The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution

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Abstract

Background

Bangladesh is identified as one of the countries with severe health worker shortages. However, there is a lack of comprehensive data on human resources for health (HRH) in the formal and informal sectors in Bangladesh. This data is essential for developing an HRH policy and plan to meet the changing health needs of the population. This paper attempts to fill in this knowledge gap by using data from a nationally representative sample survey conducted in 2007.

Methods

The study population in this survey comprised all types of currently active health care providers (HCPs) in the formal and informal sectors. The survey used 60 unions/wards from both rural and urban areas (with a comparable average population of approximately 25 000) which were proportionally allocated based on a 'Probability Proportion to Size' sampling technique for the six divisions and distribution areas. A simple free listing was done to make an inventory of the practicing HCPs in each of the sampled areas and cross-checking with community was done for confirmation and to avoid duplication. This exercise yielded the required list of different HCPs by union/ward.

Results

HCP density was measured per 10 000 population. There were approximately five physicians and two nurses per 10 000, the ratio of nurse to physician being only 0.4. Substantial variation among different divisions was found, with gross imbalance in distribution favouring the urban areas. There were around 12 unqualified village doctors and 11 salespeople at drug retail outlets per 10 000, the latter being uniformly spread across the country. Also, there were twice as many community health workers (CHWs) from the non-governmental sector than the government sector and an overwhelming number of traditional birth attendants. The village doctors (predominantly males) and the CHWs (predominantly females) were mainly concentrated in the rural areas, while the paraprofessionals were concentrated in the urban areas. Other data revealed the number of faith/traditional healers, homeopaths (qualified and non-qualified) and basic care providers.

Conclusions

Bangladesh is suffering from a severe HRH crisis--in terms of a shortage of qualified providers, an inappropriate skills-mix and inequity in distribution--which requires immediate attention from policy makers.

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Most cited references 16

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Producing effective knowledge agents in a pluralistic environment: what future for community health workers?

H Standing, M A K Azad Chowdhury (2008)

This paper is concerned with how poor populations can obtain access to trusted, competent knowledge and services in increasingly pluralistic health systems where unregulated markets for health knowledge and services dominate. The term "unregulated" here derives from the literature on the development of markets in low income countries and refers to the lack of state enforcement of formal laws and regulations. We approach this question of access through the changing roles and fortunes of community health workers over the last few decades and ask what kind of role they can be expected to play in the future. Community based health agents have been used in many settings as a way of filling gaps in service provision where more skilled personnel are not available. They have also fulfilled a more transformative role in broad based community development. We explore the reasons for the decline of programmes from the 1980s onwards. Using the specific experience of Bangladesh, the paper considers what lessons can be learned from past successes and failures and what needs to change to meet the challenges of 21st century health systems. These challenges are those of establishing credibility and legitimacy in a pluralistic environment and creating a sustainable livelihood strategy. The article concludes with a discussion of four potential models of community based health agents which are not necessarily exclusive: a generic agent that is closely linked to a reputable supervisory agency; a specialist cadre working with particular health conditions; an expert advocate; and a mobiliser or facilitator who can mediate between users and health markets.

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Pharmacies, self-medication and pharmaceutical marketing in Bombay, India.

M Nichter, V. Kamat (1998)

Studies of pharmaceutical practice have called attention to the role played by pharmacists and pharmacy attendants in fostering self-medication and medicine experimentation among the public. Left undocumented is the extent to which clients passively follow the advice of pharmacy personnel or question their motive or expertise. While research has focused on pharmacists and pharmacy attendants as agents encouraging self-medication and medicine experimentation, adequate attention has not been paid to pharmacist-client interactions that are sensitive to the social, cultural, and economic context in which medicine sales and advice occur. This paper highlights the context in which pharmacy attendants engage in "prescribing medicines" to the public in Bombay, India. An ethnographic description of pharmacies and pharmaceutical-related behavior in Bombay is provided to demonstrate how reciprocal relationships between pharmacy owners, medicine wholesalers and pharmaceutical sales representatives (medreps) influence the actions of pharmacy staff. Attention is focused on the role of the medicine marketing and distribution system in fostering prescription practice, pharmacy "counter-pushing" and self-medication. In documenting the profit motives of different players located on the drug sales continuum, it is argued that the economic rationale and the symbiotic relations that exist between doctors, medreps, medicine wholesalers and retailers, need to be more closely scrutinized by those advocating "rational drug use".

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Informal sector providers in Bangladesh: how equipped are they to provide rational health care?

M Chowdhury, A. Ahmed, A. S. Md. Mukarram Hossain (2009)

In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.

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Author and article information

Journal

Journal ID (nlm-ta): Hum Resour Health

Title: Human Resources for Health

Publisher: BioMed Central

ISSN (Electronic): 1478-4491

Publication date Collection: 2011

Publication date (Electronic): 22 January 2011

Volume: 9

Page: 3

Affiliations

[1 ]Research and Evaluation Division, BRAC, 75 Mohakhali, Dhaka-1212, Bangladesh

[2 ]James P Grant School of Public Health, BRAC University, 66 Mohakhali, Dhaka-1212, Bangladesh

[3 ]ICDDRB, Mohakhali, Dhaka-1212, Bangladesh

Article

Publisher ID: 1478-4491-9-3

DOI: 10.1186/1478-4491-9-3

PMC ID: 3037300

PubMed ID: 21255446

SO-VID: adf6cb5c-b6a2-4077-a092-21ebab79efa1

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution

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Abstract

Background

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Most cited references 16

Producing effective knowledge agents in a pluralistic environment: what future for community health workers?

Pharmacies, self-medication and pharmaceutical marketing in Bombay, India.

Informal sector providers in Bangladesh: how equipped are they to provide rational health care?

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