A study on accessible healthcare in Bangladesh: Challenges to overcome

Rights and requirements of people with disabilities are neglected while planning, designing and building different healthcare facilities, leaving them unable to access the services available, amplifying their vulnerability, and negatively affecting health and wellbeing.

Some of the major barriers to accessing healthcare services for people living with disabilities include:

• Physical barriers related to poor architectural design of health facilities
• Inadequate knowledge, skills and sensitisation of healthcare providers
• Barriers to accessing information and difficulty communicating their needs

The Centre of Excellence for Gender, Sexual and Reproductive Health and Rights at BRAC James P Grant School of Public Health, BRAC University carried out a nationwide research with financial support from the Royal Embassy of the Kingdom of Netherlands. The study documented sexual and reproductive health experiences and service challenges through a survey among 5,000 people with disabilities, covering all 12 types of disabilities as mentioned in Persons with Disabilities Rights and Protection Act 2013. In addition, 51 ethnographic case studies, 45 key informant interviews and 18 health facilities were visited to get an in-depth understanding of these aspects.

The agreement on accessibility

Bangladesh is a signatory body of the United Nations’ Convention on Rights for Persons with Disability, and is therefore obligated to provide equal access to healthcare, including sexual and reproductive health for people with disabilities. Article 25 of the convention states, “Persons with disabilities have the right to access healthcare without discrimination on the basis of disability”. The Sustainable Development Goals also stress on improving access to healthcare infrastructure for all through universal health coverage. 

Bangladesh’s Persons with Disabilities’ Rights and Protection Act 2013 defines ‘accessibility’ aligned with the CRPD, which includes physical accessibility into all premises, and unrestricted access to services, information, and any form of communication.

Bangladesh National Building Code 2008 (BNBC) contains regulations for disability-friendly construction and is working towards ensuring minimum standards for making buildings accessible.

The reality of accessibility: What the study found 

Despite the regulations in place, a majority of the healthcare facilities visited under the study were found to be inaccessible due to implementation challenges.

1. Ramps of inappropriate width (less than 120cm), narrow doorways and corridors (width less than 90cm), make it difficult for wheelchair bound individuals to move around the facilities. There were many cases where doors complied with the accessible width, but lacked proper door-maneuvering clearance because of the arrangement of equipment in a room.
2. Very few healthcare facilities have Braille inscription on the lift buttons and tactile markings in pathways, making it difficult for persons with visual and/or hearing impairment to maneuver.

Only the tertiary healthcare facilities have separate waiting areas with proper seating arrangements, separate billing counters to prioritise persons with disabilities.

1. As people living with disabilities experience personal, social and economic exclusion, many are financially dependent on family members and they hesitate to seek formal healthcare or to spend money on medicines. This hesitation is even greater among women living with disabilities, particularly if they are not financially independent.
2. Certain prejudices exist regarding the sexual needs and sufferings experienced by persons with disabilities. Lack of understanding among healthcare providers on how to support them as well as societal bullying is often a deterrent from seeking timely sexual and reproductive healthcare.
3. There is an absence of effective communication between providers and patients during consultations. A clear gap exists in training for healthcare providers on how to communicate sensitively and effectively with persons living with disabilities as well. Study respondents reported negative attitudes by healthcare providers, lack of gender-sensitive services and insufficient consultation time at the facilities. Although the concept of privacy and confidentiality is crucial in medical ethics, the required presence of family members to act as an interpreter breach these concepts.

Recommendations

Simple initiatives can be taken to mitigate some of these major challenges:

1. Infrastructure must be made inclusive:

• Ensuring ideal ramp (120 cm) with contentious handrail on both sides
• Facilitate easy movement by ensuring ideal pathway, corridors and door size (at least 90 cm)
• Separate waiting area, ticket counter and toilets
• Renovation of lavatories to make accessible water closets

2. Sensitising healthcare providers can encourage people with disabilities to use facilities, as they often feel intimidated and daunted by the prospects of visiting facilities with little to no support.
3. The National Building Code and Schedule 3 of the Disability Rights Act should be immediately followed to ensure all healthcare facilities are accessible for persons with disabilities.

Finally, design and construction of health facilities and other basic services need to be brought into discussion in engagement with people living with disabilities, across gender, age and diverse types of disability. A coordinated approach from relevant ministries, stakeholders and disability experts can fill some of these key gaps to achieve government’s priority areas. In consequence, we will be on track to achieving the Sustainable Development Goal of building a participatory and inclusive society where people with disabilities can live with dignity.

Adrita Kaiser is an assistant coordinator, BRAC James P Grant School of Public Health. Nigar Sultana Zoha is an intern, BRAC James P Grant School of Public Health. The authors would like to thank Dr Tanvir Hasan, associate professor and principal investigator of the research project and Dr Sabina Faiz Rashid, dean and professor of BRAC James P Grant School of Public Health, for their valuable support.