Inside the parallel physio economy growing around Savar's CRP

Sanaullah was travelling by autorickshaw on a highway in Dinajpur when a bus hit the vehicle from behind. He was thrown into a nearby field, resulting in a complete fracture of his right shoulder joint. After the incident, he underwent surgery at Dinajpur General Hospital.

However, due to the lack of reliable physiotherapy centres in Dinajpur, he was taken to the Centre for the Rehabilitation of the Paralysed (CRP) in Savar. Sanaullah stayed in Savar for nearly two months with his wife, renting a house during the treatment period.

One day, while out for a walk, he reached a gate and spoke with a security guard. From the conversation, he learned that he was standing outside the CRP hospital. But that was not where he had been receiving treatment.

It was then that he discovered that the place where he had been receiving therapy all this time — believing it to be CRP — was, in fact, a privately operated physiotherapy centre with no affiliation whatsoever with the original institution.

Proliferation of private physiotherapy centres

There are approximately 50 to 70 such private physiotherapy centres operating outside CRP, mushrooming within a one-kilometre radius of the hospital. These centres offer physiotherapy, speech therapy, occupational therapy, and other rehabilitative services. 

Many patients like Sanaullah, especially those from remote rural areas, mistake these external centres for the CRP hospital itself. These clinics often claim that therapy is provided by CRP doctors; in reality, no CRP doctor is authorised to practice in these external private chambers.

Therapist Lutfur Rahman was once a student at CRP, at a time when bachelor's or undergraduate programmes had not yet been introduced there. After completing a diploma at CRP, Lutfur enrolled in a bachelor's programme at Gono University. To support his education expenses, he established Neurocare Physiotherapy Centre near CRP in 1999. 

He later completed a master's degree in gerontology from the Institute of Social Welfare and Research (ISWR) at the University of Dhaka.

Among external therapy centres, Neurocare was the first of its kind. Although it remained closed for a period, it has been operating regularly since 2008.

Five therapists currently work at his centre, three women and two men. Lutfur says he conducts an oral examination before recruitment and personally provides three months of training. 

"It has happened that someone completes a course but cannot name a single bone or muscle, or even say how many muscles the human body has. I have to teach all of this properly," he said.

Anwara Begum, 32, recovered at Lutfur Rahman's centre, says her mother, Hosne Ara. The patient had suffered a sudden stroke that left one side of her body completely paralysed. She was first taken to the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) in Agargaon, and later to Suhrawardy Medical College Hospital.

For nearly a year, her mother took her from one hospital to another without improvement. Eventually, they brought her to CRP. But due to the overwhelming number of patients at the hospital, obtaining daily appointments proved difficult. Ultimately, they learned about Lutfur Rahman from another CRP patient.

After three months of therapy, Anwara can now walk independently and move both hands. Her speech remains unclear, but Hosne Ara remains hopeful. She says physiotherapy is currently ongoing, and speech therapy will begin soon.

Hosne Ara has been living in a rented one-room house nearby for three months, paying Tk6,000 per month. "I don't know how long we'll have to stay," she said. "As long as my daughter doesn't recover, we will have to remain here."

Duration vs quality of therapy

Ismail Jahangir, from Narayanganj, has been staying at Savar for over a month with his mother. After enquiring, he found that CRP does not provide appointments every day, nor does it offer extended therapy sessions.

"Getting an appointment is difficult, and CRP no longer provides services the way it used to. Physiotherapy centres outside offer nearly one hour of therapy, while CRP provides about half that," he said.

But Lutfur Rahman disagrees with the perception. "Patients think that longer therapy sessions mean better results. If a quack provides therapy for a long time and a master's-level therapist provides it for a shorter duration, patients will choose the quack."

However, therapy involves more than hands-on treatment alone. Observing the patient, determining the appropriate type of therapy, consulting with other therapists, providing advice, and conducting evaluations are all part of the process.

This is why, according to Dr Anwar Hossain, head of the Physiotherapy Department at CRP, even if a therapy session lasts 30–45 minutes, half of that time is devoted to documentation and assessment rather than direct therapy.

Technicians, therapists and technologists

According to information available on the website of the Bangladesh Physiotherapists' Association, the country currently has around 3,000 practising physiotherapists. Therapy services are mainly provided through a combination of three categories: therapists (bachelor's degree holders), technologists (diploma holders), and technicians (one-year course holders).

Asked about CRP's internal view regarding external centres, Professor Anwar Hossain said, "Except for five or six centres, all the rest are operating through deception. They are using our name, opening centres by identifying themselves as our doctors or students. Most of them are technologists and technicians. Some people have no certificates or institutional education at all — they have simply learned by observing others — and they are now running chambers and providing therapy."

To become a physiotherapist, one must obtain a bachelor's degree from an institution affiliated with the University of Dhaka, the Bangladesh Health Professions Institute or NITOR.

To become a technologist, one must complete a three-year diploma under institutions affiliated with the State Medical Faculty of Bangladesh, the Bangladesh Health Professions Institute, the Armed Forces Institute of Health Technology, and Institutes of Health Technology (IHTs) in Dhaka and elsewhere.

However, technicians can complete a one-year course from any recognised and registered private institution.

According to the Bangladesh Therapy and Rehabilitation Council Act, 2017, physiotherapy centres must obtain a trade licence from the Bangladesh Physiotherapy Council, and practitioners must also be licensed or registered. Those without licences may work only as assistants.

Legally, only therapists are authorised to provide direct therapy to patients. Technologists may work as assistants, while technicians may support administrative tasks and assist therapists and technologists. In practice, however, there are numerous examples of entire centres being run by technicians who perform the duties of therapists.

"We are only waiting for the council. Once the Bangladesh Therapy and Rehabilitation Council is established, all unregistered and unlicensed institutions and individuals will be punished according to the schedule. But taking advantage of this gap, some dishonest businessmen and unethical individuals continue to run therapy centres," said Dr Hossain. 

Poor, underprivileged and uneducated patients are not the only ones affected — many educated patients also fall into this trap. 

Ismail Jahangir said, "I personally came here one day and checked everything before bringing my mother. Still, when you go to someone for treatment, you cannot ask about their certificates or where they studied. You are forced to trust the signboards and visiting cards they display."

Session fees at these external centres are largely aligned with CRP's rates. In fact, patients report that these centres have recently started charging lower fees than CRP. For example, when the fee at CRP is Tk300–350, these private centres charge Tk200–250.

However, Nazmul Hossain, founder of United Therapy Zone, said, "A therapist with a bachelor's or master's degree should charge the standard session fee. Some concessions may be made for underprivileged patients. But those providing services for Tk150-200, are they really therapists, or are they technicians claiming to be therapists?"

Nazmul Hossain completed his diploma at Prince Institute of Medical Technology and later earned his bachelor's degree from Chattogram Medical College. He works with children with disabilities. Eight to 10 therapists and technologists work at his centre. In addition, a lecturer and a professor are present for patient consultation and diagnosis.

Therapy session fees at his centre range from Tk400-500. However, demand is higher for speech and language therapy and ABA (Applied Behaviour Analysis) therapy. ABA requires a psychologist, which is why the session fee is Tk500-600. Around 10-20 children receive therapy sessions there every day. To date, 923 children are claimed to have recovered through treatment at the centre.

CRP is essentially a voluntary organisation of physiotherapists. Its primary objective is to ensure comprehensive rehabilitation for people with physical disabilities. At the bachelor's level, 287 physiotherapists (including sub-centres) are working with CRP. Of them, around 140 are based at the Savar CRP alone. In addition, there are 30 speech therapists and around 80 occupational therapists.

However, patients come from all over Bangladesh. Approximately 1,000 patients visit the hospital every day.

Because the number of patients is several times higher than CRP's capacity, patients cannot receive regular or daily services within CRP. As a result, fully privately owned therapy centres have emerged outside CRP. 

Each therapy centre employs an average of five to six therapists. With 50-70 centres in operation, this area outside CRP in Savar has created employment for nearly 500 people, most of whom work on a commission-based salary structure. However, the number of women remains significantly lower than men.