|
 
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| REVIEW ARTICLE |
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| Year : 2019 | Volume
: 2
| Issue : 4 | Page : 168-177 |
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Disability and rehabilitation medicine in Bangladesh: Current scenario and future perspectives
Taslim Uddin1, Mohammad T Islam1, Farooq A Rathore2, Colleen O’Connell3
1 Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
2 Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan
3 Stan Cassidy Centre for Rehabilitation, Dalhousie University Faculty of Medicine, Fredericton, Canada
| Date of Submission | 19-Jul-2019 |
| Date of Decision | 29-Aug-2019 |
| Date of Acceptance | 20-Sep-2019 |
| Date of Web Publication | 13-Dec-2019 |
Correspondence Address:
Dr. Farooq A Rathore
Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi
Pakistan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jisprm.jisprm_61_19
Physical medicine and rehabilitation (PMR) is evolving in low- to middle-income countries. Although established as a separate specialty in Bangladesh 40 years ago, there has been no formal documentation of the history and current state of PMR, or associated disability issues in Bangladesh. The aim of this review is to provide a brief overview of the health-care system in Bangladesh, to discuss the available disability statistics, legislation for persons with disability (PWD), and current system(s) of disability management in the country. The evolution of PMR is presented along with an exploration of future perspectives. Data sources included an online literature search (English language only; 1970–2018) with predefined keywords. Official government websites were examined for disability-related statistics, and informal interviews with Bangladeshi government officials and rehabilitation professionals provided further insights. The reported disability prevalence in Bangladesh varies widely from 5.6% to 16.2%. Currently, there are 130 physiatrists, and over 1400 physiotherapists, 190 occupational therapists, and 200 speech and language therapists. A developing economy, illiteracy, maldistributions of wealth, and a rising prevalence of chronic diseases add to the burden of the existing disability. Legislations have been passed with an aim to protect the rights and dignity of PWD, but there are major barriers in implementing the acts. Social stigmatization of PWD remains largely unaddressed, with low rates of community reintegration. PWD also face mobility barriers and accessibility issues. PMR and other rehabilitation services are improving, but disability management is largely considered a social issue rather than a medical problem. There is a need to involve all stakeholders in disability management to strengthen medical rehabilitation and improve service delivery, while advocating for the rights of PWD.
Keywords: Demographics, disability rights, history, legislation, occupational therapy, persons with disability, physiotherapy, rehabilitation sciences
How to cite this article:
Uddin T, Islam MT, Rathore FA, O’Connell C. Disability and rehabilitation medicine in Bangladesh: Current scenario and future perspectives. J Int Soc Phys Rehabil Med 2019;2:168-77 |
How to cite this URL:
Uddin T, Islam MT, Rathore FA, O’Connell C. Disability and rehabilitation medicine in Bangladesh: Current scenario and future perspectives. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2023 Mar 27];2:168-77. Available from: https://www.jisprm.org/text.asp?2019/2/4/168/272897 |
| Introduction | |  |
According to the 2011 World Report on Disability by the World Health Organization (WHO) and the World Bank (WB), 80% of persons with disability (PWD) worldwide reside in low- and low- to middle-income countries (LMICs).[1] Despite this disproportionate burden, the mapping of disability and awareness of rehabilitation services in this majority part of the world remains low. Bangladesh is a LMIC in South Asia. It is a developing economy with a large population and an underdeveloped health-care system [Table 1].
In Bangladesh, like most developing countries, disability management and medical rehabilitation are not health priorities, and the current focus is on acute and basic primary health-care services. Reliable and accurate disability statistics are not available, and the provision of high-quality comprehensive rehabilitation services remains a challenge in Bangladesh. Disability statistics, rehabilitation needs of PWD, and the situational analysis of PMR have been reported from developing countries including China,[2] India,[3] Pakistan,[4] Ghana,[5] Rwanda,[6] and Mauritius.[7] We were unable to identify any similar studies or reports for Bangladesh in the recent English biomedical literature. The aim of this review is to provide a brief overview of the health-care system in Bangladesh, to discuss the available disability statistics, legislation for PWD, current system of disability management in the country, and the evolution of PMR. This information then forms the foundation from which we propose a roadmap for the future development of PMR and disability management services in the country.
| Methods | | |
We modified and used the data collection methodology previously described by Rathore et al.,[4] which included an online literature search and exploration of official websites for data and figures. The search was complemented by discussion with senior rehabilitation professionals and informal interviews with government officials working in disability and social welfare sectors.
The online literature search was conducted between March 2017 and January 2018 using Medline, Google Scholar, and Bangladesh Journals OnLine (BanglaJOL),[8] restricted to English language, 1971 – January 2018. The keywords included (but were not limited to) Bangladesh, South Asia, developing countries, disability, disabilities, causes, statistics, neurorehabilitation, persons with disability (PWD), medical rehabilitation, physiotherapy, occupational therapy, speech and language therapy, and orthotics. Boolean Logic was employed to generate different combinations of search strings.
The lead author (TU) conducted informal interviews with selected senior officials from the Bangladesh Ministry of Health and Family Welfare, Ministry of Social Welfare (MOSW) and Directorate General of Health Services (DGHSs). Interviews were conducted face to face and by telephone. The interviews mainly consisted of open-ended questions focused on the types of disability, disability-related legislation and budget issues, and rehabilitation supports. Senior Bangladeshi PMR physicians and allied health-care professionals from physiotherapy, occupational therapy, and speech and language therapy were approached to solicit further insights and to fill information gaps.
Further, statistical data were extracted from the websites and online reports of the WHO, United Nations (UN), the WB,[9] CIA World Fact Book,[10] Bangladesh Bureau of Statistics,[11] and DGHSs.[12] Proceedings of the annual scientific convention of the Bangladesh Association of Physical Medicine and Rehabilitation (BAPMR),[13] Bangladesh College of Physicians and Surgeons (BCPS),[14] reports of Center for the Rehabilitation of the Paralyzed (CRP)[15] were also reviewed for relevant information and statistics.
| Results | | |
Country demographics and health-care indicators
Bangladesh (previously East Pakistan) is situated in South East Asia. It gained independence in 1971 following a 9-month-long war of liberation. This small country is of 144,000 km2 with a population of 162 million (2016 estimate),[9] with a population density considered to be one of the highest in the world (1238 persons/km2),[16] with the majority (65%) living in rural areas.[10] The life expectancy at birth is 71 and 75 years, respectively, for males and females.[9] Muslims make up 90% of the population, with 10% identifying as either Hindu, Buddhist, Christian, or animist.[10] The adult literacy rate of population aged above 15 years old is 72.3%.[17] Bangladesh has a very diverse climate and is prone to natural disasters, especially cyclones and floods, which result in significant numbers of deaths, injuries, and losses of assets and infrastructures.[18] Around 40% of the population lives in poverty.[19] The WB classifies Bangladesh as a LMIC.[9]
Health-care indicators in Bangladesh, including budget allocation and facilities, are graded as poor. According to the Health Bulletin DGHS-2017, there are 93,763 registered physicians in the country, with only 5.34 doctors/10,000 population.[17] There are 5630 public and private hospitals registered with the DGHS, totaling 137,024 beds.[17] Most doctors are working in the urban areas.
The country's health system is facing major challenges yet receives little priority in terms of national resource allocation. Only 2.8% of the gross domestic product is spent on health services.[10] The total annual expenditure on health per capita is 88 USD (2014 estimate).[20]
The out-of-pocket health costs paid by individuals in Bangladesh (63% of the country's total health expenditure)[21] is one of the highest in this region when compared to that of Maldives (18%), Bhutan (25%), Nepal (47%), Pakistan (56%), and India (62%).[22]
The health system in Bangladesh faces multiple challenges, such as a lack of public health facilities, scarcity of skilled workforce, inadequate financial resource allocation, and political instability.[23]
Disability in Bangladesh
According to the Persons with Disabilities' Rights and the Protection Act, 2013, a PWD is “any person who is physically, psychologically, and/or mentally not functioning properly due to social/environmental barriers. Any person who can't take part actively in the society is considered to be disabled.”[24]
Disability prevalence and statistics
To date, no comprehensive national disability survey has been carried out in Bangladesh.[25] The available reports vary in their estimates depending on the methodology employed and population studied. Government of Bangladesh surveys in 1982, 1986, and 1998 estimated a national prevalence rate of disability at 0.64%, 0.5%, and 1.60%, respectively.[26] This is much below the national and global estimates of disability prevalence. A nationwide survey of 12,000 participants throughout the country estimated that 5.6% people in Bangladesh have a disability of one kind or another.[25] According to the Household Income and Expenditure Survey carried out in 2010, the net percentage of population in Bangladesh suffering from any type of disability is 9.07%.[27] Marella et al., using the Rapid Assessment of Disability questionnaire in a cohort of 1855 persons, estimated a disability prevalence of 10.5%.[28] ActionAID Bangladesh in 1996 conducted a survey of four regions and documented that 14.04% people suffered from at least one form of disability.[29] Mitra et al. reported a disability prevalence of 16.2% among working-age (18–65) individuals.[30]
A 2014 UNICEF report cited a varied estimate of disability prevalence among children in Bangladesh, ranging from 1.4% to 17.5%. Given the estimated child population of 57.5 million, the number of children with some form of disability could range from under 0.8–10 million.[31] The disability prevalence varies among different groups and reflects inequalities in the society. Higher ratio of disability is reported in females, elderly, unemployed, residents of rural areas, and singles.[25],[27],[32] Similarly, people with low levels of income, food security, education, and access to sanitation are more likely to have disability.[30] Dhaka (the capital city) and Rajshahi divisions (4th largest in Bangladesh) have the highest ratio of disability among all the eight divisions in Bangladesh.[31]
Types and etiology of disability in Bangladesh
Surveys over the past 20 years have documented the causes of disability in different ways. The wide variation in the available statistics on disability, lack of registries, and comprehensive nationwide data on different disabilities highlights the current gaps in disability research in the country. The DGHS and Jatiyo Protibondhi Unnayan Foundation carried out a large survey in 2013 to document disabilities in different parts of the country, identifying 1.65 million persons having at least one form of disability. The important causes and patterns of disability detected in this survey were autism, physical disability, mental illness, visual disability, speech disorders, intellectual disability, hearing and visual disability, cerebral palsy, multiple disabilities, down syndrome, and others.[33] Physical disabilities were the most common followed by visual, intellectual, and multiple disabilities. Titumir and Hossain categorized disability into different types of impairments such as hearing (18.6%), visual (32.2%), speech (3.9%), physical (27.8%), intellectual (6.7%), and multiple (more than one type) (10.7%).[25] A Household Income and Expenditure Survey (2010) utilized eye sight difficulty, hearing difficulty, walking and climbing difficulty, remembering and concentrating difficulty, self-care difficulty, and speaking and communicating difficulty as classifiers of disability.[26] The main contributory factors toward preventable disabilities in Bangladesh are maternal and child malnutrition, noncommunicable diseases, congenital anomalies, accidents, and injuries.[30] Road traffic injuries rank the leading cause of trauma, with approximately 33% of the beds in primary- and secondary-level hospitals occupied by injury-related patients.[34] Cancer is predicted to be an increasingly important cause of morbidity and mortality in Bangladesh in the next few decades. Lung and oral cancers are most common in males, whereas breast cancer and cervical cancer predominate in females.[35] Disability burden and economic loss incurred by cancer patients are more pronounced in poor income groups.[36]
The major causes of permanent disabilities in children under 17 years include falls, burns, falling objects, cut injury, transport injury, machine injury, and others.[37] Burns injure over 170,000 children every year in Bangladesh and permanently disable over 3400 children.[35] In many cases, lack of appropriate rehabilitation services results in temporary impairments progressing to permanent disability.[31]
Unlike developed countries with more robust health-care systems and health record keeping, Bangladesh lacks national disability registries and comprehensive large-scale data for different diseases. There is a need to conduct a nationwide survey of PWD. The survey must be designed through consultation with all major stakeholders including rehabilitation professionals and PWD themselves.
Disability rights, legislation, and protection for persons with disability
The National Constitution of Bangladesh grants equal rights to PWD and encourages their community participation. The MOSW mainly deals with disability issues through its different offices and programs including the National Foundation for the Development of the Disabled Persons or Jatyo Protibondhi Unnayon Foundation (JPUF)[38] and Neurodevelopment Disability Protection Trust.[39] In 1995, the first National Policy for the Disabled was approved by the government. In 1996, the MOSW, in association with the National Forum of Organizations Working with the Disabled, initiated a draft legislation on disability-related issues. This legislation was formally enacted in April 2001 and is known as the Disability Welfare Act of 2001.[25] It provides a comprehensive commitment to ensure equal opportunities for PWD, ranging from prevention to access to basic and specialized services to support the socioeconomic development of PWD. In 2006, a National Disability Action Plan was developed by the National Coordination Committee on Disability to facilitate implementation of the Disability Welfare Act 2001.[30] In 2013, the Rights and Protection of Persons with Disability Act was passed by the Parliament, replacing the Disability Welfare Act 2001, with focus shifted from a welfare-based to a rights-based approach.[24] However, the actual implementation of this legislation still remains a challenge.
Participation and inclusion of persons with disabilities
PWD face social discrimination and cultural and mobility barriers that prevent full and equal participation in the community. In addition, many medical professionals and health-care workers are not yet sensitized or educated on disability issues.[30] As reported from other developing countries,[4] a negative belief that disability is a curse and a punishment for sinful behavior is strongly held in Bangladesh as well.[30] Families may feel embarrassed about a family member with disability. These attitudes negatively affect access of PWD to adequate care, health services, education, and their participation in the society. Most mainstream schools are not inclusive for children with disabilities. The MOSW in 2012 reported that 1720 children with disability were residing in institutions and 280 students with disability were residing in residential schools.[30] These children are not growing up in a supportive and familiar home environment, and concerns have been raised that institutional care environments in most cases are inadequate and violate many rights of children with disability.
PWD have a lower economic status and inadequate access to education and employment as compared to individuals without disabilities. PWD have higher rates of unemployment (65%) as compared to persons without disability (46%).[29]
PWD face discrimination even within their own families and are sometimes deprived of inheritance. Marriage and family life of women with disability is very challenging in Bangladesh, particularly in rural areas where literacy rates are not high, and the environment is not disabled friendly for mobility. The government has officially allocated reserved jobs in public sector for PWD, but negative attitude toward PWD is a barrier to fulfill this reserved quota. Major hurdles in improving employment opportunities for PWD include lack of clear organizational policies; negative perceptions regarding the skills and abilities of PWD; attitudinal-, environmental-, and institutional-level barriers; and nonprovision of health benefits, insurances, and incentives.
Disability challenges in Bangladesh are similar to challenges reported in other LMICs such as limited skilled workforce, lack of knowledge of disability services, and a general lack of awareness of what PMR services can provide. A large population and relatively small number of rehabilitation professionals mainly based in the urban areas make it extremely difficult to provide quality rehabilitation services to the majority of the PWD in Bangladesh, many of whom live in the rural areas.
Disability organizations in Bangladesh
There are more than 150 disability-related organizations, institutes, and nongovernmental organizations (NGOs) working in public and private sectors in Bangladesh.[40] Handicap International estimates that of the nearly 30,000 NGOs working in the country, approximately 300 have worked with people with disabilities.[41] Activities of these organizations include disability program implementation, advocacy, and financial support for PWD. Depending on mandate and structure, such organizations may also provide medical, social, and vocational rehabilitation including community-based rehabilitation, as well as provision of assistive devices, gait aids, and communication devices to those who cannot afford it. A number of these organizations are also working to provide education to PWD, particularly for children. We describe few organizations below:
Jatyo Protibondhi Unnayon Foundation/National Foundation for the Development of the Disabled Persons[38]
JPUF is the pioneer governmental organization in Bangladesh for addressing the rights of PWD. It was established in 1984 with an aim to ensure that PWD are included in the mainstream society with equal rights, opportunities, and dignity within a protective environment. It runs disability-inclusive programs, including establishing and operating special schools for students with disability in Bangladesh. The significant achievements of this governmental organization in support of PWD include establishment of autism centers in different parts of the country, mobile van physiotherapy services, provision of assistive devices, training of parents of children with autism, publication of a monthly magazine for PWD, and distribution of microcredits and grants to PWD.[38]
National Institute of Traumatology and Orthopaedic Rehabilitation
The National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) is a 500-bed orthopedic hospital, at undergraduate and postgraduate training institute located in Dhaka affiliated with the University of Dhaka. It was established in 1972 by Dr. R. J. Garst, an American missionary orthopedic surgeon who came to Bangladesh on the request of Bangabandhu Sheikh Mujibur Rahman. Along with his wife, he started a 100-bed hospital at the outpatient department of Shaheed Suhrwardy Hospital. Upgraded to 400 beds in 1978 and to 500 beds in 1993, it was renamed as NITOR in 2002. It is the largest trauma and orthopedic rehabilitation hospital of the country, providing service to more than 120,000 patients each year, with over 20,000 admissions annually. It houses the largest prosthetic center of the country. Although considered a national center for rehabilitation, there are only three qualified physiatrists working at the institute along with a few team members including physiotherapists, occupational therapists (OTs), and prosthetic and orthotics technicians.
Centre for the Rehabilitation of the Paralysed[15]
The CRP is an NGO established in 1979 by a small group of Bangladeshis and a British physiotherapist Ms. Valerie Taylor OBE as the first center in Bangladesh to provide comprehensive medical, psychological, social, and vocational rehabilitation for patients with spinal cord injuries (SCIs). Located at Savar since 1990, which also serves as the headquarters, the CRP to date has established eight subcenters in different parts of the country. CRP Savar accommodates both inpatients (100 beds) and outpatients, the majority with traumatic SCI. Other patients served by CRP include persons with strokes, those with orthopedic and neurological conditions, and children with cerebral palsy.
CRP also hosts the Bangladesh Health Professions Institute, a training academy for physiotherapists, OTs, rehabilitation nurses, special education teachers, and community-based rehabilitation workers. It is important to mention that CRP currently does not have a full-time physiatrist among the staff.
Other institutes and nongovernmental organizations working for rehabilitation of persons with disability
The Society for the Welfare of the Intellectually Disabled, established in 1977, has been working specifically for persons with intellectual disability including autism, cerebral palsy, Down's syndrome, communication disorders, and behavioral disorders, providing services to 15,000 patients annually.[42] The National Council of Disabled Women is working across 23 districts in Bangladesh to support females with disability through advocacy and better implementation of disability-related legislation. The current membership is approximately 10,000.[43] The Centre for Disability in Development is an NGO established in 1996 to develop a more inclusive society for persons with a disability. Key focus areas include support for the deaf and blind, empowerment of PWD, provision of health services, and social support and opportunities for livelihood.[44] Humanity and Inclusion is an international NGO working in Bangladesh since 1997, providing services to PWD including community-based rehabilitation, educational opportunities, educational support, legal assistance, and establishment of a disability resource center.[40]
| Discussion | | |
Physical medicine and rehabilitation in Bangladesh
Physical medicine and rehabilitation (PMR) started in Bangladesh in 1967 as Physical Medicine, and was later changed to Physical Medicine and Rehabilitation by a government order when Professor Muhammad Quamrul Islam (“Father of Physiatry” in Bangladesh) joined the Government Health Services at Dhaka Medical College Hospital after completing postgraduate degree in PMR from Royal College of Physicians (RCP), UK. Two years later, two additional RCP-qualified physiatrists, Professor MA Wahed and Professor Ilias Hossain, joined different medical colleges and started working with limited resources. These pioneers provided services to patients with pain, musculoskeletal disorder, and paralysis in collaboration with physiotherapists.
The current practice of PMR in Bangladesh is mostly limited to the management of musculoskeletal and rheumatological disorders and pain management. In recent years, many young PMR physicians have started showing a greater interest in regenerative medicine including the use of platelet-rich plasma, prolotherapy, and stem cells for various musculoskeletal disorders. Neurological rehabilitation of conditions such as SCI, traumatic brain injury (TBI), and multiple sclerosis is not well developed due to factors including lack of formal training during PMR residency, dearth of qualified rehabilitation professionals, lack of incentives in treating more chronic conditions as compared to musculoskeletal disorders, and inadequate infrastructure and equipment. PMR physicians in general also lack expertise in electrodiagnostics which is primarily performed by neurologists in Bangladesh.
History of physical medicine and rehabilitation training and courses
Between 1989 and 1990, the Bangladesh Medical Research Council organized a nationwide search of medical graduates for enrollment into a variety of specialty training programs including PMR. The first author (TU) was the pioneer resident at the Institute of Post Graduate Medicine and Research, which was later upgraded to Bangabandhu Sheikh Mujib Medical University (BSMMU). To promote the specialty of PMR, physicians who had qualified the Fellowship of College of Physicians and Surgeons (FCPS) part I in Medicine or Surgery were allowed to enroll in the PMR postgraduate training program. Concurrently, FCPS Part I course in PMR under the auspices of BCPS was introduced. Currently, Bangladesh PMR has fellowship, MD, and residency courses and have produced 122 physiatrists to date, with BSMMU recognized as the Centre of Excellence in PMR. This number is seriously inadequate to meet the medical rehabilitation needs of the Bangladeshi population.
[Table 2] describes the current numbers and training opportunities for physiatrists, PMR residents, and allied rehabilitation professionals in different institutes across the country. | Table 2: Overview of physical medicine and rehabilitation, specialists, and residents in Bangladesh - February 2018 estimates
Click here to view |
Of the total 85 public posts in the government sector, 35 posts are vacant due to shortage of qualified staff. Most of these institutes lack the essential members of a multidisciplinary rehabilitation team. All PMR centers in the country have well-developed musculoskeletal pain management and rehabilitation protocols with fewer facilities for SCI and amputation rehabilitation.
Academic training and research in physical medicine and rehabilitation
PMR has been introduced at the undergraduate level in medical colleges across the country. Fourth-year medical students have a 2-week mandatory rotation in PMR, whereas in the final year, there are five classes for PMR-related topics. Exposure of students to PMR at the undergraduate level is very important as it helps promote the value of medical rehabilitation in disability management and helps students consider PMR as a career choice.
There are two postgraduate PMR courses offered in Bangladesh: the Fellowship program of the BCPS and the MD PMR program conducted by BSMMU. Bangladeshi physicians appear for FCPS Part I examination after graduation, and then undergo a 4-year structured FCPS II training program at an accredited institute, which includes core rehabilitation training and mandatory rotations in other specialties. Trainees attend lectures, deliver cases in clinicopathological conferences, and submit a research-based dissertation. At the end of the 4 years, candidates fulfilling the requirement are eligible to sit for the exit examination for the Fellowship of BCPS in PMR. MD Residency in PMR is a 5-year program comprising clinical work in PMR and rotations in other specialties including internal medicine, neurology, and orthopedic surgery [Figure 1]. | Figure 1: An overview of the 5-year MD physical medicine and rehabilitation structured training program
Click here to view |
This course is popular among the national and international students with a minimum dropout rate. Currently, there are 103 BCPS fellows in PMR and 13 MD residents in PMR under BSMMU.
Research is a mandatory requirement for residents to qualify for their final examinations and for faculty academic promotion. Of the 144 dissertations available in the database of BCPS, the majority are on topics related to physical modalities, musculoskeletal disorders (adhesive capsulitis, osteoarthritis, knee pain, and cervical radiculopathy), and rheumatic disease, with few titles related to cardiac rehabilitation and cerebral palsy.[45] There are only three dissertations on the rehabilitation of SCI and TBI. The published research of the faculty also reflects the same trend.
Research grants are available mainly from BSMMU, BMRC, University Grants Commission, and the University of Science and Technology, but the amounts are small and the competition is strong.
Rehabilitation professionals in Bangladesh
PMR is multidisciplinary and entails services of other rehabilitation professionals. The following is a summary of the current state of rehabilitation professions in Bangladesh [Table 3]:
- Bangladesh Physiotherapy Association (BPA) is the representative body for the physical therapists (PTs) in the country.[46] There are an estimated 2200 PTs in the country. Three training programs in PT are available in the country; 3-year diploma and 4-year bachelors and masters program. BPA has more than 1000 members who have completed the diploma course in PT, and graduates are commonly referred to as physiotherapy medical technologists. There have been some concerns raised about such diploma courses as not all programs have been accredited or registered
- According to Mr. Zulkarnain, Official of Bangladesh Occupational Therapy Association,[47] and the course coordinator of Occupational Therapy programs at CRP, 244 OTs have graduated from CRP. This program is affiliated with Dhaka University
- There are reportedly 240 speech and language pathologists (SLPs) in Bangladesh (Personal Communication Ms. Sanjida Akter, Secretary of Speech and Language Therapists Association in Bangladesh – July 2018). Almost all are graduates of CRP. The opportunities for SLP in Bangladesh are limited. Most SLPs are working in the private health-care sector, some are employed by CRP, a few are working in government hospitals, and others are working with NGOs.
Some PTs use the suffix of doctor and prescribe medications, which is a violation of the medical code of Bangladesh and beyond their scope of practice. This creates confusion both among the patients and nonrehabilitation physicians. There have been occasional incidences of professional conflict between PMR physicians and therapists at some institutes and departments, which acts as a major barrier in the multidisciplinary rehabilitation team-building process.
Bangladesh Association of Physical Medicine and Rehabilitation[13]
BAPMR is the only official representative body of PMR physicians in Bangladesh. Established in 1995 with four PMR fellows and few PMR residents, it currently has approximately 200 members. BAPMR is affiliated with the International Society of Physical and Rehabilitation Medicine and the Asia Oceanian Society of Physical and Rehabilitation Medicine.
The BAPMR regularly organizes scientific seminars, Continuing Medical Education activities, and social events for the members. The 1st Annual convention and scientific meeting was held in 1997, with a BAMPR Scientific congress held every 2 years since. In 2012, an international conference was organized in association with the International Rehabilitation Forum.
Future directions
Disability management in Bangladesh requires a multipronged strategy, beginning with documentation of the actual magnitude of disability in the country through a nationwide survey on disability. The survey should be representative and classify specific disabilities clearly and in accordance with the international standards, instead of cataloguing in vague groups. Positive developments have occurred toward achieving this goal; a disability detection survey program has launched a website and an online data collection form to detect and enroll more PWD in the database.[32] The disability legislation should be implemented, and steps should be implemented to address the cultural and social barriers faced by PWDs. Transportation networks, buildings, public spaces, and educational institutes must be accessible to PWD.
These efforts must involve PMR physicians and other rehabilitation professionals. There is a need to produce more qualified PMR physicians and other rehabilitation professionals to address the increasing burden of disability in Bangladesh. This can be done by improved training, offering incentives, and building infrastructure to deliver quality rehabilitation care. PMR fraternity also needs to take on a leadership role by strengthening the residency training programs, interacting with other specialties and apprising them of the value of an early and coordinated multidisciplinary rehabilitation, developing neurorehabilitation training and services (including SCI and TBI rehabilitation), and being strong advocates for the PWDs.
There is also a need for strong leadership and political commitment, for advocacy of the legal framework for inclusivity, for investment in infrastructure and human resources, as well as for better coordination in health care and research for PWD.
| Conclusions | | |
Health-care systems in Bangladesh have progressed in the last three decades, but disability remains neglected and PWD face cultural and mobility barriers. PMR physicians in collaboration with other rehabilitation professionals can help provide comprehensive medical, social, and psychological rehabilitation services for PWDs in Bangladesh. There is a need to collect large-scale epidemiological data on disability and to enforce the disability legislation in the country. PMR services should be strengthened, including improved training opportunities for PMR physicians and other rehabilitation professionals. PMR physicians also need to take a leadership role in identifying the service delivery gaps in disability management and offer solutions that are practical, culturally appropriate, and evidence based. This would ensure a better future and quality of life for PWDs in Bangladesh.
Acknowledgments
We sincerely thank and acknowledge the following for their contribution to the information presented in this study:
- Professor Md Moyeenuzzaman, first PMR fellow of Bangladesh and Ex-chairman, Dept. of PM&R, BSMMU for providing academic and historical perspectives on PMR services
- Prof. Quamrul Islam FCPS, D PhysMed, Ex-Professor and Chairman, Department of PMR BSMMU, and President of BAPMR, provided information on the history and establishment of PMR in Bangladesh
- Prof M Habibur Rahman FCPS, Professor, Department of PMR NITOR, provided information on statistics and overview of NITOR
- Prof AKM Salek FCPS, Professor, Department of PMR, BSMMU, helped with the review of the manuscript and suggested resources
- Prof Moniruzzaman Khan FCPS, Professor, Department of PMR, BSMMU, helped with the review of the manuscript and suggested resources
- Mr. Aynul Kabir, Additional Secretary, Ministry of Child and Women Affairs, Government of Bangladesh, provided official statistics and suggested resources for referencing
- Dr. Anwar Ullah, Director, Protibondhi Unnayan Foundation, provided information on the role of NGOs in disability management in Bangladesh
- Brigadier General M Yousuf FCPS, Department of PMR, Combined Military Hospital and AFMI Dhaka Cantonment, for his interviews and insight into PMR and disability management in Bangladesh
- Associate Prof Shahadat Hossain FCPS, Vice Principal, Shahid Suhrawardy Medical College, and General Secretary, BAPMR, provided information on the activities of BAPMR
- Mr. Mahtab Uddin PT, Physical Therapist, Department of PMR, BSMMU, and Vice-President of Bangladesh Physiotherapy Association, provided information and statistics related to physical therapists in Bangladesh
- Mr. Julkar – Nayan OT, Head OT in CRP, and Secretary of BOTA, provided information and statistics related to OTs in Bangladesh
- Ms. SanjidaAkther, Department of SP SLP at CRP, Secretary of Speech and Language Therapists Association, Bangladesh, provided information and statistics related to speech therapists in Bangladesh.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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