Politics and USAID cuts put a telehealth program on life support

Mahbubur Rahman is used to the rhythms and interruptions of running a telemedicine center on the northern fringe of the Sunderbans, the world’s largest mangrove forest. 

At the government-funded hospital in Dacope, Bangladesh, the internet sometimes cuts out for days. Or the power goes out, like it did one recent morning in May, with more than a dozen patients waiting.

Rahman, a 36-year-old administrator, technician, and all-around troubleshooter at Dacope’s telehealth clinic told them to hold on. 

No one complained. Rahman is widely respected, and they knew he didn’t have to be there. He hasn’t been paid since January. Bangladesh’s health sector has been beset by crisis since a new government came to power last August. It was further worsened when the U.S. Agency for International Development (USAID), which gave around $88 million yearly to Bangladesh’s health programs between 2021 and 2023, halted funding in January.

The health ministry has so far not funded the telehealth program, which treated more than 8,000 patients a month during its peak years after the Covid-19 pandemic. Rahman has struggled to keep the Dacope clinic running.

“I find a deep sense of joy in serving. Even though I’m not able to provide the same quality of care as before, I can’t bear the thought of the center closing completely,” he told Rest of World. 

“But we have no food on our plates. We can’t show this hardship to anyone,” he said.

Telemedicine, which includes virtual consultations and other remote health care technologies, surged in popularity worldwide during Covid-19 as millions went online to visit doctors. It was the future of health care, experts said, especially in poorer regions, but it is often hampered by poor infrastructure, lack of funding, and digital illiteracy. 

In Bangladesh, too, the modestly named “telemedicine service” got a boost during the pandemic, Israt Jahan Kakon, who heads the telemedicine program at the Directorate General of Health Services, told Rest of World. By 2024, there were 234 such centers across the country, and they treated more than 100,000 patients last year. It was Bangladesh’s longest-running telehealth program.

The centers, located within subdistrict hospitals, had a computer and LED screen for video conferencing, a backup battery, a 2 Mbps internet connection, and an assortment of smart devices for remote monitoring, including a stethoscope, an ECG machine, and a spirometer. 

But with the funding crisis, only about 35 centers have survived, kept on life support by unpaid staff who occasionally open the clinics, leading to uncertainty about the future of this program in Bangladesh. Rural residents who used the centers earlier told Rest of World they are no longer receiving sufficient care. 

“Without strong policy backing or well-thought-out planning, telemedicine has yet to reach its full potential in Bangladesh. It’s an idea with promise, but it needs much more support to become truly effective and accessible,” M.H. Choudhury Lelin, a doctor and public health expert who was not involved in the program, said. 

Bangladesh’s government spent just 0.7% of its gross domestic product on health care last year, among the lowest in the world but similar to other lower-income nations, such as Pakistan and Nigeria.

Virtual care makes sense for the nation, where 68% of the population lived outside cities in 2022. Millions of working-class people find traveling to the capital Dhaka or other cities too expensive, especially for chronic conditions that require regular checkups. 

Bangladesh also suffers from a severe shortage of doctors, with only five available to treat every 10,000 people — much lower than the global average of 17. The scarcity is even worse in rural areas.

“Hospitals are often far from rural villages. Normally, patients are referred to [city] hospitals when a specialist is needed, but through this telemedicine system, they could access specialist care without leaving their [area],” Kakon said.

The Dacope clinic is set in the busy town on a low-lying riverine island in the Ganges delta. The water here is so saline that many residents develop skin infections due to constant salt exposure. 

But Dacope does not have a dermatologist. In fact, the town has only one specialist — an orthopedist — and 10 vacancies, according to Sudip Kumar Bala, Dacope’s health officer. 

The telehealth center, launched in 2011, provided some relief. Local doctors would refer patients to the clinic, where a medical officer would connect them to a dermatologist in a distant city. The doctors would decide on a course of treatment together, either prescribing medicines or referring to a hospital. Skin disorders are easier than other conditions to diagnose using only photos, without other diagnostic tests.

Rahman, then 21 and a second-year university student of philosophy, was hired to run it. Fifteen years on, he is well-known and respected by villagers, army officials and administrators alike. He liaises between patients and physicians, gently asking people to put up with the constant delays caused by recurring tech failures. He also does basic nursing tasks such as measuring blood pressure, taking photographs of affected areas, and organizing the material for the physician. 

One morning, while waiting for the power to be restored, physician Selim Reza praised the center. “For just 10 taka [8 cents], patients can speak directly to a senior doctor while sitting in their local health center,” he told Rest of World. “For many, it feels like a dream.”

As Rahman switched on the battery backup, the LED screen blinked to display a dermatologist in the nearby city of Barishal. Reza presented the case of Sagar Chandra Mondal, a middle-aged farmer and tutor who had a persistent, generalized itch. 

The dermatologist suggested medicines, which Reza prescribed. 

Mondal said the treatment was a “blessing.”

“Getting specialist care without having to travel far is very important for us. We are working-class people,” he told Rest of World. 

Then, the battery drained and the power went out.  

Reza said the internet, too, is slow and unreliable, sometimes making it difficult to diagnose. “Sometimes, it is really hard to understand the voice and see the photo due to slow internet speed,” he told Rest of World.

Rahman unlocked a cupboard in a corner and pulled out the internet-connected diagnostic medical devices, including a stethoscope and a microscope the clinic received a decade ago. But the government never provided the software to run them, so they are kept in storage, he said. 

The clinic, like most of rural Bangladesh, has a 2 Mbps internet connection provided by Bangladesh Telecommunications Company Limited, the nation’s largest telecom provider, which maintains a 38,000-kilometer (over 23,00 miles) fiber-optic network. But the cables are vulnerable to the delta’s ferocious storms, leading to regular power and internet outages. And there is only one repair technician for the entire district, where 2.6 million people live. 

“We don’t have enough manpower,” M.D. Jubaer Ahmed, an assistant manager at the telecom company, told Rest of World. 

The internet is among the biggest barriers to telemedicine in Bangladesh, B.M. Mainul Hossain, director of the Institute of Information Technology at the University of Dhaka, told Rest of World.

“Because of internet speed issues, telemedicine services are inconvenient for many, so they are a little reluctant [to use it],” he said. “Since patients are seen from a distance, it is important that the internet not be inconvenient for both the patient and the doctor. Otherwise, there is a risk of misdiagnosis.”

Satellite internet provided by Starlink has recently launched in Bangladesh, but it costs at least twice the price of the cable connection. 

Despite its bare bones set up, the center treated as many as 300 patients every month at its peak, Rahman said, confirming, “So many patients depend on it, and they would truly suffer without it.” 

Shah Ali Akbar Ashrafi, director of management information systems in the health department said the ministry has not committed to restoring the telehealth service.

“We have written several letters, but no decision has been made at the relevant levels of the government yet. As a result, we still do not know its future,” Ashrafi told Rest of World.

A three-hour drive by road from Dacope leads to a telehealth clinic at Bagerhat, which has fared poorly compared to its neighbor. Cobwebs hung from the ceiling, and a layer of dust covered the furniture and equipment. The internet has been cut.

Pranto Mondal, 25, the administrator who ran the center, told Rest of World he stopped getting paid last August and quit in February. 

“I kept going for nearly six months, hoping things would get better. But, honestly, how long can someone keep pushing through like this?” he said.