Health workforce crisis in Bangladesh

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

A study revealed that the density (per 10,000 population) of physicians and nurses in Bangladesh increased over the last decade (from 1.9 physicians and 1.1 nurses in 1998 to 5.4 physicians and 2.1 nurses in 2007), though it remains much lower than the estimated average for low-income countries in 1998. The density of dentists has increased, but remains very low (from 0.01 in 1998 to 0.3 in 2007).

The density of formally qualified health care professionals (doctors, nurses and dentists) is lower than other south Asian countries (7.7 in Bangladesh, compared to 21.9 in Sri Lanka, 14.6 in India and 12.5 in Pakistan) and falls far short of the estimate projected by World Health Organization (23) which would be needed for achieving targets for the Millennium Development Goals. During this time, the density of traditional birth attendants declined (from 55 in 1981 to 33 in 2007), presumably due to the stoppage of traditional birth attendant training by the Bangladeshi government in 1998.

The current nurse-doctor ratio of 0.4 (i.e., 2.5 times more doctors than nurses) is far short of the international standard of around three nurses per doctor. An estimate of shortage based on the doctor-population ratio currently prevalent in low-income countries revealed a shortage of over 60,000 doctors, 280,000 nurses and 483,000 health technologists in Bangladesh.

“The large-scale shortage of qualified healthcare providers, coupled with an inappropriate skill-mix (more doctors than nurses and technologists) needs urgent attention to cater to the healthcare needs of the population,” the study said.

1. Ahmed SM, Hossain MA, Rajachowdhury AM, Bhuiya AU. The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution. Human Resources for Health 2011; 9: 3. (open access)

Task shifting may provide additional access to health services

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Task shifting–delegating tasks to existing or new health cadres with either less training or narrowly tailored training–is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost, a study finds.

For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynecologists.

Although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance.

“Task shifting is a policy option that should be considered to help achieve productive efficiency and provide access to services that otherwise might not be available,” the study concluded.

1. Fulton BD, Scheffler RM, Sparkes SP, et al. Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Human Resources for Health 2011; 9: 1. (open access)

Successful approaches to retaining skilled health workers in India’s rural areas

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Uneven distribution of health workers can be solved.

The lack of skilled health care providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74 percent of whom live in urban areas where they serve only 28 percent of the population, while the rural population remains largely underserved.

A new study indicates that the problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programs have shown promising results in India, according to the study.

The availability of doctors and nurses is limited by a lack of training colleges in Indian states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Initiatives under India’s National Rural Health Mission to reach out to the rural populations include an increase in sanctioned posts for public health facilities, financial incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82,343 skilled health workers to the public health workforce.

Before 2005, the most common strategy to reach out to rural populations was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programs.

1. Sundararaman T, Gupta G. Indian approaches to retaining skilled health workers in rural areas. Bulletin of the World Health Organization 2011; 89: 73-77. (open access)