Mizanur Rahman

Mizanur Rahman is enhancing the quality of rural health care in Bangladesh by educating Rural Medical Practitioners, also known as “bare-foot doctors,” to higher professional standards.

Mizanur Rahman has created a new system of health care in rural Bangladesh, where the ratio of physician to population is among the lowest in Asia. In nearby Pakistan, there is one doctor per 200 people; in Bangladesh the figure is one to 12,500, and nearly all of the licensed physicians are in the cities. From time to time citizens’ organizations and the government have identified rural public health needs for which they have then trained non-degreed practitioners to implement specific responses such as oral rehydration, immunization or family planning. Preparation for these assistants is short and limited, but growing numbers move on to provide a whole range of medical services for which they have no training. There are an estimated 400,000 to 600,000 such Rural Medical Practitioners (RMPs) currently providing health care in the rural areas. No government regulations exist to monitor their practice, which is the only medical care available to most of Bangladesh’s rural poor.
Through a comprehensive training program, Mizanur is guiding the RMPs to become skilled health practitioners. His program is the first to offer in-depth training to large numbers of them, so that they have the tools to deliver high quality services and the judgment to know their limitations and refer cases beyond their scope of knowledge to certified doctors. Through post-training forums, Mizanur is also forging strategic links between the rural practitioners and government health workers, two groups whose relationship has previously been characterized more by conflict than by cooperation.

The vast majority of trained, certified doctors in Bangladesh live in Dhaka and other divisional cities and district towns. This presents a serious problem of access to medical care for the 85 percent of the population who live in rural areas, particularly the poor. Although there are government health facilities located at the headquarters of each thana (an administrative unit), these facilities are not easily accessible, are relatively expensive, offer an inadequate and unreliable supply of essential drugs and are typically understaffed.
Faced with this situation, ill people turn instead to the services of RMPs who provide low-cost consultations, make house calls, and will often accept payment in kind. The practitioners are typically friendly and familiar to their patients, providing a welcome contrast to the institutional and impersonal atmosphere of the public health complexes.
Unfortunately, these village doctors often do more harm than good. Each year hundreds of rural people die under the care of RMPs due to misdiagnosis or incorrect treatment. Pregnant women, babies and children rank high among the victims. RMPs are also characterized by their indiscriminate prescription of drugs. They are often unaware of the proper dosage of medication necessary for various treatments, and the possible side effects of the medicines they prescribe. Research on their practices reveals case after case of asthma patients and diabetics who suffer adverse reactions or die, as well as countless pregnant women who abort, after following the prescription of their local practitioner. Several important antibiotics have also lost their efficacy due to overprescribing. The substitutes for these antibiotics are frequently unavailable and unaffordable.
Despite the obvious risks, villagers continue to enlist the services of RMPs on a regular basis. Due to the health education efforts of both government and citizens’ organizations, villagers are becoming more informed about their health care needs. The demand for health care far exceeds the supply. In a region of roughly 200 villages, the ratio of qualified doctors to RMPs can be as low as 4 to 900. Many people seeking medical attention are left with no alternative to an unqualified RMP.

Recognizing that RMPs play a valuable social role not likely to disappear in the near future, Mizanur’s strategy is to bring them to a more advanced level of medical competency. He is offering them comprehensive training in anatomy and physiology, gynecology, pediatrics, prescription writing, hygiene and doctor-patient relations. With these basic health care tools, the practitioners can more responsibly serve the members of their communities.
Mizanur begins in a target area by going door-to-door to meet the rural practitioners and then invites them to attend a one-week training session to sharpen their skills and learn about the latest health care techniques. He employs various incentive measures to ensure the attendance and participation of both the RMPs and the doctors working at thana level health complexes.
The RMPs are required to pay a fee of 1,000 taka (US$25) for the training sessions. Each day they gather to hear lectures and review case studies with a broad range of trainers, recruited by Mizanur. The trainers include doctors from the public health complexes, representatives from pharmaceutical companies, government health education officers and specialists such as dental technologists and pathologists. Health professionals evaluate the prescriptions of RMPs to see whether they were appropriate for the ailments in question and provide general feedback. At the end of the training course, participating RMPs undergo written and oral examinations; they examine a patient, make a diagnosis and prescribe treatment under the observation of their trainers. Those who successfully complete the course receive a certificate and letters of recommendation upon graduation.
Medical doctors have been reluctant to participate in RMP training, so Mizanur is working with the Ministry of Health and Family Welfare to promote it. He is demonstrating that RMPs can provide critical information to thana doctors about local health care needs and that their role is to supplement the work of certified physicians, not to replace it. As the system becomes more efficient the RMPs will handle the noncritical cases, giving government doctors and clinics time to focus on patients with special needs.
As part of systematizing his training process, Mizanur has listed all the RMPs in the six sub-districts of Jenaidah district. He is organizing more comprehensive training for those who possess the aptitude and interest to go beyond the week-long sessions. With a long-term view, he is reaching out to citizens’ groups and physicians’ associations to create a lobbying forum through which health policy issues can be addressed at the national level.

When Mizanur was eleven years old, he developed an infection under the skin on his back. He was part of a rural family; an unlicensed village practitioner injected medicine at the site of the infection. Five years later Mizanur inexplicably developed a speech impediment. An examination by a specialist revealed that he was suffering from permanent paralysis of the left side of his tongue as a result of the injection.
Mizanur went on to earn a master’s degree in chemistry from Dhaka’s Jahanginagar University and graduate certificates in health science and community health. He became a senior medical representative for a major pharmaceutical company; while traveling in this role he was shocked to discover the insufficient medical knowledge of RMPs. He began to offer free instruction to the RMPs on the use and misuse of drugs and was overwhelmed by the positive response and enthusiasm generated among participants. Mizanur’s efforts were applauded by his company, and other pharmaceutical firms soon followed with offerings of similar education programs. This experience served as a springboard for his comprehensive RMP training course.