‘I doubt even one percent of our garment workers have health insurance coverage’

The Institute of Health Economics of Dhaka University (DU) recently revealed that 40% of the country's ready-made garment (RMG) industry's workers, out of 42 lakh, are deprived of medical treatment due to the high cost of healthcare.

This number does not surprise me. In fact, I think around 60% to 70% of workers in this sector are deprived.

I believe at best 10 to 20% of factories ensure this fundamental right for their workers.

However, before reacting to this, we must be aware of how many RMG workers are actually involved in this industry and how big the sample size was of that particular report. 

Our paper in the Oxford Journal of International Health in 2019 titled 'A disease burden analysis of garment factory workers in Bangladesh: Proposal for annual health screening' also revealed that around 10% to 12% of our workers have chronic diseases like hypertension and diabetes, and many of them are even unaware of the fact that they have these diseases and do not seek out any treatment.

As the RMG workers are mostly young, with an average age of 27, they usually do not pay much heed to health issues. 

Usually, they intend to get over more common illnesses by taking one or two day's rest, using a few home remedies, and then they come back to work without taking any proper medication. But in the long run, neglecting such issues can become harmful as these chronic diseases, if left untreated, can damage vital organs such as the heart, kidney, eyes and brain.

I doubt even one percent of our garment workers have health insurance coverage. 

Bangladesh Garment Manufacturers and Exporters Association (BGMEA) and Bangladesh Knitwear Manufacturers and Exporters Association (BKMEA) can start taking steps and help this whole industry to restructure, which is not impossible to execute. 

HAEFA’s medical teams. Photo: Collected.

Additionally, there is no need to wait for the government or any private sector's contribution to initiate this if BGMEA and BKMEA sincerely wants to achieve universal health coverage for the workers by 'risk pooling' or 'cost sharing', as follows:

Firstly, each factory can create a risk pooling fund, perhaps by including the international buyers, owners, and workers, which will take care of the workers' medical issues all over the year. 

I sense creating a risk pooling fund might be a little tricky hence our factory owners will have to be convinced first that the chronic diseases among 10% to 12% of their young workers are counterproductive for the owners themselves. Chronic diseases such as hypertension, diabetes, malnutrition including anemia, are also called non-communicable diseases (NCD), which pose major health risks and are known as 'silent killers' as they do not produce symptoms until late in the disease process. NCDs are a major problem around the globe including Bangladesh.

We must remember that worldwide, buyers are usually under pressure for exploiting the labour force and buying garments at a cheaper price from the developing nations' markets. 

We can utilise this opportunity and offer them branding saying – 'we provide health care', in exchange of a small cost for the workers' healthcare which can be used in the risk pooling healthcare funds.

For example, if 10% of the workers in a factory of 2,000 are diagnosed with hypertension (HTN) and diabetes (DM), a total of 200 workers will require medications for HTN and DM. If each patient requires Taka 150 worth of medicines per month on average, the total cost will be (150 X200) =Taka 30,000 per month. If each worker deposits Taka 5 per month in the 'common' or risk pooling fund, there will be a total monthly collection of (5 X2,000) =Taka 10,000. 

If the owners and buyers each pay Taka 5 per worker per month, there will be (5 X 2 X 2,000) = Taka 20,000. So the cost of all medications for NCDs can be covered using this risk pooling fund. 

However, if a factory of 2,000 workers produce 100,000 pieces of shirts or pants per month, and the buyer pays 1 cent ($0.01) or Taka 0.85 per piece of items in exchange for a branding that 'We provide healthcare to our workers', an average of (0.85 X 100,000)  = Taka 85,000 per month, which will not only cover the medicine costs, it will also cover diagnostics and the healthcare providers (physicians, nurses) expenses. 

The branding that will not only help the buyers save their face in the international arena and rather will make them more competitive in the market does not seem at all an expensive option for the buyers and factory owners. This ability to use such powerful and positive branding will also ensure that the buyers stick around in Bangladesh for a few more years. 

RMG business is not stable. In the sense that, after a few years, industrialists might shift their business elsewhere with cheaper labour. We should prepare our market for that and use these remaining years to create a healthy environment for our workers. 

Workers also need to understand the urgency of healthcare and agree on contributing a little amount in order to force the owners and buyers to pay their major shares. 

Another point: all factories are supposed to have a doctor on-site. According to Bangladesh Labour Act-2006 and Bangladesh Labour Rules-2015, wherever 300 or more workers are employed at one place, at least one registered physician and one trained compounder/medical assistant, nurse and subordinate employee shall be employed there.

Although most do not follow this, they usually have at least one paramedic to provide primary medical treatments or take care of emergencies. 

Since we have been providing on-site healthcare using electronic health records and digital health card systems since 2013, we can offer capacity building to the available paramedics and health workers under a more unified system, and to do that, Health and Education for All (HAEFA) is ready to help. 

To open this gateway, though, BGMEA needs to make their health care centres fully functional. Once these health care centres become functional, they can adopt NIROG, a portable (hand-held Tablet-based) electronic health record system, track the patients and keep them under regular treatment. 

It might sound like heavy work and a time-consuming thing but actually, it is not. Through Grand Challenges Canada (GCC) Award work ('Stars in Global Health') in 2018-2019, HAEFA alone has already covered 10,000 workers' chronic disease (including HTN and DM) screening and treatment using NIROG within only three months in seven factories. 

It has also taken care of 1,200 women's cervical cancer screening and treatment using the 'See-and- Treat' digital method. Cervical cancer is the second biggest cancer killer of women in Bangladesh. With HAEFA's see-and-treat proposition, I believe it can be implemented for women above 30 years of age in all the factories. 

According to our proposed plan, health care centres can work in two ways. 

Firstly, they can work as a data hub of workers (using NIROG) from where doctors can track down how many patients need treatment monthly or yearly and for which disease. 

Secondly, they can be operated as hospitals where serious chronic patients can be admitted and treated when they need intensive care.

To work out all these plans, the government also needs to play a vital role. As of now, it can ask for a yearly 'health audit' from BGMEA and BKMEA. I believe it will accelerate the procedure and make it more organised.

So, overall, these systems HAEFA can implement would not do any harm to the overall productivity of the factory, rather it would downsize the number of sick leaves and create an overall positive impact for the workers, factory owners and the international buyers in the very near future.

Dr Ruhul Abid. TBS Sketch.

Dr Ruhul Abid is the President and Founder of Health and Education for All (HAEFA).