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Project Report on
Submitted To: DR. MahbuburRahman Course Instructor – Legal and Ethical Issues in Business School Of Business Independent University, Bangladesh
Submitted by: Md.Arif Imran Khan, ID: 1110885 Md. NazmusSakib, ID:1231066 Mohammad Imran Khan, ID:1110835 Md. Abu Hayat Adnan, ID: 1231067 FarjanaYasmin, ID: 1221554
March.31, 2013
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DR. Mahbubur Rahman Course Instructor – Legal and Ethical Issues in Business School Of Business Independent University, Bangladesh Subject:Submission report on Unethical Medical Practices in Bangladesh. Dear Sir, We are pleased to submit the following report that you had asked us to develop with a given guidelines. For this purpose, we made “Unethical Medical Practices in Bangladesh”, to be the subject matter of our report.
We are glad to submit it as part of completion of the requirements for our (MBA-515) course with you.
We have tried our best in trying to put up a good report with as much information as we could gather during the limited span allotted for writing the report.
Thanking you for your kind support and help throughout the course, we remain. Thank you very much.
Sincerely yours-
Md.Arif Imran Khan, ID: 1110885 Md. NazmusSakib, ID: 1231066 Mohammad Imran Khan, ID: 1110835 Md. Abu Hayat Adnan, ID: 1231067 FarjanaYasmin, ID: 1221554
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Table of Content
EXECUTIVE SUMMARY
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INTRODUCTION
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OBJECTIVE OF THE REPORT
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Methodology
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Regulations of Healthcare Professionals
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Medical Wrongs and Negligence
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Present Status of Dhaka Medical College Hospital
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Key Findings
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Recommendations
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Private Hospital’s Unethical Practices
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Recommendations
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ETHICAL PERSPECTIVE
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CONCLUSION
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REFERENCES
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EXECUTIVE SUMMARY
Concern over the quality of health care services in Bangladesh has led to loss of faith in public and private hospitals, low utilization of public health facilities, and increasing outflow of Bangladeshi patients to hospitals in neighboring countries. Under the circumstances, assessment of the country's quality of health care service has become imperative, in which the patient's voice must begin to play a greater role. This study attempts to identify the determinants of patient satisfaction with public, private and foreign hospitals. An investigation was conducted involving inpatients in public and private hospitals in Dhaka City. Policy implications are discussed. Entrepreneurs run the hospitals and clinics with the help of doctors,nurses and medical technicians and other experts and employees.And all these primary laws are applicable, as appropriate, to providethe above Healthcare services in Bangladesh.
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1. INTRODUCTION "Health Service" sector of the country is one of the very crucial needs of the country and to ascertain the status of the Medical Service, we have selected the most renowned hospital of the Capital - "Dhaka Medical College Hospital" from the Public Medical sector and some renowned Private Medical Hospitals. - the college as the source of creating the talented professionals in health service of the country, the hospital having the perception of Nucleus of Medical services of country among the population and the health service organization enjoying the highest government supports.
We have intended to find out the overall Operation Management system for providing the Health Service by these Top graded Hospitals of the Capital of Bangladesh. How the system works, whether there is any gap in the management system and if ―yes, what is the impact of lacking in the management system, the positive or negative outcome of the professional Operation Management planning, were the intension of the study in back of mind.
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OBJECTIVES The objectives of doing this study are given below: The goal of this study is to bring about how unethically the government and private hospitals are operating their service/business To evaluate the Utilitarianism, right, ethics of care and justice in the government and private hospital. To identify illegal and unethical practices of medical sector. To get an idea about the violation of patients rights and justices.
To find/check whether the private hospital ethically and legally increasing the service charge or not. Describing how the society is losing benefits by those unethical practices based on Utilitarian theory, Rights and Justice Point of view. We have described all of the above issue throughout this paper and we have tried to show how the private hospitals are fixing the service charge without government control as well as how the public is suffering.
METHODOLOGY
This study involved in understanding the current situation of government and private hospital and the reasons behind the rapidly increase in service charge of private hospital and decreasing the service of government hospital. There are significant findings which we have collected by working intensively. Collected and analyzed primary information through market visit, interviewing patients , pharmacy, as well as media representatives. Collected the primary information from government authority. Collected and analyzed secondary information/data from published research documents, newspapers, and other media. Collected additional Secondary information from Internet and printed resource.
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Based on above evidences we have found the issue about how unethically and illegally the private hospital increasing the service charge and decrease the service even in life-saving medicine and without any consulting with government authority as well as without any control by government. Regulations of Healthcare Professionals: Healthcare practitioners have been generally brought under: (i) The Medical and Dental Council Act, 1980, (qualifications and registration of medical practitioners and dentists); (ii) The Bangladesh Nursing Council Ordinance, 1983, (qualifications and registration); (iii) The Bangladesh Homoeopathic Practitioners Ordinance, 1983, (regulation of the qualifications and registration of practitioners); (iv) The Bangladesh Unani and Ayurvedic Practitioners Ordinance, 1983, (regulation of the qualifications and registration of practitioners). In addition to them, The Medical Practice and Private Clinics and Laboratories (Regulations) Ordinance, 1982 was enforced to regulate medical practice and functions of private clinic and laboratories i.e., charges & fees, maintenance of chambers & registers, license to establish private clinic, inspection etc. Bangladesh Medical and Dental Council hasits own Code of Medical Ethics, under which any practitioner convicted of false pretences, forgery, fraud, theft, indecent behavior or assault, is liable to disciplinary action by the Council. But such Council actions are never heard of. Medical Wrongs and Negligence: In course of providing the aforesaid services, medical negligence is a common phenomenon. Numbers of such incidents are unknown in Bangladesh, as there is no accurate data recording system. However, in the newspapers, almost every day, there is news on medical negligence of a kind or the other. In microscopic level, legal actions are seen to be taken. The forms of common medicalwrongs/faults/negligence are: Wrong diagnosis, Wrong prescription, Wrong doses of medicine, Wrong or faulty medical equipment -.lack of maintenance, Prescribing extra medicine with business interest, Medical Corruption, Out-dated medicines, Medical Malpractice, Breach of Confidence by the Doctors and Nurses, False Medical Certificates, Lack of quality Care.
Present Status of Dhaka Medical College Hospital: The Dhaka Medical College Hospital (DMCH) is the central point of public health services of all the government hospitals in Bangladesh. It was established in 1946. Every day, on an average, 1,432 patients come to the outdoor and 450 to the emergency units of the hospital, while 184 patients are admitted to the indoor for treatment. The patients are supposed to receive medical treatment at a low cost as it is a government-run hospital. However, it is alleged that the patients are regularly deprived of the health facilities due to a number of irregularities and corrupt practices.
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As there is a dearth of knowledge and organized information about the nature, process and magnitude of corruption, we undertook an in-depth study on this hospital. In conducting the study, information was collected from both primary and secondary sources. Primary information was collected from observation and open discussions.
Key Findings of Unethical Medical Practices in DMCH: There are 1,700 beds in the hospital at present, out of which 1,441 are general beds, 143 hired beds, 43 double cabins, and 30 single cabins. The DMCH has one director, one deputy director and two assistant directors. The total administrative manpower is 1,137 (194 female and 943 male). Out of the service providing manpower there are 594 doctors (199 female and 395 male), 653 staff nurses, and 673 student nurses. There are 25 departments, 48 units, and 45 wards in the hospital. Patients are attended at the outdoor between 8.30 am and 1.30 pm. However, most of the patients informed that they had to wait for the doctors for 78 minutes on an average. Senior doctors are expected to visit indoor patients at least once a day, but some of the patients alleged that doctors did not visit them regularly. Patients were not satisfied at the services ofthe doctors –outdoor and indoor patients showed their dissatisfaction. The outdoor patients mentioned absence of doctors on time, careless treatment and presence of other people (such as medical representative) during treatment as the reasons of dissatisfaction. They further informed that the doctors spent only 5 minutes on an average for attending each outdoor patient, and many of them were suggested to visit the doctors‟ private chambers. On the other hand, the indoor patients mentioned irregular visit by the doctors, carelessness and lack of attention of the doctors in providing health services, and unavailability of the doctors in time of necessity as the reasons of dissatisfaction.
There are numerous allegations against the nurses. Many of the patients did not receive good behavior and many of them did not get regular services from the nurses. Most of the
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indoor patients reported about maltreatment from the ward boys and other 4th class attendants, while most of them did not get them in time of their necessity. Many of the outdoor patients alsomentioned about the misbehavior of these employees. Employees of the outdoor are also alleged for breaking of the serial of the patients waiting for the doctors in exchange of bribes. Many of the patients gave Tk 21 each as bribe for visiting doctors breaking the serial.
The domination of dalals(middlemen) in the DMCH is also remarkable. Different classes of employees including ward boys, sweepers, gatekeepers, and even the relatives of many employees are involved in the strong network of dalals. They are actively involved in arranging appointments with doctors, admitting patients, diagnostic tests, arranging operations, managing beds, and all such activities of the hospital. It is found that many of the outdoor patients took assistance of the dalalsand for this they gave Tk 96 on an average. However, many of them stated that they did not get help from the dalalseven though they had paid money.
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The patients of the DMCH also face financial irregularities. The fixed rate of the admission form is Tk 5.50, but the patients were forced to pay Tk 11.50 on an average. Accordingly, an additional Tk 4,02,960 is collected illegally from the patients annually in this way. The most conspicuous crisis is shortage of beds. For this reason many patients do not get bed right afteradmission in the hospital. We found that most of the patients got bedimmediately after admission, some stayed on the floor for four days on an average before getting beds, and a few shared beds with others for 5 days on an average. It was informed that a few dishonest employees acquire additional benefits through bribes by creating artificial crisis of beds. They manage to provide beds to the patients by taking bribes. Among thepatients, most of them had to give bribe to the middlemen an average Tk 188 to get bed in the hospital. Considering the disease and nutritional need of the patients, the DMCH provides 11 types of food. For this purpose Tk 45 per person per day is allocated. In reality, the quality and quantity of these foods is not maintained. According to the study, Most of the patients consume food provided by the hospital. Among them most of the patients mentioned that the quality of food is good, while many considered it bad. The reasons mentioned by those who described the food as of bad quality were bad odor in food, bugs and other elements in food, and poor menu. The reasons behind providing less quality food were manifold. From the supplier‟s point of view, it was found that firstly the supplier had to pay bribe and they try to get the
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money back from the food, secondly, the quality and quantity gets down when they try to increase the profit, and thirdly, they have to bribe the staffs in the kitchen to accept the low quality food. Itwas also found that some of the hospital staffs take away a part of the food for themselves. Corruption also exists in the supply of food. We found that on an average 704 meals are wasted every day, which is worth Tk 31,680. According to this, every year food worth Tk 1,15,63,200 is wasted. After getting admitted in the hospital the patients have to pay money to different people in the name of tips. It was found that most of the patients who used trolley paid Tk 42 as tips, the patients who were bandaged and got dressing paid Tk 53, some of them paid the sweeper Tk 13 to clean the flooraround their bed, and many patient staying in the hospital for 15 days on average paid Tk 27 on average every day to the ward boy. The visiting hour in the hospital is between 4 p.m. to 7 p.m. but most of the patients had visitors other than this hour by paying on average Tk 9 to the gate keeper. There are various kinds of mismanagements and corruption in diagnostic tests. In such cases the patients are harassed by the doctors, staffs and the middlemen. Most of the indoor and some of the outdoor patients was instructed to undergo diagnostic tests from particular diagnostic centers. It should be mentioned here that doctors get commission of 30% to 50%from these centers. We found that most of the patients got their tests done from the DMCH, some from particular centers and some from both. Among those who conducted the test from the DMCH, most of them had to pay on average Tk 140 extra. Blood collected from drug addicts and physically unfit donors are sold here at two or three times higher price. Investigation shows that a bag of blood of any general group is bought for Tk 80 to 100 and sold for Tk 400 to 700. Since the DMCH is a government hospital, patients are supposed to get free medicine and other medical apparatus. However, the study shows that most of the indoor and the outdoor patients did not get free medication. Even those who got medication got cheap medicine in a small quantity. Doctors claimed that there is adequate supply of many high cost medicines in the hospital, but when the patients asked for them they were refused from thecounter. Patients who stayed on average 15 days got medicines such as parasitamol (1 to 3), oral saline (1 to 2 packs), pain killer (1 to 2), vitamins (1 to 3), antacids, and ointments for skin diseases. Medicine and other medical equipment are not supplied in the hospital according to the amount needed. Besides, the supplied medicines do not reach the patients for some corrupt staffs. These medicines are sold illegally to the nearby drug stores. A list of these places and medicines are given bellow:
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Medical equipment Different medicines specially thecostly ones
Distributed illegally to Drug stores nearby the hospital and some other drug stores
Laboratory chemical, X-ray films
Various unpopular diagnostic centers of the city Drug stores nearby the hospital
Bandage, fenyl, savlon
The process of transferring these things is shown below: There is special form for the outdoor patients to get free medicine. This can only be received through the recommendation of the doctor. The people involved with illegal trafficking steal these forms and later write names of medicines and forge the signature of the doctor to get free medicine which they sell it to the drug stores. •
According to an intern doctor, getting medicine of the patient depends on the concerned doctor, nurse, and ward boys. The patient can only get medicine when he is willing. In the indoor section, prescribed medicines are collected from the counter and sold outside.
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Medical equipments other than medicine such as laboratory chemicals, gauge, bandage, fenyl, savlon etc. are collected through requisitions more than the actual need and later sold outside without fulfilling the patients‟ need adequately.
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The patients who undergo surgery in the hospital have to buy various medicines from outside. But some of it remain unused which is not returned to them. Information from the study shows that not even single per cent patient got the unused medicines back. Corrupt staffs sell these things to other patients or in the nearby drug stores.
There is also evidence of corruption in appointing staffs in the DMCH. Though there was circular for employing 243 third and fourth class staffs, total 340 staffs got employed. In these appointments there is exchange of bribe besides nepotism and influence. For these appointments bribes of Tk 50,000 to Tk 2,50,000 were given. Beside these corruption prevails in the allotment of quarters for the staff. There is quarter for the fourth class employees in Ajimpur and Elephant Road. Though the quarters are supposed to be allotted according to the seniority of the service, influence and money has become the main deciding factor for these allotments. It was found that bribes worth Tk 10,000 to 1,00,000 is to be given for an allotment.
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Recommendations: A set of recommendations is suggested for curbing corruption and mismanagement in the hospital. It is suggested that there should be a complaint center for the patients under the direct supervision of the director. Internal audit should be done and monitoring team should be immediately set up. Harassment of the patients will be reduced if the staffs are ordered to wear uniforms and ID cards. Remuneration of the intern doctors should be increased. The quality of service of the hospital will increase if honest and efficient people get employed by avoiding political pressure, corruption and bribe during the staff appointment procedure. Harassment of the staffs will reduce greatly if the activities of the middlemen can be stopped. Bed and medical supplies for the patients are not adequate and should be increased. Above all the administration should be stricter and free flow of information should be ensured.
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Private Hospital’s Unethical Practices:
1. In private hospitals especially in the renowned and big private hospitals they charge three times higher than the normal rate of the consultancy fee. They collect these moneys by the forced purchase of different toiletries items for the patient, gloves and also as service charge. 2. In most of the cases they admit patients unnecessarily just to earn money in the name of checkups which might not be necessary 3. They do provide any emergency lifesaving treatment to the patients if not paid first. 4. They charge three to four times higher than the Govt. rate in all diagnosis. 5. They transfer normal patients to CCU or ICU to charge higher. 6. In many cases they kept dead people on artificial ventilator saying that they are still alive and thus charge an extra bill. 7. They unnecessarily make surgery to the pregnant women who could easily give birth normally for extra profit. 8. The most serious allegation against them taking hostage of the dead bodies for not clearing the hospitalization costs. 9. They lack specialists in off-pick hours like Midnight but still they admit critical patients and sometimes they become unable to give them proper treatment and as a result in some cases the patient died. 10. Tragic Case in Square Hospital: A student of Masters of Business Administration (MBA) of Independent University, Bangladesh was allegedly killed for the miss-treatment in Square Hospital in the month of June 2012. The deceased was identified as Ashique Ahmed, 28, son of Haji M. Shoyeb used to live in Bongshal area of the Capital. He was taken to the Operation Theater unnecessarily without the consent of his parents. .
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Recommendations: 1. Proper laws should be planned to regulate the private hospitals. 2. A representative of the government should be always available in the hospital as an administrative officer to ensure that no patient is being mistreated or cheated. 3. There should be a box where the sufferers can post complaints and this should be under the supervision and be investigated by the government representative fortnightly. If anything fishy is found out investigation should be conducted right away. 4. Government audit about the earnings and the sources of those earnings should be ensured annually to see if there is anything unethical going on to increase the rate of profit. 5. There should be exemplary punishments given to the doctors and nurses who are found involved in unethical medical practices. 6. The patients and their relatives should be made aware of their rights and be encouraged to take necessary steps against the authority if anything unlawful is going on while treating them. 7. Many physicians have special connections with various pharmaceuticals and diagnostic companies and are adamant about using their products and services. In many cases they discard the reports of diagnosis if that is not done in their recommended hospitals. The patients should be provided with opportunity to complain about it and the government representative need to handle it immediately. 8. In many cases multiple number of unnecessary diagnosis are prescribed just to earn commission, such habit should be strongly discouraged and be punished if found to be practiced by anyone. 9. It is the first and foremost duty of a doctor to ensure the best treatment of a patient. This cannot be ensured until they feel it morally and heartily. While they are perusing their graduation and post graduations as doctor there should be moral and ethical lessons regarding the duties of a doctor. Because nothing can be more fatal than a selfish and greedy heartless doctor who thinks of own profit than the wellbeing of his or her patient.
ETHICAL PERSPECTIVE Utilitarianism Point of View: The main concept of the utilitarianism is to maximize the benefit and minimize the harm/cost. The present consequence, however, is just opposite of utilitarianism principle that‟s maximizing the harms and minimizing the benefits. In private hospital the patients are not getting the proper medical service in return of their expenses equally; the patients have to pay more than the actual service. As a result, the society is losing the benefits, as the private hospitals are imposing more cost on society.
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Rights Point of View: Unethical practice violates the both the Moral Rights, Negative Rights as well as the Positive Rights. The private hospital has adjusted its service charge at higher than logical so only the patients/customer who has the ability and highly necessity of such services are going to pursue those facilities. The poor people/patients who has highly necessity of medical facility but is not getting those desire services because of financial inability is violating the peoples‟ right to pursue their interest. The authorized group like the government and the medical Administration is not supporting to control the high charges medical services is also violates the peoples‟ rights. Moreover, from the moral point of view it is violates the peoples right as the medical service save the life so every peoples should have the right to get the proper medical services without facing any dishonesty.
Justice Point of View:Where the increase in medical charges and is opposite of human rights and utilitarianism so it is normal that it also separated from justice. The main concept of Capitalist Justices is that what each person receive should equal to what s/he is has paid. However, the people is paying much more that they are actually getting from the private hospital which is injustices. Finally, the people living in any society have the right to maximize the utility, and should have the right to know the particulars or the relative issue with those have impact on their live. Not only those but also the respective parties like government and other administrations should provide the support to the peoples with the rights to live with maximum utility, with rights an obviously with justices and fairness.
CONCLUSION:
Along with the study and it„s analysis, it has been clearly visualized the number of areas in DMCH where many policy implications are needed backed by a aggressive and quality planning of Operation Management in order to do the proper judgement to the reputation of Dhaka Medical College Hospital as the core institution for Medical Service provider to the peoples of the country.
The Visiting Hour of the Patients and the number of allowable attendants to be strictly controlled in order protect the safe - hygienic - secured environment of the hospital. There is a administrative failure in the total system of the operation.
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The number of nurses is in alarming situation to provide the proper medical services towards the patients. Only one or two nurses were observed per ward and many patients addressed the issue that Doctors are communicating to their illiterate attendances to brief them how and when, what medicine to be given to patients. The number of nurses to be increased substantially in DMCH.
The poor inventory of medicine is of crucial importance in order to provide the right treatment and health services. Moreover corruption has been critically identified and reported many times in the news media, which need to be addressed strongly. The crisis in the number of Beds are acute, whereas number of cabins are keeping idle in DMCH. The economic classes of the patients who are coming to DMCH from different districts do not need luxury of cabins rather a normal bed.
During vacation, admission is totally stopped. Serious patients are lying down outside, though the there are beds available in wards. There are no alternative supportive plan to provide the services to the patients during long holidays which can not be think of in this modern world and in the hospital which is perceived as the centre and idle of the medical services in the country. Introduction of Help desk, round-the clock duty roaster of support staffs, controlling of corruption are the other areas to look at. Even there are huge unemployment problem in
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our country and in govt. organization rotational transfer happens, but here in DMCH most of the ward boys are working since long and involved in other activities rather than their professional services.
Administrative bureaucracy to be eliminated and human touch is required for the service organizations like DMCH if it really wants to be a service centre for the people.
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