MEDICAL UNIVERSITIES AND MEDICAL COLLEGES IN BANGLADESH:

PROBLEMS AND PROSPECTS

Author affiliations: Dr Tanzina Islam, graduated from Mymensingh Medical College, Mymensingh, Dhaka, Bangladesh and serving as a Senior Finance Controller, Bangladesh Navy, Mirpur 14.  Email address: drtanzina @yahoo.com

Publication information: This article published in Bangladesh RAOWA journal Vol 2 issue 2 on December 2022

Abstract

Medical education is higher or tertiary education in medical universities and medical colleges.This research is made on existing medical education in Bangladesh following the mixed method of qualitative and quantitative methods. Primary and secondary data are collected through interviews, visits and surveys in various medical colleges, affiliating universities and regulating bodies. There exist problems in medical education, and prospects too are available to ensure quality with increase in quantity. There are 5 medical universities and 115 medical colleges in Bangladesh. All 5 medical universities are public under Universities Grants Commission (UGC). 37 public and 72 private medical colleges are under Ministry of Health and Family Welfare (MoHFW). 1 public and 5 private medical colleges are under Ministry of Defence (MoD). 5-year medical graduation is called bachelor of medicine and bachelor of surgery (MBBS). Post-graduations are master of surgery (MS) and doctor of medicine (MD). Bangladesh Medical and Dental Council (BMDC) acts as the central regulatory body for quality medical education deciding on the quantity i.e., number of students each year in available facilities. Enrollments each year in each medical college vary from 50 to 230 basing on respective medical college’s capacity. Total in year public medical colleges offer 4350, private medical colleges 6040 and armed forces medical colleges 400. All medical colleges are affiliated to one of the medical universities or to University of Dhaka. Recommendations are made to have qualitative and quantitative improvements in medical universities and medical colleges.

Keywords: Medical College, Medical University, Health Care, Medical Education, Research, Development.

1.0 Introduction

Medical education at higher or tertiary is very important for a healthy nation. Our Constitution mentioned in Article 15 (a): Ensure basic necessities of life (including medical care) to its citizens and in Article 18 (1): Raise the level of nutritional status and improve public health. Every adult is primarily responsible for her or his health care though children and elder-lies may depend on others. There remain familial, social and state responsibilities in health care beside individual responsibility of prevention and cure. 5 medical universities and 115 medical colleges show state’s initiative. World Health Organization (WHO) defines health, “Health is a state of complete physical, mental and social well-being and not mere the absence of disease or infirmity.” Health has a central position in the UN agenda through Sustainable Development Goals - SDG 3: Good Health and Well-being. It is closely linked to over a dozen targets in other goals related to public health, equal access to treatments, non-communicable diseases, health care education etc. 

WHO in 2001 defined ‘allopathic medicine’ as "the broad category of medical practice that is sometimes called western medicine, biomedicine, evidence-based medicine, or modern medicine." Preventive health care deals with hygiene, sanitation, nutrition etc whereas curative health care deals with curing diseases and deformities through medicine and surgery by bachelor of medicine and bachelor of surgery (MBBS) and post graduate doctors. Greek Hippocrates (460-370 BC) is known as the ‘Father of Medicine’ who revolutionized ancient Greek medicine, establishing it as a discipline distinct from other fields with which it had traditionally been associated: theurgy and philosophy. Besides allopathy, Samuel Hahnemann (1755-1843), a German physician, introduced the pseudo-scientific system of alternative medicine which is now called ‘homeopathic medicine’. ‘Ayurvedic medicine’ evolved over more than two millennia in Indian Subcontinent that includes yoga, massage with medical oils, laxatives, special diets, herbal medicines, meditation etc.

Besides MBBS, bachelor of dental surgery (BDS) is obtained from a dental college, a homeopathic college provides bachelor of homeopathic medicine and surgery (BHMS), an ayurvedic college gives bachelor of ayurvedic medicine and surgery (BAMS), and a unani college provides bachelor of Unani medicine and surgery (BUMS). There are 37 public medical colleges and 72 private medical colleges under jurisdiction of Ministry of Health and Family Welfare (MoHFW). 1 armed forces medical college (AFMC) and 5 army medical colleges (AMCs) are under jurisdiction of Ministry of Defense (MoD). There are 10 public dental colleges and 26 private dental colleges in Bangladesh. All these medical and dental colleges are affiliated to 5 public medical universities and University of Dhaka in their respective areas. Bangladesh Medical and Dental Council (BMDC) regulates and ensures with other regulatory bodies the quality of medical education and gradual development following the standards and curricula of international especially the commonwealth countries.

2.0  Literature Review

Remaining within the Constitution of Bangladesh 1972 framework, National Health Policy (NHP) accepted the health definition of WHO. The NHP has 19 goals and objectives, 16 policy principles and 39 strategies (MoHFW, 2011). Medical education in Bangladesh follows NHP and conforms with the international systems.  It is subject-didactic evidence-based education instead of opinion-based at levels. The levels are: entry-level, graduate and post graduate level through residency and fellowship, and continuing medical education during professional practice (Wilson, 2013). Medical students need to experience health care practices during their studies which facility is provided through own medical college hospitals or 500 bed capacities district hospitals. Medical Education and Family Welfare Division notes that evidences-based learning become diverse and effective as better laboratory and clinical facilities are made available to medical students for in-patient and out-patient practices (MoHFW, 2011).

Medical education systems in Bangladesh progress slowly and suffers from lack of financial support, sociocultural malpractices, and nonavailability of qualified and dedicated health care professionals and teachers. Insufficient pre-medical education and inadequate preparation by students lead to diversified teaching-learning problems in medical colleges and universities (Begum, 2013). The MBBS degree is a 5-year programme followed by 1-year compulsory logbook-based internship. The medium of instruction in medical colleges and universities is English. Bangladesh implemented a community oriented and competency-based medical curriculum since 1988 with an aim to produce need-based doctors to provide quality health care to the community. The findings of a study Medical Negligence: Bangladesh Perspective (Hossaini, 2019) highlighted the need for major review of medical curriculum toward more effective community-orientation and restructuring of evidence-based teaching to ensure adequate exposure of medical students to health care problems. Appropriate career motivation and counseling is necessary to attract appropriate competent students in medical studies (Wilson, 2013).

3.0 Research Objective

Primary objective of this research paper is to evaluate and measure the medical education problems and prospects in Bangladesh medical universities and medical colleges. Secondary objective is to find out the scope of improvement and develop both qualitatively and quantitatively the medical education at medical universities and medical colleges in Bangladesh.

4.0 Methodology

This research adopted an eclectic approach in mixing and blending both qualitative and quantitative methods. Physical visits, interviews, surveys and focused group discussion (FGD) were conducted in exploring primary and secondary data. Interviews were taken of doctors and patients, medical and dental faculty members, medical assistants and nurses, medical university and colleges students, and administrators for collecting primary data. FGD with guardians of different income group, my experience as a medical graduate alumni, and formal and informal meetings at Retired Armed Forces Officers’ Welfare Association (RAOWA) ladies and children club assisted to find out financial and administrative aspects of medical education and public psyche on medical education prospects in Bangladesh. Literature review of books, scholarly journals, articles, internet, social media, case studies and related other sources were used for collecting secondary data. Data analysis was done through statistical procedures and mathematical formulas and confirming those by triangulation and percolation.

5.0 Discussions and Findings

5.1 Practices of Allopathy and Its Education over Homeopathy and Ayurvedic Medicine

Surveys showed that conventional MBBS, MS, MD, MPhil and PhD study though costly are preferred to other medical degrees like BHMS, BAMS, BUMS etc. The word ‘allopathic’ comes from Greek allos - meaning opposite, and pathos - meaning to suffer. Allopathy is a system in which medical doctors and other health care professionals such as nurses, pharmacists, and therapists treat symptoms and diseases using drugs, radio therapy, physio therapy or surgery. Biomedicine, conventional medicine, mainstream medicine, orthodox medicine, and western medicine are synonyms. Homeopathy is a pseudoscientific system of alternative medicine based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself. Doctrine is called similia similibus curentur, or ‘like cures like’ which scientific and medical communities term as placebo, quackery and fraud. Sanskrit ayus means life or longevity, and veda is knowledge; ayurveda as knowledge of longevity. The main classical ayurveda texts begin with accounts of the transmission of medical knowledge from the gods to sages, and then to human physicians. The Sushruta Samhita (Sushruta's Compendium) reveals the work as the teachings of Dhanvantari, god of ayurveda, god Vishnu’s incarnation as King Divodasa of Varanasi. Ayurveda practitioners had developed various medicinal preparations and surgical procedures from at least the beginning of the common era (CE).

Greeks believed that medicine and healing are associated with god Apollo, mediated through his son Asclepius. Asclepius Rod, a snake-entwined staff is an accepted medical symbol. Asclepius had 5 daughters performing Apollo's art: Hygieia - health, cleanliness, and sanitation; Panacea - universal remedy; Iaso - recuperation from illness; Aceso - the healing process; and Aglaia – beauty and splendor. Coincidentally Greek philosopher Hippocrates (460-370 BC) became the Father of Medicine. The Hellenistic origin of four humours: phlegm (balgham), blood (dam), yellow bile (ṣafra) and black bile (sauda) are seen in unani. Unani medicine is Greco-Roman origin Persian-Arabic traditional medicine as practiced in South and Central Asia with modifications from Sino-Indian influences. Bureau of Health Education (BHE), Institute of Public Health (IPH) and such others under MoHFW have been trying to make aware the citizens for good health and students to study medicine. Enrollments each year in a medical college vary from 50 to 230 basing on medical college’s capacity. Total in a year 37 public medical colleges offer 4350 seats, 72 private medical colleges 6040, and 6 armed forces medical colleges 400.

Figure 1: Asclepius (Apollo’s Son) with Serpent entwined Rod   

5.2  Medical Universities and Colleges Legislative Acts/Ordinances/Codes

5 public medical universities are established with separate parliamentary legislation of each: Bangabandhu Sheikh Mujib Medical University (BSMMU), Chittagong Medical University, Rajshahi Medical University, Bangamata Sheikh Fazilatunnesa Mujib Medical University Sylhet and Sheikh Hasina Medical University Khulna.  Allopathic medicine practices are legalized and elaborated by the Medical and Dental Council Act 2010, the Medical Practice and Private Clinics and Laboratories (Regulation) Ordinance 1982, and the Drugs (Control) Ordinance 1982. Medical practice includes surgical operation, conduction of labour, pathological or radiological examination and any other medical examination or service with appropriate license and government permission.  Public AFMC and 5 private AMCs with total 400 military and civilian seats each entry are affiliated to Bangladesh University of Professionals (BUP) under BUP Act 2009. Additional jurisdiction is of MoD for these 6 medical colleges beside MoHFW. There are 10 public dental colleges with 650 seats and 26 private dental colleges with 1300 seats for each BDS entry in a year.

The 37 public medical colleges with 4350 seats and 72 private medical colleges (with 6040 seats every year) are affiliated to one of the 5 medical universities or University of Dhaka. Legal control is under jurisdiction of MoHFW. The Bangladesh Nursing and Midwifery Council (BNMC) is the regulatory body formed with the Bangladesh Nursing and Midwifery Council Act 2016. It is the focal point from where all nursing supports are managed. This includes all involved in nursing and midwifery education and practices. Regulation of Nursing education and practices is by Bangladesh Nursing and Midwifery Council. It works closely with the Directorate of Nursing Services of MoHFW. Nursing and midwifery education is very important in health care education especially to complement medical education in medical universities and colleges. There are 131 public nursing and midwifery colleges and institutes, and 720 are in private sector. Military runs 7 such nursing colleges and institutes in Bangladesh. The degrees are MSc, BSc, and Diploma in Nursing and Midwifery. Seats each year in public are 6700, in private 34105, and in military 260 making a total of 41065.

Homoeopath means a practitioner of Homoeopathic system of medicine and includes a practitioner of biochemic system of medicine founded by Dr Schuessler (1821-1898). Homoeopathy means the system of medicine founded by Dr Samuel Hahnemann. Homoeopathic Practitioners Ordinance 1983, and Regulation 1985 made Bangladesh Homeopathic Board (BHB) functional as an autonomous body under MoHFW. BHB has been thriving for effective homeopathic education, requisite patient care and relevant research activity. BHB imparts both BHMS (bachelor of homeopathic medicine and surgery) and DHMS (diploma of homeopathic medicine and surgery). There are 62 homeopathic colleges in Bangladesh: 22 in Dhaka, 11 in Chattogram, 1 in Sylhet, 7 in Rajshahi, 7 in Rangpur, 8 in Khulna, and 7 in Barishal divisions. WHO suggests for pharmaco-vigilance activities by member states on the traditional medicine quackery.

Unani medicine is the amalgamation of Greco-Roman and Arab-Persian medicinal practices influenced and shaped by Sino-Indian traditional medicines. Ionia (in Turkey, Ionian Sea in Greece, and Ionian Peninsula in Italy) may have etymological relation with the word ‘unani’.  Ayurvedic system of medicine including the Siddha is thought to be from Hindu gods to sages to human physicians based on indigenous herbs and curing materials. Board of Unani and Ayurvedic Systems of Medicine was established at Dhaka by the Bangladesh Unani and Ayurvedic Practitioners Ordinance 1983. Tabib or Hakim means a practitioner of unani system of medicine. Vaid or Kabiraj means a practitioner of ayurvedic system of medicine. There are 16 unani colleges and 10 ayurvedic colleges in Bangladesh. BUMS (bachelor of unani medicine and surgery), BAMS (bachelor of ayurvedic medicine and surgery), DUMS (diploma of unani medicine and surgery) and DAMS (diploma of ayurvedic medicine and surgery) are provided from these colleges. Government Unani and Ayurvedic Medical College is affiliated to University of Dhaka. Hamdard, a private university provides unani and ayurvedic education.

5.3  Research and Development Activities in Medical Education

Bangladesh College of Physicians and Surgeons (BCPS) provides fellowship and membership through extensive research and development work. This is besides 5 medical universities: Bangabandhu Sheikh Mujib Medical University (BSMMU), Chattogram Medical University, Rajshahi Medical University, Bangamata Sheikh Fazilatunnesa Mujib Medical University Sylhet, and Sheikh Hasina Medical University Khulna. Medical university will be set up in each division one soon. BSMMU offers MS, MD, MPhil and PhD only; not offering MBBS or BDS which are affiliated to University of Dhaka. BSMMU was renaming of the Institute of Postgraduate Medicine and Research (IPGMR), established in 1965. From 2010, many of the medical and public health colleges and institutes became affiliated to BSMMU: Bangladesh Institute of Health Sciences (BIHS); Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM); National Institute of Cardio Vascular Diseases (NICVD), National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) and others. Bangladesh Medical Research Council (BMRC), established in 1972 by order of the President as an Autonomous Body under MoHFW.

BMRC objectives, rules and regulations were formulated by resolution of the MoHFW in 1974 and 1976. As per resolution of the Government, BMRC is the focal point for health and medical research. The objectives of BMRC are to identify problems and issues relating to medical and health sciences and to determine priority areas in research on the basis of health care and medical education needs, goals, policies and objectives. BMRC has developed a national retrieval system containing more than 5000 abstracts of scientific articles published in different Bangladeshi Journals. The retrieval system is updated regularly. Database on reproductive health and education research with retrieval capacity is available in the BMRC. It provides medline-literature search service (M-LSS) to the students and health care practitioners engaged in medical and health research. BMRC has abstracts of all scientific articles (indexed in Index Medicus) from 1966 to till date. BMRC also has access to the WHO reproductive health library. They also provide online-literature search service (O-LSS) to the learners engaged in medical research.

Medical education is evidence-based and practical-oriented for which continuous research and development need huge expenditures. Many countries in the world cannot afford to run standard and quality medical colleges providing lot of subsidies and subventions. Expenses in 37 public medical colleges in 5 years MBBS are mostly borne by government for which meritorious students compete very hard to get entry there.  In average a student of MBBS need to pay around Tk 40 lac in her/his 5 year study in any of the 72 private medical colleges facing tough competition in entrance examinations. Similar expenditure scenario and competition in 6 military run medical colleges with limited reserved seats kept for defence services children and wards in special quota. Still Bangladesh medical colleges are thought to be of quality, monetarily cheaper and economic compared to other countries costly medical education. Quite a good number of foreign students have been choosing Bangladesh public and private medical colleges for their MBBS degree since long. Bhutan prime minister Dr Lotay Tshering and foreign minister Dr Tandi Dorji studied MBBS at Mymensingh Medical College and FCPS at BCPS (1991 to 1999) for which they are proud of like many.

6.0 Conclusion

Medical education is at higher or tertiary level conducted in medical universities and medical colleges for good national health. Health care and awareness is primarily the responsibility of every individual. One needs to concentrate on preventive health care that BHE, IPH etc under MoHFW have been trying their best to make people understand, “Prevention is less costly and always better than a cure”. MoHFW is supporting medical education for preventive, promotive and curative health care activities through training, education, research, publication, laboratory, production of biologicals, and quality control in the field of people’s health. WHO defined health, “Health is a state of complete physical, mental and social well-being and not mere the absence of disease or infirmity.” Health has a central position in the UN agenda through 17 Sustainable Development Goals (SDGs), SDG 3 is on Good Health and Well-being. It is closely linked to over a dozen targets in other goals related to public health, equal access to treatments, non-communicable diseases, health care and medical education. Bangladesh Constitution 1972 mentioned in Article 15 (a): Ensure basic necessities of life (including medical care) to its citizens and in Article 18 (1): Raise the level of nutritional status and improve public health.

Medical education in 5 public medical universities and 115 medical colleges: 37 public with 4350 MBBS entry each year and 72 private with 6040 entry have both problems and prospects. All public and private medical colleges are affiliated either to one of the 5 public medical universities or to University of Dhaka and work under jurisdiction of Ministry of Health and Family Welfare (MoHFW). 1 public armed forces medical college (AFMC) and 5 private army medical colleges (AMCs) with 400 MBBS entry each year function under jurisdiction of Ministry of Defence (MoD) remaining affiliated to Bangladesh University of Professionals (BUP). There are 10 public dental colleges with 650 BDS seats and 26 private with 1300 seats for each entry in a year. There are 131 public nursing and midwifery colleges and institutes, and 720 such colleges and institutes in private sector. Military runs 7 nursing colleges and institutes. There are 62 homeopathic colleges in Bangladesh: 22 in Dhaka, 11 in Chattogram, 1 in Sylhet, 7 in Rajshahi, 7 in Rangpur, 8 in Khulna, and 7 in Barishal divisions. There are 16 unani colleges and 10 ayurvedic colleges in Bangladesh providing bachelor and diploma degrees under control of Board of Unani and Ayurvedic Systems of Medicine. Affiliation of Government Unani and Ayurvedic Medical College for BUMS and BAMS is with University of Dhaka. Hamdard University, a private university provides BUMS and BAMS under University Grants Commission (UGC).

Medical education of allopathy is more scientific and popular compared to pseudoscience of alternative or traditional medicine. Allopathy is called biomedicine, conventional medicine, mainstream medicine, evidence-based medicine and western medicine. The word allopathic comes from the Greek allos - meaning opposite, and pathos - meaning to suffer. Homeopathy is a pseudoscientific system of alternative medicine based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself. Homeopathy doctrine is called similia similibus curentur, or ‘like cures like’ which scientific and medical communities term as placebo, quackery and fraud. Unani medicine is combination of Greco-Roman, Persian-Arabic and Sino-Indian traditional medicine as practiced in South and Central Asia. Ayurveda as knowledge of longevity as Sanskrit ayus means life or longevity, and veda is knowledge. The main classical ayurveda texts begin with accounts of the transmission of medical knowledge from the gods to sages, and then to human physicians. Greeks worshiped god Apollo and his son Asclepius for good health. Coincidentally Greek philosopher Hippocrates (460-370 BC) became the Father of Medicine and his one writing was accepted as medical ‘Oath’. Medical education in 37 public medical colleges are highly subsidized for which meritorious students compete a lot for entry there. In 72 private medical colleges every student needs to pay around Tk 40 lac for 5 year MBBS study where entry is tough too facing competitive selection examinations. Similar competition and expenditure scenario exist in 6 military medical colleges. Separate selection exams are conducted for them keeping few reserved seats for armed forces children and wards in special quota.   

Figure 2: Hippocratic Oath in Medical World

7.0 Recommendation

Medical education in Bangladesh needs special attention as it is the most densely populated country in the world with the 8^th largest population. Hence, concentration should be more on the quantitative aspects keeping qualitative standards and compliance for large population’s good public health and rising gradually in the UNDP’s human development index (HDI) ladder.

7.1 Medical education in medical universities and medical colleges are curative health care dominated; emphasis should be on preventive health care strategies which are less costly and of lesser efforts. Follow of Hippocratic Oath will enable physicians and surgeons to be more patients oriented and people friendly. 

7.2 Comprehensive medical education needs to be planned and executed combining modern and western allopathic medical educations with traditional homeopathic, unani and ayurvedic under one umbrella of MoHFW. Quantity and quality compliance through medical universities affiliations will enhance SDG 3 by 2030 avoiding quackery.

7.3 Adding behavioural and social science in medical education curricula at medical universities and colleges will improve problem-based learning to customize health care adopting and adapting contents in Bangladeshi contexts. Humanity, patriotism and ethical motivation of teachers, students, guardians and all others will show Bangladesh the way.

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