a tremendous transformation especially in private sector over the last two decades. The establishment of new private hospitals and clinics and availability of improvised diagnostic facilities brought health care closer to various communities, especially in Metropolitan Dhaka and other large urban centres.

However, a closer observation will reveal that the health care delivery system is still largely fragmented, highly profit driven and far from being consumer friendly. It is not to say that the doctors lack competence, professionalism and compassion. In fact, the problem can be attributed to the failure of health care delivery system in private and public sectors to modernise and to adapt itself to the need of the consumers.

The Primary Health Care has been the weakest link of the health care system in Bangladesh. Our health care has traditionally been specialist oriented. Except for very minor ailments, consumers choose to consult specialists in various disciplines. In general, they visit General Practitioners where there is no specialist available or if they are unable to afford the specialist’s fee. Many a times they end up consulting doctors in inappropriate speciality as they take themselves to the specialists rather than being referred by adequately trained General Practitioners/ Family physicians.
For example, a patient with chest pain may self-refer to a Cardiologist. However, not all chest pains originate in the heart. Problems in Lungs, Stomach, Oesophagus, Gall Bladder or even Pancreas may present in the form of chest pain.

Sometimes a chest pain may even be psychogenic in origin. After few consultations, lengthy and expensive investigations it may be revealed that the chest pain was not caused by a heart problem after all. Although valuable consultation time, money, resources and some time life saving moments have already been spent. A structured, well networked and planned Primary Health Care delivery system would have prevented this mismanagement and wastage. 

However, when appropriate system is not developed, adequately trained General Practitioners/ Family Physicians are not available and the consumers lack insightful information, they do not have any other option but to present to the specialist as the first point of contact whether it is appropriate or not. This phenomenon over burdens the domain of specialist health care delivery.

The core to this problem is a lack of appropriately trained General Practitioners in the country. It is obvious that if the practitioners are not trained, proper referral network can’t be developed. The domain of General Practice has gone through a tremendous transformation over the years not only in western countries but also in many developing countries (e.g. South Africa, Malaysia) through proper training programme and up-skilling of the practitioners. Bangladesh lags far behind in improving this vital sector of essential health care delivery. In fact, Family Medicine has not developed as an organised discipline in Bangladesh. Traditionally the domain of health care in Bangladesh has been networked through specialists in various disciplines. General/ Family practitioners do not play their due role in organised primary health care in the country.

There are only a few practitioners in the country who practice in the field of Family Medicine on their own accord as appropriately trained personnel. A large number of family/ general practitioners practice in this discipline as they are unable to specialise in any other field for various reasons. A significant number of the practitioners work in general practice while waiting to specialise in other disciplines. So, in most cases family/ general practitioners lack motivation and enthusiasm to practice in the field of Family Medicine. This is detrimental to their career growth and also to good patient care.

Some professional bodies had taken lead so far to break this cycle of lack or expertise, inadequate number of appropriately trained manpower and improper patient care. Among them, Bangladesh College of Physicians and Surgeons (BCPS) currently offers FCPS (Fellow of the College of Physicians and Surgeons) degree and the BCGP (Bangladesh College of General Practitioners) offers MCGP (Member of the College of General Practitioners), both by examinations.

However, there is no formal or structured training programme for the preparation of these examinations. Sometimes, there are some clinical refreshers course conducted prior to the examinations. But, if one looks through the curriculum of the FCPS programme s/he would find it so extensive and specialised Internal Medicine oriented that s/he would wonder why someone would be interested in sitting for this examination instead of sitting for the equivalent examination in Internal Medicine. The structure and curriculum of this degree is definitely a discouraging if not an obstructionist one. 

The University of Science and Technology Chittagong offers Family Medicine Diploma (FMD) programme through part time study. The course mainly incorporates review of clinical topics. It is not recognised by the Bangladesh Medical and Dental Council (BMDC). However, this course is recognised by the University Grants Commission (UGC).

As mentioned, currently available examinations and programmes include revision of clinical topics. The trainees/ examinees do not get exposure to quality improvement cycles, practice based research, critique of journal articles, sociology of General Practice and practice management issues which should form a core component of a modern and dynamic Family Medicine training programme.

To properly develop and improve Primary Health care in Bangladesh, to reduce the burden on the specialised services and for the efficient use of human resources and logistics, we need to train and equip the new generation of General Practitioners and help them to leap forward and transform as Family Physicians. This vision can only be materialised if such training is carefully designed to incorporate not only clinical up-skilling but also need oriented population based training that will encourage the practitioners to become lifelong learners. This programme should be designed such a way that it gets equivalency of the other specialist training programmes (i.e. those in Internal Medicine, Surgery, Obstetrics etc). In order to achieve this status, the proposed programme should be of similar vigour and intensity.

A paradigm shift in thinking of the policy makers is needed to revolutionise the domain of Primary Health care in Bangladesh. It is definitely not going to be an easy path. At the same time we should also be pragmatic in our aspiration and accept the fact that things will not change overnight. Various institution and professional bodies may come forward with different models of such training programmes. These programmes may go through regular transformation and adaptation before we can find the right model that suites our need. However, the quest must begin now. We can’t afford to lag behind the world that is marching forward.

It is not all doom and gloom. There is a ray of hope in the midst of this crisis. As far as we are aware, there are some institutions and individuals who are spending some time and effort in designing and planning for such a training programme for the new generation of Primary Health care providers in Bangladesh. Among them the most notable one is the Bangladesh University of Health Sciences (BUHS). The BUHS is soon launching a Masters Programme in Family Medicine to cater for the time demanding need for the appropriately trained Primary Care Practitioners. 

We should not be under any illusion that the change in the Primary Health Care in Bangladesh will be an automatic one after launching such a programme by BUHS or any other institution. It needs time and continuous evolution. Most importantly it will need paradigm shift in thinking of the policy makers in this field. The medical fraternity of the country also need to be pragmatic in recognising that through proper training programme Family Medicine should gain a speciality status. Dignity, job satisfaction and appropriate recognition are of paramount importance if we are to attract and retain some of our finest practitioners in the Primary Health Care sector. General Practice should no longer be run from the back of a suburban Pharmacy nor should it be allowed to be practiced by the doctors who do not go through continuous professional development. General Practice should form the back bone of health care delivery system. The most important pillar of our health care can’t depend on the untrained professionals. We need an overhaul of General Practice in Bangladesh. 

It is exciting to see the Bangladesh University of Health Sciences is coming forward with a vision and a plan. We hope the others will follow suit. We can’t change everything overnight. But, we should start somewhere.

The writer is Family Physician currently based in Melbourne, a free lance columnist and one of the co-ordinators of the proposed Master in Family Medicine Programme at BUHS, Dhaka

BDST: 1618 HRS, MAY 18, 2014