Urban Bangladesh lacks a well-functioning primary healthcare system. Currently, the Ministry of Health and Family Welfare, through its Directorate General of Health Services (DGHS), operates 35 urban dispensaries nationwide. Additionally, the Local Government Division runs a public-private partnership (PPP) model under the Urban Primary Health Care Services Delivery Project (UPHCP) in selected areas across the country.

The need for a well-functioning and structured primary healthcare system with nationwide coverage is paramount. According to the World Health Organization (WHO), primary care can meet around 80-90 percent of a person's lifetime health needs. If unaddressed, the problems due to inadequate primary healthcare in urban areas are only likely to worsen, exacerbated by the ever-increasing urban population and the consequent increased demand for healthcare.

Consider the situation in Dhaka city. People come from all over the country to the hospitals here, which are often overburdened with patients and operate at overcapacity, struggling to provide quality care. Patients frequently face difficulties, such as limited accommodation, extended waiting times, and transportation hurdles due to late-night commutes.

One of the major problems in the current healthcare system is the lack of an effective referral system and inadequate gatekeeping at tertiary care facilities. Barring emergency care and referrals from lower-tier health facilities, patients should not visit hospitals as they are meant to provide tertiary-level care. However, due to the lack of primary healthcare centres—and perhaps also due to the lack of awareness—patients are often left with no choice but to visit tertiary-level hospitals, further burdening these facilities. Patients should have primary care centres close to their homes. The community clinic model in rural areas aims for one clinic for every 6,000 people, trying to mitigate pressure across these facilities.

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Urban health-seeking patterns present a more complex scenario. While hospitals remain crowded with patients, data from the Household Income and Expenditure Surveys (HIES) shows that pharmacies are the most frequented healthcare providers. Findings of the 2010, 2016, and 2022 HIES all show that pharmacies consistently emerge as the preferred choice, with 53 percent of healthcare seekers choosing them in 2022, whereas, 11 percent preferred visiting qualified doctors' chambers, the second-most-used option.

So why are pharmacies so frequently preferred? Firstly, pharmacies are easily accessible and closer to people's residences, as there are 200,000 registered and over 100,000 unregistered pharmacies across the country. Secondly, the average waiting time to access care at pharmacies is 8.22 minutes in urban areas, significantly shorter than the average of 17.51 minutes at formal healthcare facilities, and 48 minutes at government hospitals, according to the 2022 HIES data.

However, pharmacies do not have medically trained professionals who are licensed to diagnose patients. Nor are they pharmacists, as they do not hold a formal degree in pharmacy.

To standardise the retail pharmacy sector, the Directorate General of Drug Administration (DGDA) launched a novel concept in 2016 called model pharmacies, consisting of accredited pharmacies that comply with DGDA-recommended and health ministry-approved standards. Requirements include 300 sq-ft of floor space, an air-conditioning system, a pharmacy-grade refrigerator, a graduate pharmacist, etc.

While the initiative sounded very promising, media reports revealed that many of the model pharmacies were involved in various irregularities, such as non-compliance with the DGDA guidelines for drug sales and the absence of registered pharmacists. It has also been found that pharmacies without the DGDA approval use the logo of model pharmacy at their shops and mislead consumers. The DGDA lacks adequate manpower to properly monitor these irregularities.

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In the absence of a well-functioning primary healthcare system, the proposition is to leverage the existing pharmacies and transform them into comprehensive points of care for a primary healthcare system. Despite the current shortcomings of the model pharmacies, lessons can be learnt from a thorough evaluation. If the DGDA collaborates with other wings of the health ministry and the local government bodies in formulating a comprehensive policy and guidelines, along with strict monitoring and regulation, there is a potential to create a robust primary care system.

Converting even 10 percent of the 200,000 registered pharmacies into comprehensive primary care centres could result in 20,000 such facilities in urban areas, which would result in a better ratio than one clinic per 6,000 people ratio in rural areas. As pharmacies are already the most popular choice for seeking treatment, transforming them would require minimal resources compared to launching new dedicated primary care centres.

Solving the primary care gap can go a long way in ensuring health equity for all citizens of the country and the country's ambition of attaining Universal Health Coverage status by 2032.

Mohammad Ihtesham Hassan is research associate at the Power and Participation Research Centre (PPRC).

Views expressed in this article are the author's own.

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