Why Bangladesh may not meet its SDG health goals
When the United Nations General Assembly laid out its 2030 agenda in 2015, no one could have imagined that Bangladesh would surpass some of the milestone targets for health ahead of time. The Global Goals for Good Health—Sustainable Development Goal (SDG) number 3—includes child-related indicators of under-five mortality rate and neonatal mortality rate, as well as women-related targets for maternal mortality ratio and deaths by road accidents. Indeed, Bangladesh ranks above two South Asian giants—India and Pakistan—in its overall performance.
In terms of health, Bangladesh has managed to achieve its performance by establishing an extensive network of over 13,000 community clinics, which provide primary care for a significant number of people. There is no doubt that preventive medicine, by means of primary care, is the key to achieving all the targets. However, the nine years that we have left will not be enough to develop the complete infrastructure required to deliver the entire spectrum of preventive healthcare across the country.
The only other approach that could be used to achieve these targets in the given time is by developing emergency care services, where essential medical treatment is provided appropriately for time-critical cases such as sepsis, bleeding, stroke, and heart attack. This was recognised by the 72nd World Health Assembly back in 2019, when they adopted Resolution #72.16, which states that emergency care systems are essential for universal health coverage.
This would be a promising path for the country to take, were it not for the fact that Bangladesh does not have any efficient emergency care systems in place. This may sound odd, especially as the casualty department has existed in most medical colleges, and the High Court has directed the government to ensure that healthcare facilities and practitioners provide emergency medical services to every patient brought to them.
It is true that all hospitals have now introduced emergency departments; the bastion that is Bangabandhu Sheikh Mujib Medical University (BSMMU) only just opened its emergency department in November 2021. These, however, can be described as cosmetic facelifts at best, as the systems required to deliver standardised emergency care are grossly lacking.
Emergency care has been in development since the 1950s in the West, arising from the casualty departments of old, developing into accident and emergency in the UK and finally into its own field of emergency medicine. Training in this specialty allows a single clinician to provide the first few hours of care appropriately for any patient presenting any condition. As opposed to other fields of medical science where diagnosis is key, this field looks at optimising a patient's condition before they receive definitive care by more traditional specialties. Despite its 50 years of existence, and all the other South Asian countries developing this field, Bangladesh has yet to recognise emergency care.
Recognition of this specialty would allow for standardised training of not only doctors, but also of nurses, paramedics, and other related healthcare professionals, so that patients receive quality care in the moments when they need it the most. This, unfortunately, leads to the second major issue that Bangladesh faces. Due to the lack of recognition, there are no defined career pathways for professionals in emergency care. This leads to clinicians being seconded to the emergency departments from a parent specialty for a short period of time. It is well and good when a cardiology trainee receives a patient with crushing, central chest pain in the emergency department, but the value they provide would be questionable when they are to deal with a new mother who is bleeding profusely following childbirth. Also, a placement for six months or so does not allow a clinician to develop new skills with confidence—especially when those skills learnt will never be called upon again. It is, therefore, vital that clinicians get embedded in the emergency department and move up their career ladder, so that they may instil confidence in their patients.
Nine years may not be enough time to bolster up the primary care services in the country to achieve its targets for SDG 3, but an emergency care training programme for clinicians across the country over the course of the next five years will contribute to bringing down death rates and ratios across all spectra of health issues. We do have time to amend our course, but the time of action is now. We have the benefit of skilled human resources by virtue of a local and expatriate community of trained medical professionals, as well as the support of regional and national organisations keen to develop a framework for emergency care. The Covid-19 pandemic has already proven that the health sector in Bangladesh is ready to take up a challenge, no matter how large; all we need now is guidance.
Dr Mir Saaduddin Ahmad is academic director at Dr Nizam Medical Centre in Dhaka, Bangladesh, and a trained specialist in emergency medicine.