The hospital is her home. She toils away serving patients and sometimes nurses and doctors on request, eats the leftovers of patients and sleeps wherever she finds space to lie down inside the hospital.

Still, the woman, who identifies herself only as Aleya, is nobody in Dhaka Medical College Hospital. The authority does not recognise her as an employee even though she has been working there for nearly 20 years. 

Aleya, who seems to be in her late 40's, is one among hundreds who have become part of the hospital management system over the years. The hospital needs them as much as they need the shelter and protection they get from the hospital.

The backdrop to the situation at the DMCH is an acute shortage of manpower, especially third and fourth-grade employees.

The hospital has not been able to hire since 2013. Recruitment for the posts had been done under a policy formulated in 1985 by the regime of Lt Gen Hussain Muhammad Ershad. 

But things became complex as the Supreme Court declared illegal the policies and orders made by Ershad between March 24, 1982, and November 10, 1986.

Due to the court order, the promotion of existing employees has also remained suspended.

TRAPPED IN THE PAST

The government is yet to replace the policy in question, and all public hospitals, including the DMCH, are affected because of this as an increasing number of posts fall vacant every year through retirement and deaths.

To learn about the situation outside the capital, The Daily Star looked into two other medical college hospitals, two district hospitals and two upazila health complexes and got a similar impression. 

A total of 46,000 posts of support staff are vacant at public hospitals across the country, estimated in accordance with the organograms drawn up during the founding of the hospitals in the 60's, 70's and in some cases updated years after the Liberation War.

The capacity of the hospitals has been increased on several occasions over the decades to accommodate more patients, but the number of posts of doctors, nurses and other staff remained the same.

“So, the quality of health services is in a mess,” says Brig Gen Mizanur Rahman, director of the DMCH.

He elaborates the case of his hospital that had 800 beds in 1981. The hospital's capacity has been increased three times, to 2,600 in the latest move in 2013. The organogram has never been updated.

But a proposal was put forward to create 2,500 new posts, including those of third- and fourth-grade support staff, when the hospital had an arrangement for 1,400 patients.

But the authorities only approved 803 new posts after the latest expansion.

The hospital that now serves at least 1,000 more patients every day beyond its capacity requires much more staff than the number of posts it has in its organogram to even ensure moderate quality services, Brig Gen Mizanur says.

What could happen in a situation when many of the sanctioned posts remain vacant? Doctors, nurses, ward boys, cleaners -- all struggle to keep the hospital running. And they are forced to get help from anywhere they can.

THE UNAUTHORISED, ESSENTIAL

 Zillur, one of the six ward masters of the DMCH, says nearly 120 fourth-grade employees -- ward boys, hospital attendants and sweepers -- work under his supervision in 20 wards, but the manpower is far less than what is necessary to provide services round the clock in three shifts.

 Some 20-22 “outside staff” join them, relieving the work pressure to some extent, he says, adding that he prepares the duty roster keeping in mind how the system can function at its best, including the outsiders.

 But then a question arises as to why those outsiders work without any pay.

Pushing a wheelchair through the labyrinth of corridors, Aleya, who is blind in her left eye, says she is from a poor family and has long been left by her husband.

In exchange for her labour, she is allowed to stay in the hospital.

As she talks on her way to the women's psychiatric department, she offers serious patients, leaning on others' shoulders, a wheelchair ride to their destinations -- for Tk 20 to Tk 50 depending on what they can afford.

This is how she gets some cash for rainy days.

People like Aleya, who are available to patients for tips but are not on the government's payroll, help ease the hospital's huge workload.

“Without them, the service quality will deteriorate further…. So it is like having an alternative arrangement,” the DMCH director says.

But not all public hospitals have this “alternative arrangement”.

The 1,250-bed Rajshahi Medical College Hospital is outsourcing and it hires employees on daily basis. They get nominal pay, far less than what government staffers get, and are largely dependent on tips.

The 1,000-bed Barisal Sher-e-Bangla Medical College Hospital has 120 support staff employed through outsourcing. They get a salary of Tk 5,550 a month.

Similar alternative systems are in place at Tangail and Nilphamari district hospitals.

SKILLED BUT UNRECOGNISED

Some of the unauthorised staffers at the public hospitals have been working for as many as 20 years or more. They have gained skills required to provide health services.

Photo: Palash Khan

Abdul Khaleq, president of the DMCH fourth-grade workers union, citing an example says the 300-bed burn unit itself has 60-70 such staffers who have been working since the inception of the unit 16-17 years ago.

“I know about them because the hospital authority itself engaged them promising that they would become permanent employees one day.

“They have gained skills on the job. Now without them, the unit cannot function at all,” he says.

ANOMALIES

However, when this flawed system of unauthorised employees working for years goes on, it creates scope for anomalies, irresponsible behaviour and poor accountability.

Twenty-six-year-old Manik, who has been working in a ward of the DMCH medicine department, says one of the two ward boys designated to work in the ward does not work at all.

Some of the hospital's employees are unhappy as their promotion has remained suspended. To reduce the tension, they have been given bigger responsibilities, but that does not solve the problem fully since they are not getting better pay, said sources at the hospital administration. 

In Barisal hospital, at least 10-15 fourth-grade employees get their work done by outsiders for money, apparently because they are not physically fit anymore to do laborious job.

Apart from all these factors, Abdul Khaleq says the accountability of government employee can be ensured, but that of the outsiders cannot.

To discipline the unauthorised workers, the DMCH authority warned them against malpractices and charging patients highly for services, said several staff members. On a number of occasions, people were handed over to police.

The “alternative arrangement” helps keep the hospital running, but services cannot be improved without more staff. This is the reason the DMCH proposed outsourcing support staff.

Khaleq says the workers' union is opposed to this recruitment procedure since contractors would be appointing people at their will and the outsourced employees do not get retirement benefits.

Union president Khaleq, who is to retire in 2018, adds that hospital employees' children can apply for jobs under a quota if the government directly hire employees. 

However, the actual concern is that those who have been working for years, in cases decades, could possibly be not recruited by the winning bidder, says DMCH Director Mizanur. And most of the unauthorised staffers are relatives of regular employees as they are the ones who helped these “so-called staff” find work at the hospital.    

So, the hospital's administration has recently convinced the union members saying that those working for years and have no complaints against them would be considered for official recruitment.

As for the recruitment policy for support staff, Health and Family Welfare Minister Mohammad Nasim says he has been working on the formulation of a new policy for the last one year and expects that the whole process will be completed in a month or two.

The law ministry has been engaged to untie the legal tangles.

Regarding modification to the organograms, the minister says an effort is on to bring changes needed but that may take a couple of years.

While any change to overhaul the public health sector seems distant, Aleya keeps doing her job, serving patients for peanuts.

When asked what she will do on a July afternoon at the hospital, she says she will take a bath, pray and have lunch (with leftovers of patients). Asked where she would sleep at night, a surprised Aleya points to long corridors of the hospital.

Our correspondents in Rajshahi, Barisal, Tangail and Nilphamari contributed to this report.