A call for certifying healthcare providers

It is perhaps true that some health indicators like infant and maternal mortality have improved. Attainments in crude death rates, weight at birth, and related measures of health also show favourable signs. At least that's what we are told in the documents of the ministry (MOHFW) and other international bodies. Are these documents reliable? Have they been externally validated? I raise these questions because the evidence about healthcare in publicly available documents -- especially in the media -- paints a completely different and rather foreboding picture. Here's a miniscule sampling of the daily headlines:
- 74% doctors dodge duty (DS: Sept 22, 2003)
- Banned drugs on sale (DS: Nov 14, 2003)
- Anomalies, corruption rule Nalitabari health complex (DS: Nov 21, 2003)
- Giant health plan, little success (DS: Jan 3, 2004)
- Trolley touts, clinic brokers rule the emergency units (Independent: Oct 25, 2003)
- Health practitioners: Above the law? (DS: Feb 26, 04)

For a service that is best classified as credence-based, where the consumer has little knowledge or understanding of what (s)he receives for the money paid or the tribulations endured, the above headlines can be very unsettling. What is most troubling is the growing evidence that people's trust in healthcare providers is low or one of calculated ambivalence. The number of people seeking health services abroad is one strong indicator of this lack of trust. Unless this trust can be boosted, the prognosis for the nation's physical, emotional, and economic health is dire.

In an era, when there is much talk about transparency and accountability, periodic certification of healthcare providers can play a crucial role in gaining public confidence. Certification serves as a mechanism to ensure that healthcare providers are up-to-date on their knowledge and skills while adhering to best practices. By making them undergo regular and periodic certification, and by requiring this certification to be openly displayed in the nation's health system, the public's confidence can be given a huge lift. It is pertinent to note that Bangladeshi healthcare personnel who work in other countries are subjected to rigorous certification procedures periodically. Most of them are also able to rise to the challenge. Certainly, it is also conceivable for Bangladeshi healthcare providers to be subjected to similar and rigorous certification procedures that they should be able to surmount. This process must be locally relevant, adapted to the context, and incorporate the need for periodic upgrading of standards to "raise" the quality of health care delivery over time.

The program must primarily be developed and administered by professionals from the healthcare area and vetted by healthcare recipients and regulatory bodies. Those in charge must only be responsible for developing and maintaining the program with strict oversight responsibilities. To gain public trust quickly, it may be necessary initially to use experts from abroad with stellar credentials to set up and administer the certification process. Competitive benchmarking may be used to identify, introduce and incorporate higher standards from neighbouring countries as the system evolves. Through the certification process, health care providers would have to "earn the right" to practice and maintain this right over time. Obviously, severe penalties must be incorporated and invoked for those who do not measure up, fail to comply, or try to bypass the system. Legal sanctions are also necessary to induce good service.

Interestingly, the country's healthcare providers have ensured, until now, that they cannot be held legally accountable or taken to task for their mistakes, especially the egregious one causing loss of life or limb. A bill was passed by the cabinet to punish them for negligence leading to death, serious and sustained mental suffering, or loss of limb. The proposed punishment included cancellation of practitioner's license, ten years rigorous imprisonment, and/or a penalty of Tk.10 lakhs. Unfortunately, it was withdrawn under tremendous pressure from the health practitioners. It is now time for service "recipients" to create equal or greater pressure for health practitioners to comply with basic standards incorporated in the certification process or be held accountable legally.

It is also vitally important that the certification process be understood by the general public; it must have components that they can comprehend. Rating scales, something akin to those applied to financial, educational, and even healthcare institutions in advanced countries could be established to rate the hospitals and their services. Such ratings could be based on hospital facilities, past performance records, patient evaluations and a host of other vital factors. To make things easier for those uninterested in details, certified hospitals and healthcare providers may be graded or ranked as diamond, platinum, gold, silver, and bronze that the public can readily understand. It goes without saying that it would be important to determine, specify, and strongly enforce sanctions for tampering with past records and any type of evaluations.

In addition, the certification information must be widely available to the public through mandated hospital and related information centers. Hospitals should also be required to offer only a government- or professionally-certified list of services and nothing else, thereby restricting their services to their established competencies. The list of services a hospital is "allowed" to provide should be available to patients on demand.

There is a great deal more that needs to be done to improve healthcare services. Primarily, however, the trust of the public must be re-established. To that end, certification provides renewed hope for the healthcare industry to redeem itself. I might add that there are other practitioners such as teachers or engineers who also affect human lives; they must also be brought within the ambit of a certification apparatus so that their services to the public can be measured, valued and rewarded as needed.

Dr. Syed Saad Andaleeb is Professor and Program Chair, Sam & Irene Black School of Business, The Pennsylvania State University, Erie, USA.