Zahed is striving to reduce health care costs in Bangladesh by curbing the use of nonessential prescription drugs.
The New Idea
Zahed, who is a doctor, sees that the cost of health care is prohibitively high for middle-income or poor Bangladeshis, forcing many patients to make desperate choices, often between prescription drugs and food on the table. To lower health care costs, he is encouraging a more selective use of nonessential drugs. Based on his research of ten years, Zahed believes that the majority of illnesses can be treated at a greatly reduced cost to the patient without compromising the quality of care. Thus, he is working with individual doctors, medical schools, and professional associations of doctors to raise awareness of what he sees as a dire problem of overprescription. Through formal classes and informal workshops, he teaches students and professionals to differentiate between essential and nonessential drugs. On the consumer side, he is encouraging patients to engage their doctor in an open discussion about which drugs are prescribed for their illnesses and why. To further democratize information about drugs, Zahed has set up a public drug information center. He is also pressuring the Directorate of Drug Control to follow procedure in introducing and promoting new drugs and to cancel all drugs that have not been tested properly.
The World Health Organization ranks Bangladesh in the bottom third of member states in terms of the effectiveness of its health care system. Though progress has been realized in some areas, rates of infant and child mortality stand at an unexpectedly high 79.6 and 4.3 per one thousand live births, respectively. On the treatment side, there are only eighteen doctors and five nurses for every hundred thousand persons. With most doctors living in cities, this scarcity poses an especially serious problem for the eight out of ten Bangladeshis who live in rural areas. And although there are government health facilities in most thanas, or local administrative units, they are often inaccessible and frequently understaffed. According to estimates, the total government spending on health care in 1996-1997 was 20 billion taka, of which 2 billion taka covered prescription drugs; during that same period, households spent over 33 billion on health care, of which 25 billion taka went to pay for drugs. In other words, spending on medication accounted for nearly three-quarters of the total household spending on health care. In 1982, Bangladesh adopted a drug policy that called for reduced drug prices, increased availability of essential drugs, and elimination of nonessential and potentially hazardous drugs. Though the policy promised reform and tighter controls, the implementation was lax. Meanwhile, the types of essential and nonessential brands have proliferated, and hundreds of new drugs have shown up on the shelves of pharmacies without having been properly tested or registered. Even today, many doctors lack information on drugs, and the commercial interests of some pharmaceutical companies and doctors result in the overprescription of newer, costly, nonessential drugs.
Zahed follows a strong belief that the majority of illnesses can be cured at a very low cost and with less medicine that is typically prescribed. His research has revealed that doctors generally prescribe three to four medicines per patient for an illness. For poor patients, this is a difficult cost to bear. Zahed approaches the problem first all of by educating patients to ask the right questions of their doctors and to communicate their financial, as well as health, needs. He also tackles the problem of overprescription of nonessential drugs by working with another key group: doctors. His nonprofit, Health Action Forum, organizes workshops for students of medical colleges across the country. The workshops treat a number of topics relating to drugs: essential versus nonessential, the economics of the drug industry, the role of the government in ensuring drug safety. So far, Zahed has trained over three hundred and fifty medical students at the workshops, which are also open to members of the Bangladesh Medical Association, the largest association of doctors in the country. In the next two years, Zahed plans to reach all twenty-four medical colleges in the country. To ensure lasting changes, Zahed helps students form a committee at their college to bring together peers and the faculty of relevant departments–including medicine and pharmacy–for frequent discussions. So far the response from students has been extremely positive. Zahed intends to develop a strong network through these committees and eventually aims to work into the medical curriculum a course on essential and nonessential drugs.
In addition to his responsibilities at the Forum, Zahed directs a nonprofit that trains health care workers who are employees of nonprofits. Presently, he and his team are training fifteen hundred paramedics and five hundred doctors from forty-seven health organizations. Zahed has included a mini-course on essential and nonessential drug use as part of the training course and has developed a curriculum for an association of rural doctors that reaches forty thousand doctors. To continue his public education efforts, he has opened a drug information center that is open to all: patients, doctors, journalists, and policy makers. He also sees the media as an ally and is arranging radio and television spots. In addition, he publishes a quarterly bulletin for doctors and Members of Parliament that provides unbiased information on drugs and health. The bulletin allows doctors to post their observations on the effects of particular drugs as well. Finally, Zahed is making sure that the government office responsible for the enforcement of policies related to prescription drugs takes its job seriously. This sometimes means helping patients take their complaints about drugs or pharmaceutical companies or doctors to court.
Zahed was born in a village 40 kilometers from Dhaka. His father worked in the Calcutta Corporation and owned a two-storied house there. A few years after partition, he returned to what is now Bangladesh with only Rs. 6000 to his name. The Calcutta house was taken over by others and the family underwent difficult financial times in the new country. Zahed remembers being affected by jaundice when he was nine years old, a condition for which his family could not afford proper care. On a separate occasion, his older sister became ill and after being rushed to the hospital, lay unattended for three hours. Tragically, she died there–probably from a burst appendix, Zahed now believes. After participating in the independence movement in Bangladesh, Zahed enrolled in medical school. As a student, he saw senior consultants and professors who were far too preoccupied with their private practice to properly care for patients, particularly the poor. After graduating, Zahed declined an offer to work for the government, and instead struck out on his own, working with various development agencies and actively participating in the citizens' movement against the Flood Action Plan, a proposal that threatened to displace large numbers of people in Tangail district. He conducted a number of studies observing doctors and auditing prescriptions. From these experiences, he concluded that the system is set up so that doctors very often see the illness, not the patient, and that they would prescribe medications differently if they understood more about the patient's economic situation.