180 days of the govt: Health reform needs more than expansion

Six months have passed since the government took office, and the health sector has already seen a number of policy initiatives. The government's willingness to address long-standing problems in healthcare is encouraging. There is, without doubt, a positive intent behind many of these reforms.

But in healthcare, good intentions are not enough.

The real test of reform is not how many medical colleges are approved, how many hospital beds are added, or how many people are recruited. The question is whether these measures ultimately give ordinary citizens better, safer and more affordable healthcare.

Unfortunately, several recent decisions suggest that the government may be moving too quickly towards expansion without first addressing the weaknesses of the system that already exists.

More medical colleges, but fewer teachers

The government's decision to move ahead with new medical colleges in eight districts is perhaps the clearest example.

Three have already received approval, while the others are awaiting approval. But Bangladesh's immediate problem is not simply a shortage of medical colleges. It is the inadequate capacity of many existing ones.

A medical college is far more than a building, classrooms and student seats. It requires qualified teachers, a functioning teaching hospital, sufficient patient flow, laboratories, libraries, accommodation and an academic environment capable of producing competent doctors.

Yet the latest available figures show that more than 43 per cent of teaching posts in the country's 37 government medical colleges are vacant. At the professor level, the vacancy rate is particularly alarming. More than half of professor, associate professor and assistant professor posts are vacant.

The situation is equally concerning in the basic medical sciences. Of more than 2,000 sanctioned teaching posts across eight basic science disciplines, only around 1,500 are occupied.

Without adequate teachers in subjects such as Anatomy, Physiology, Biochemistry, Pharmacology, Pathology, Microbiology, Forensic Medicine and Community Medicine, students are at risk of developing weak theoretical foundations.

Infrastructure presents another challenge. Several government medical colleges still lack permanent campuses or adequate classrooms, laboratories and accommodation. At Sirajganj Medical College, reportedly, hundreds of female students are accommodated in a hostel designed for only 100.

Under such circumstances, approving more medical colleges deserves serious reconsideration.

A medical college must also provide adequate clinical exposure. International standards commonly use roughly 500 teaching beds for every 100 medical students. Without sufficient patients and clinical facilities, medical education becomes theoretical rather than practical.

Instead of simply adding institutions, the government should establish clear accreditation standards covering teacher-student ratios, hospital beds, patient loads, operating theatres, ICUs, laboratories, diagnostic facilities and specialist availability. Colleges that fail to meet minimum standards should not be allowed to increase their student intake. In some cases, existing intake may even need to be reduced.

Most importantly, Bangladesh needs a national health workforce plan. We need to know how many doctors the country will require in five, 10 and 20 years, which specialties will be in shortage, and how many undergraduate and postgraduate doctors will be needed.

The number of doctors alone does not determine the strength of a health system. Where doctors are trained, how many patients they see during training, what clinical experience they receive and whether they work under adequate senior supervision matter just as much.

Producing more inadequately trained doctors may increase the numbers on paper. It does not necessarily improve patient safety.

A 150-bed hospital is not necessarily a better hospital

The decision to upgrade upazila health complexes to 150 beds is, in principle, a welcome move towards decentralising healthcare.

But beds without services are little more than numbers.

Bangladesh has 492 upazila health complexes. Yet many still lack basic diagnostic and emergency facilities. In around 101 upazilas, X-ray services are unavailable or non-functional. Ultrasonography is unavailable in roughly 196 upazilas. Pathology services are often limited to only a small number of routine tests because of shortages of manpower, reagents and funding.

Emergency care is an even greater concern.

Consider a critically ill patient arriving at an upazila hospital at night. The doctor makes the diagnosis and knows exactly what treatment is required. But there may be no syringe pump, no functioning monitor and inadequate capacity for continuous oxygen therapy or non-invasive ventilation.

At that point, increasing the number of beds does little to change the outcome.

Before expanding bed capacity, the government must make existing health complexes functional. They need reliable diagnostics, emergency equipment, trained personnel, medicines, oxygen and adequate budgets.

A large health workforce needs a clear plan

The government's plan to recruit nearly 100,000 people for grassroots public health, nutrition, maternal and child health, disease prevention and health awareness could become an important investment in the country's health system.

But scale must not substitute for planning.

There needs to be a clear definition of who these workers are, what they will do, who will supervise them and where their professional boundaries lie.

Bangladesh has already experienced the consequences of poorly planned expansion of the health workforce. The proliferation of Medical Assistant Training School (MATS) institutions produced large numbers of Diploma in Medical Faculty (DMF) graduates without sufficient employment opportunities, while inadequate regulation in some cases contributed to people working beyond their permitted scope.

We should not repeat that mistake.

Medical treatment at the community level must remain the responsibility of appropriately qualified MBBS and BDS doctors. Other health workers can make valuable contributions, but their scope of practice must be clearly defined, legally protected and properly monitored.

With appropriate training, the new workforce could nevertheless play an important role in areas such as pre-hospital care, community health promotion and palliative care.

Essential medicines must remain affordable

Another issue requiring urgent attention is the country's essential medicines policy.

The interim government led by Professor Muhammad Yunus expanded the National Essential Medicines List in 2025 to 295 medicines and introduced a pricing framework intended to keep essential medicines affordable. The government also required pharmaceutical companies seeking approval for new medicines to derive at least 25 per cent of their annual sales from essential medicines.

The recent cancellation of that 2025 list and pricing methodology, with a temporary return to the 1994 framework, therefore raises concerns.

The 1994 list was designed for a very different healthcare environment. Bangladesh's disease burden, treatment patterns and pharmaceutical landscape have changed considerably since then.

The government has indicated that a new policy will be introduced. That process should be accelerated, but it should also be transparent and consultative.

The pharmaceutical industry needs a sustainable business environment. At the same time, patients cannot be expected to bear the full cost of an unregulated market, particularly when it comes to life-saving medicines.

Urban healthcare has a place of its own

The government's decision to transfer 192 urban primary healthcare centres under 12 city corporations and 23 municipalities to the Health Services Division or the Directorate General of Health Services is another major change.

These centres, known as Urban Primary Health Care Services Delivery Project (UPHCSDP), have long provided important services to poor and slum-dwelling communities, including maternal and child healthcare, immunisation, nutrition, family planning and basic primary care.

The government should therefore be careful not to lose the institutional knowledge already present in these facilities.

Many existing healthcare workers have years of experience and professional competence. As the new structure is developed, the government should seriously consider integrating suitable existing personnel after proper assessment.

Reform should build on what works rather than discard it simply because the administrative structure is changing.

Doctors cannot work under threat

Perhaps the most immediate issue facing healthcare professionals is the growing incidence of violence against doctors and other healthcare workers.

Over the past six months, there have been several reports of attacks in hospitals and healthcare facilities. In some cases, political influence has reportedly played a role; in others, the death of a patient or allegations of negligence have triggered violence by relatives.

The deployment of Ansar personnel in several hospitals to improve security is a welcome measure. But security cannot depend solely on guards at hospital entrances.

Healthcare workers need the confidence that attacks against them will be investigated and punished promptly and fairly.

Doctors cannot provide safe and effective care while working under the constant threat of physical assault. The proposed Doctors and Healthcare Protection Act should therefore be brought before Parliament and implemented without unnecessary delay.

The government's first six months have demonstrated a willingness to address important problems in healthcare. That deserves recognition.

But the next stage should be about quality rather than quantity.

Bangladesh does not simply need more medical colleges. It needs stronger medical colleges.

It does not simply need more hospital beds. It needs functioning hospitals.

It does not simply need more health workers. It needs the right workers, properly trained and appropriately deployed.

And it does not simply need more policies. It needs policies that are implemented, monitored and evaluated.

The success of health reform should ultimately be judged not by what appears in government statistics, but by what happens when a patient walks through the doors of a hospital.

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Nayema Tasnim is a trainee doctor of cardiology.