“Health is a universal right”

In February, Gonoshasthaya Kendra celebrated its 40th anniversary in Dhaka. This non-governmental healthcare organisation has done pioneering work with midwives, nurses and paramedics in Bangladesh. Zafrullah Chowdhury, one of its founders, explained the approach to Hans Dembowski in an interview.

Interview with Zafrullah Chowdhury

You returned from Britain during Bangladesh’s liberation war in 1971. In what circumstances did you take up work as a doctor back then?
The situation in what was then still East Pakistan was terrible. The Pakistani military was killing people, raping women, destroying crops and burning houses. Some 10 million people had fled to India. In England, I had been a vascular surgeon, but I felt I had to help my people. So along with other doctors and health workers, we set up a hospital in Melaghar near Agartala, in India’s eastern State of Tripura. We were close to the border and treated refugees, but also took care of wounded Mukhti Bahini, as the freedom fighters were called.

What was that like?
Well, the hospital had 480 beds; it was not small. The most important realisation was that doctors alone can not provide health care. We had to run the hospital with a small number of doctors and a large number of volunteers of whom some were medical students, but most had no prior exposure or training in nursing or any other hospital work. Many of the volunteers – young women who had fled from occupied Bangladesh – were given hands-on training to become surgical assistants, medicine dispensers, nurses as well as nursing aids. This experience of successfully training a paramedical force, which was both skilled and caring, in a few weeks convinced me that it could be done on a bigger scale and that health care delivery need not be doctor centred. Nurses and other health workers can play a critical role. Many routine functions of doctors can be delegated to health workers, and if they are skilled and understand their jobs well, they can provide many essential health services without a doctor guiding them.

Please give an example.
Consider births, for instance. In Bangladesh, most women give birth at home, and that is no problem, provided they have a good midwife. Doctors are only needed when there are complications. Of course, there must be referral hospitals that can step in and take care of special emergencies. But there is no reason to start sending all women to hospitals once labour starts. That is something privatised, commercially run healthcare providers are interested in, because it helps them make money. The World Health Organisation (WHO) should not be promoting this approach; it is not a prudent health policy for a poor country.

How did Gonoshasthaya Kendra get started?
The idea was born back then in Tripura. The Bangla name Gonoshasthaya Kendra means “People’s Health Centre” in English. When the war was over, we moved to what had become independent Bangladesh and focussed on providing health care services in rural areas relying on local volunteers and traditional midwives.

So reproductive health was always a core issue of your work?
Yes, of course, it is a core issue of human life. And it is especially important in a poor country with a fast growing population. We always emphasised family planning, raising awareness for contraceptives and how to use them. But our post-war situation was special none­theless. A great number of women had been raped, and some were pregnant. They did not want those babies, so abortion became an important issue. Our country is predominantly Muslim, the culture is quite conservative, and it was even more conservative back then. And yet people agreed with the women who did not want to have the children of hostile combattants and who had violently abused and harmed them. In a way, this humanitarian catastrophe gave us an opportunity to address family planning issues with a progressive approach.

So there was always a strong gender angle to your work?
Yes, definitely, and for another reason too. We needed health workers in the rural areas. We could not send young urban women to the villages; their families would not have allowed them to work far away from home. So we told the rural people: “If you want to have health workers, then you have to send your daughters. We’ll train them, and they’ll provide care to you when you are in need.” And pretty soon, we were even giving the young women bicycles. We did not want them to serve only their own village, their skills were in demand in other villages too. So they had to move around. Young women on bicycles! That was unheard of, a small revolution.

In the 1980s, you played an important role in establishing generic pharma production in your country.
Yes, the point was that developing countries cannot afford to pay for brand name drugs. And there is no reason why they should. Most essential pharmaceuticals are not covered by patents. Fortunately, our government listened to our advice in the 1980s and enacted legislation that allowed Bangladesh to follow the example of Sri Lanka, where generic production had begun earlier.

What are pressing concerns today?
Ageing is a real issue. The number of elderly people is growing fast in Bangladesh. They have specific health problems. They don’t only need medical care, they need a warm hand and a friendly smile. Often physiotherapists are of help, and it is important to teach those skills. Old people are more likely to be disabled than young persons, and they often suffer from non-communicable diseases like diabetes, hypertension or cancer. Cancer treatment is exorbitant and out of the reach of ordinary people. This need not be so. At Gonoshasthaya Kendra, we believe that our country needs a cancer hospital to serve poor people and to develop effective low-cost approaches. We want to establish such a hospital, and it would be wonderful if Germany could provide assistance for that purpose by way of training and donations of refurbished equipment.

Is Gonoshasthaya Kendra financially sustainable?
That is a typical donor question, and I resent it. Financial sustainability is not the only thing that matters. Health is a universal right. People must not be forced to suffer poor health because they have no purchasing power. This is not an issue that can be left to the market. The state has a role to play. It must ensure universal access to healthcare. And healthcare needs physical and social infrastructures, which have to be sustainable too. It really is not all about money.

Yes, but how do you cover the expenses? Do you run a kind of micro-insurance scheme that patients join and pay premiums for?
Yes, we actually do run an insurance scheme. The premiums our clients pay depend on their economic status. The rich and well-to-do pay more, and we use the money to cross-subsidise healthcare for those who are less well off. Some poor people only pay premiums worth a few cents, and the poorest are treated free of charge. All in all, we cover about 50 % of Gonoshasthaya Kendra’s recurrent expenditures with insurance premiums and sale of medical treatments and services. The rest is covered by local donations, grants and solidarity funding from small charities and social movements from Bangladesh and abroad.

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