I always had trouble convincing my friends from the North how important an issue like responsiveness of human resources for health (HRH) is. I understand, though, it is very difficult for them to assess news articles like ‘Is there a cure for bad behavior: the toxic demeanor of many Bangladeshi doctors is a disease unto itself’, or ‘Patient’s Death: DMCH doctors assaulted, ward ransacked’, or ‘Patients suffer as doctors take strike nationwide’. These newspaper articles from my country indicate that patients often express their frustration over their physicians’ behavior in a rather aggressive way. As a result, physicians respond to the violent acts of their patients in the form of strikes or refusal to provide services. This sad turn of events eventually causes the suffering of poor, innocent, and helpless patients, often costing their life. Although I gave examples from the popular media, these issues are increasingly being discussed in scholarly articles as well, in the fields of medical anthropology, health service management, health policy and systems research, etc.
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.