In fact, I was so confident about the abundance of these types of news articles that, on the day of my doctoral proposal presentation on the responsiveness of physicians in rural Bangladesh, I took a risky yet interesting step. Before starting my PowerPoint presentation, I said to my examiners that I was ready to check any random Bangladeshi newspaper, being sure that there would be something relevant to my topic. Still, I was taken aback when I clicked on the link of the most popular Bangladeshi newspaper, the Daily Prothom Alo. The front page featured the news of a physician beating the journalist whom I had interviewed just a few weeks ago in relation to a research project. The journalist was unfortunate, but I was lucky, as I could rest my case.

Being a Bangladeshi physician, however, I did not have to resort to these newspaper clips or journal articles to find out about physicians’ lack of responsiveness (not all of them, of course). As a medical student I witnessed how a teaching surgeon pulled down an elderly person’s pant, in the middle of a crowded hospital ward, to show us how an inguinal hernia looked like. I witnessed another elderly patient being thrown out of the orthopedic consultation room just for asking what his diagnosis was. Being a physician, and with all my family members also being physicians, it’s perhaps no wonder that I chose to do my doctoral thesis on the pertinent issue of responsiveness. Indeed, if I didn’t, who would do so?

“Responsiveness” refers to the social actions that HRH take to meet the legitimate expectations of service seekers. The World Health Report 2006 identified four domains of HRH performance: availability, competence, productivity and responsiveness. There’s an abundance of literature on the first three domains, but there are hardly any articles on HRH responsiveness. In my literature review, I found only four such studies. One primarily discussed the overall HRH performance; responsiveness came as a part of an overall discussion on performance. The second one involved telephone interviews of European patients, but did not discuss how the construct of responsiveness was derived.  The third one, a study on Brazilian nurses, described the psychometric steps in developing an instrument to assess their responsiveness; but again, this study failed to clarify the method used for developing the construct. The fourth one concerned Thailand, analyzing the degree of responsiveness of physicians, but it did neither clarify the concept of responsiveness nor investigate the reliability and validity of the tool used.

So, my task was challenging, as I had to first understand what responsiveness meant to the physicians as well as to the patients. I thus conducted a qualitative study involving interviews and focus group discussions with the service providers and clients, followed by observation of actual consultations. In the next step, based on the qualitative findings, coupled with literature review, I developed a structured observation tool to measure responsiveness. Applying the tool on 393 physician consultations, I developed the Responsiveness of Physicians Scale (ROP-Scale) after psychometric analyses and tests of validity and reliability. The ROP-Scale consists of 34 items, grouped under five domains, namely, Friendliness, Respecting, Informing and Guiding, Gaining Trust, and Financial Sensitivity.

I also employed the tool to distinguish the responsiveness of the public sector physicians vs. the private sector’s. Most of such previous comparative studies in Bangladesh had found the private sector outperforming the public. We, however, discovered in the qualitative part of our study that neither of the sectors actually live up to the expectations of the people. Although private sector physicians scored slightly higher on the overall scale, public sector physicians scored higher in domains of Gaining Trust and Financial Sensitivity; private sector ones in the remaining domains. The ‘Respecting’ domain was considered the most important domain in terms of responsiveness.

In spite of this criticism, I must acknowledge the huge workload Bangladeshi physicians endure, and their provision of health care against a backdrop of extremely scarce health systems support. Many physicians, in fact most of the ones under my observation, were quite respectful to the patients, and supportive towards my study.

My take-home message is that Bangladesh and similar countries with a booming and unregulated private health sector, urgently need well-defined and functioning regulatory and mediatory mechanisms. If people don’t find a legitimate and regular way of venting their frustrations, they will do so in a rather unexpected way, which is neither good for them nor for the physicians. Obviously it’s not good for the health system as a whole either.

A modern-day apartheid has been in place against the Rohingyas since 1974’s Emergency Immigration Act, bolstered by 1982’s Citizenship Act of Myanmar, which created three tiers of citizens, resp. Full Citizens (pink card), Associate Citizens (blue card), and Naturalized Citizens (green card). Rohingyas along with some other minority groups have been classified by the junta as ‘Resident Foreigners’. They are denied freedom of movement (cannot go outside Rakhine or outside the country for even religious pilgrimage), education (only up to primary education), jobs (no civil service, private job is equivalent to enforced labor or slavery), property (arbitrary confiscation) and even courtship (special permission required for marriage, which is also very strictly controlled). Other human rights violations include arbitrary detention and arrest, rape, mass killings, displacement, denying traditional religious education and practices, etc.

As a result of these persecutions, large numbers of Rohingyas eventually fled illegally to many countries. The infamous Naga Min operation by the junta in 1977 resulted in mass arrest, persecution, and eventually the first massive exodus of Rohingyas to Bangladesh after its independence in 1971. Approximately 200,000 refugees entered Bangladesh, many of whom eventually returned to Myanmar as a result of a bilateral agreement between the two governments. But 10,000 people, predominantly women and children, died of malnutrition as the food ration was cut in order to compel them to return to Myanmar. Then in mid-1991 through to early 1992, another bout of mass influx of Rohingyas took place as a result of a bloody crackdown on civilians by the junta. This operation was named the ‘State Law and Order Restoration Council’ and resulted in expulsion of 260,000 Rohingyas to Bangladesh. In 1994, many of them were forcibly repatriated to Myanmar by the Bangladesh government. Since then a slow and irregular influx of refugees to Bangladesh continued. Communal violence erupted in Rakhine in June 3, 2012 as a result of the rape and murder of a Rakhine (the majority ethnic group in the Rakhine state) girl by three Rohingyas. The initial riot allegedly cost the lives of 16 Rohingyas and 13 Rakhines, torching of 2,600 homes of both sides, and forced exodus of 32,000 Rohingya refugees to Bangladesh. The riot quickly scaled up causing more Rohingyas to try to take refuge in Bangladesh, but this time with strong resistance by the Border Guard, Bangladesh Coast Guard and Bangladesh Army. And finally, on  October 9^th, 2016, a fresh bout of violence broke down upon the Rohingyas, as a result of an alleged attack by a few Rohingyas on three police outposts, killing nine Myanmar Border Guard Police, and seizing weapons and ammunition. Eight attackers were also killed. Thousands of Rohingyas are trying to flee the country by land and sea routes to survive atrocities committed by Burmese authority, which UN officials have termed as ‘ethnic cleansing.’

Bangladesh is a lower middle income country with a massive population density of 1,237 per square kilometers. The officially recognized 31,000 refugees in Bangladesh (unofficially estimated to be between 230,000 and 500,000 or more) are living in two official UNHCR refugee camps (and several unofficial ones) in an overcrowded setting, squalid housing, and inhumane conditions, riddled with diseases (40.4% prevalence of respiratory infections, 7.1% diarrheal diseases, 2.3% worm infestation in general and 7.6% malnutrition among 12-59 months old children) and hunger.

It is not only the Rohingya refugees who are suffering,   local Bangladeshis are also faced with dire consequences in terms of the impact on the economy, law and order, politics, international relations, culture, and public health. Local people face severe competition for jobs. Many refugees, forced to get involved in clandestine businesses, illegal trades, drug smuggling, prostitution, and even arms dealing, are taking the already volatile law and order situation out of control. Crimes committed by some Rohingya refugees in Middle Eastern countries have reportedly been mistakenly attributed to Bangladeshi workers due to their forged Bangladeshi passports, adversely affecting the remittance market of Bangladesh, a prime source of Bangladesh’s GNP. Bangladesh is also faced with extra pressure on its already over-burdened public health services. The political landscape is also shifting as a result, as many ultra right-wing Islamist groups in Bangladesh are allegedly capitalizing on Rohingyas’ misfortunes to recruit them for militancy. Above all, the  disruption to Bangladesh’s social fabric has already been revealed by the communal riot that took place in 2012 against innocent Buddhists in Bangladesh, allegedly instigated by some Rohingyas.

The question is, then, how should Bangladesh handle this, in the most  humane way? Should it open its border to the refugees, as suggested by some right-wing groups, ultra-nationalists (alluding to taking refuge by 15% of total Bangladeshi population in India during the Liberation War in 1971), and most humanitarian agencies? Or should it turn its face away from the helpless refugees including numerous women, children and elderly, as suggested by many supporters of the current ruling party, chanting racist slurs (calling the Rohyingya’s terrorists, criminals, smugglers, drug peddlers and more)? In my opinion, none of these extreme positions are the answer.

It is important to wage a concerted effort involving the governments of Myanmar and Bangladesh, and international organizations such as UNHCR. The government of Bangladesh should handle the issue with a humane face, instead of taking aggressive action, which may further complicate the situation. Dialogue and communication among involved parties are essential for providing the Rohingyas with an acceptable future. International NGOs should consider improving the lives of the Rohingyas both in Bangladesh and more importantly,  Myanmar, at the source of persecution. Humanitarian organizations should work on the Myanmar side of Rohingya communities, and should brief the world on the real situation there. International agencies such as the United Nations, or UNHCR, should appreciate the dynamics of the crisis from the perspectives of all involved parties. It is incumbent on them to create substantial pressure on Myanmar’s government to improve the humanitarian record in Myanmar and refrain from persecuting and discriminating their own citizens. If the situation is not improved at the source of the crisis, similar incidents will continue to take place, and a sustainable solution will never be possible. Finally, since local integration of Rohingyas is not feasible due to the socio-economic conditions of Bangladesh, if repatriation attempts fail, resettlement in a third country should be considered by multilateral organizations and humanitarian agencies. And this should happen very soon.