The quality of any healthcare service is only as good as its practitioners. For any health system, health workers are the most critical driving force. They are the ultimate resource for promoting health, preventing disease, and curing sickness.
The continuing increase in the demand for health services is putting tremendous pressure on healthcare providers thereby compromising quality. The importance of investing in human resources for health has been reiterated globally which state in no uncertain terms that the route to achieving the health MDGs is through workers; there are no short cuts. There is a severe shortage of skilled health workers in the places where they are most needed. A major constraint identified towards reaching the MDGs and other national health goals is the issue of the health workforce. This includes their production, training, practice, attrition and motivation.
Human Resources for Health (HRH), the backbone of the health care delivery system, is in a crisis situation in Bangladesh with a critical shortage of health workers, although health workers command three-fourths of the national health budget. Worker numbers and quality are positively associated with gains in health. The density of workers in a population is closely associated with some of the key health MDG indicators. Huge shortages of qualified providers and presence of a huge body of unqualified providers with unknown quality are major issues.
By international standards, Bangladesh has an absolute and relative scarcity of qualified medical personnel, with an overwhelming bias towards urban areas in their distribution. International agencies have been greatly concerned over the growing shortages of skilled workforce, as their production rates are not keeping pace with the growing demands in health services. In fact, one of the major constraints identified for achieving the Millennium Development Goals is the lack of qualified healthcare providers in sufficient numbers and with appropriate skills. For Bangladesh, according to the UN Task Force on MDGs 4 and 5, reaching the Millennium Development Goals would mean a paradigm shift in the way that health services are delivered.
WHO has declared Bangladesh as one of the 58 crisis countries facing an acute HRH crisis. The density of formally qualified registered Health Care Providers (HCP), i.e. doctors, nurses, and dentists, in Bangladesh is 7.7 per 10,000 population, and constitute only about 5% of the total health workforce. This is lower than all other countries in the SEARO region and falls far short of the estimate projected by WHO (23.0) needed to achieve the MDG targets. In other words, if the magic number is approximately 2.3 workers per 1,000 population as the threshold density for the health system to perform optimally, Bangladesh has an HCP density of only 0.58 (0.3 physicians, 0.28 nurses and midwives, and 0.02 dentists).
In countries that successfully provide healthcare to all citizens, a larger proportion of nurses and midwives are available in the health workforce compared to the number of physicians. In Bangladesh, both the number of nurses per 1,000 population and the nurse-to-doctor ratio are among the lowest in the world.
Bangladesh faces all 5 challenges identified by the Joint Learning Initiative on Human Resources for Health (JLI, 2004). These are:
Shortages: Bangladesh has severe shortages of HCPs. If we take the doctor-population ratio prevalent in low-income countries as a standard as well as the suggested doctor-nurse ratio of 1:3, Bangladesh has a shortage of over 60,000 doctors and 280,000 nurses!
Skill mix imbalance: Bangladesh needs to revamp its health systems towards a workforce that more closely reflects the health needs of their populations. A gross imbalance in the skill-mix of HCPs, particularly with a doctor-nurse ratio that is hugely out of line with WHO suggested norms, creates huge inefficiency in the health system of Bangladesh. While the suggested ratio is 2 or 3 nurses for each doctor, the doctor-nurse ratio in Bangladesh is just the reverse or even worse.
There are around 5 physicians and 2 nurses per 10,000 population, making the nurse-doctor ratio in Bangladesh only 0.4. This falls far short of the WHO standard of 3 nurses per doctor. In other words, there are 2.5 times more doctors than nurses in Bangladesh. Interestingly, the equal nurse-doctor ratio in Khulna and very low nurse-doctor ratio in Sylhet is also associated with better health indicators in Khulna and worse health indicators in Sylhet.
Maldistribution and migration: Over 75% of the population of Bangladesh live in rural areas, but have less than 20% of the health workforce available to them. A gross imbalance in distribution of workforce favoring urban areas is exacerbated by both internal and international migration for Bangladesh.
There is an overwhelming bias towards urban areas in the distribution of HCPs. The doctor to population ratio is 1:1500 in urban areas and 1:15000 in rural areas. There is also substantial variation among different divisions, with Dhaka having the highest density of physicians followed by Chittagong, while this trend is reversed for nurses.
Another factor that contributes to rural-urban imbalance is the high rates of vacancy in the public health system. The vacancy rates, the difference between the sanctioned number of workers and the actual numbers in post, are higher in the rural and the poor regions of the country. For example, 40% of the Upazila Health Complexes (UHCs) have no RMO (Resident Medical Officers), and up to 74% of UHFWCs (Union Sub-centers) have no Medical Officer. Bangladesh government has sanctioned 20,234 positions for physicians of which 11,300 are currently filled up, which means a total vacancy of 44.2% across the country.
Finally, the male bias among doctors in the formal health sector of Bangladesh compromises women’s access to culturally appropriate health services.
Weak knowledge base: The poor knowledge base about the workforce hampers planning, policy and programs.
Negative work environment: Bangladesh is unable to educate and sustain the right kind of health workforce. It must develop strategies to retain their skilled workforces by creating more positive work environments in which workers feel recognized, rewarded, and productive. For example, 20% of registered doctors and 11% of registered nurses produced are not on the health workforce of Bangladesh.
Nursing Workforce in Bangladesh
The Nursing profession is an indispensable piece of the health system. Nurses play a vital role in the treatment and recovery of patients. As a 93% women-majority profession in a traditional society like Bangladesh where many women may not seek care for themselves or their children without access to a female health care provider, the nursing profession represents an opportunity to bridge understanding of women-specific problems and the peculiarities of their utilization patterns. The Bangladesh Government has recently upgraded the status of entry-level nurses to Class 2 employees due to their contribution towards achieving MDG’s 4 and 5 thru promoting health and reducing mortality, morbidity and fertility rates.
As of January 2011, Bangladesh had 26,644 registered nurses with 17,605 posts in the public nursing services and education, of which 15,086 nurses are working in the public sector and 2,513 posts are vacant. Vacancies in public sector posts are higher among nurses of higher qualification, with 96% of class 1 (senior) posts, 68% of class II (junior) posts, and 20% of class III (aide) posts being vacant!
It is estimated that around 3,000 registered nurses are employed in the private sector, and about 3000 are working abroad. A study suggests that 99% of nurses are employed in hospitals while another source suggests 95% work in urban hospitals and clinics.
Bangladesh has a population-nurse ratio of 5000:1, a bed-nurse ratio of 13:1, and a doctor-nurse ratio of 2.5:1. These fall far short of the international standard for bed-nurse ratio of 4:1 and doctor-nurse ratio of 1:3. Thus, there is acute scarcity of nurses for providing inpatient care, where inadequacy of HCPs is a strong limiting factor of population health. Also, with more physicians than nurses, the role of the nurse is very circumscribed, and doctors perform many tasks that nurses are qualified to do, either as a job preservation strategy or due to a lack of confidence in the capability of nurses.
Bangladesh faces a shortage of 280,000 trained nurses, which is a major obstacle towards achieving its MDG targets, as well as national health goals outlined under the 2011-2016 Health, Population and Nutrition Sector Development Program (HPNSDP) and the 2008 Bangladesh Health Workforce Strategy. In other words, a tenfold increase of the current size of the nursing workforce is needed!
Each year, public Nursing Institutes graduate 1250 nurses, while private Nursing Institutes graduate 530 nurses. This level of production is clearly inadequate to fulfill the current demand of trained nurses in Bangladesh without significantly increasing institutional capacity. Unfortunately, public Nursing Institutes face the following constraints in terms of establishing quality and increasing capacity:
Faculty shortages: There is an acute shortage of teachers, with one-third of all sanctioned posts of nursing instructors in public NIs vacant. The resulting teacher-student ratio is very high at 1:57, where a ratio of 1:20 is considered to be the standard.
Teaching capacity: Scarcity of faculty with nursing specialty knowledge and clinical skills coupled with limited teaching and learning resources pose significant losses with regard to appropriate facilitation of learning and assessment. Most of the teaching institutions run by the deputed nursing staff. Students are also taught by physicians, medical assistants, and retired faculty who often work in more than one place.
Curriculum: Principals, teachers, and students have reservations about the current curriculum and syllabus. Students cite complaints about outdated syllabus and limited knowledge of nursing received through training. Although there has been international support for curriculum development, teachers may simply continue with previous lectures because they lack capacity or resources to deliver the new courses.
Infrastructure: A lack of sufficiently sized classrooms and accommodation result in overcrowding of students hampering both quality of education and life.
Facilities: Many institutes lack sufficient equipment for practical training, and most students also feel the number of practical classes is insufficient for training.
Along with the challenge of meeting the shortage of nurses, the question of quality is key. According to HPNSDP, the quality of nursing education and training does not meet the demand of the health sector in Bangladesh and is far from availing the opportunity of the demand for nurses in the international market, and consequently many private hospitals with specialized services rely on nurses from abroad. It also found the quality of nurses to record and report in English to be poor, and interaction with patients and their attendants needing improvement.
HPNSDP also recommends that nursing services be expanded to cover specializations such as cardiology, pediatric, community, psychiatric, gerontology, trauma & orthopedic, nephrology, neurology, etc. According to 2008 DFID review of nursing crisis in Bangladesh, experts agree that it is crucial to see an increase in baccalaureate education and the need to hire qualified external faculty until local capacity is developed.
In terms of quality of care delivery, several studies have revealed nursing services at public hospitals in Bangladesh to be inefficient and ineffective.
Bridging the Nursing Gap
According to NHSDP, nursing services is the weakest of all the HPN service providing organizations in the public sector. Although Bangladesh has the necessary human resources for contributing to the international market, existing nursing curriculum will need to be updated to international level to produce quality nurses of international standard, along with communication skills development.
Pre-Service Education and Training need to be prioritized in both public and private sectors to meet shortage of qualified nurses and improve service delivery particularly to achieve MDG 4 & 5. Continuous need-based In-Service Training programs, local & foreign, need to be identified, contracted out, and imparted to improve existing quality of nursing services.
Establishment of new Nurse Training Institutes and Nursing Colleges will provide skilled and qualified nurses to meet the existing acute shortage of Nurses in Bangladesh, and be a source of meeting the need of technical personnel in both the public and private sectors. In addition, Nursing Colleges need to be strengthened to introduce Post-graduation program. Such personnel may also become a source of earning valuable foreign exchange for the country by rendering their services abroad.
The current supply of nurses will not meet the shortage even in decades, and the current quality of nurses will not suffice to generate positive health outcomes at scale and address evolving health needs.
The choice is to opt for affordable, quick-win strategies for the short and medium terms that maximize returns from the existing health workforce. Private and not-for-profit sectors can set up Nursing Training Institutes (NTI) offering 3-year Diploma in Nursing Science and Midwifery, and Nursing Colleges (NC) offering 4-year B.Sc in Nursing, 2-year Post-basic B.Sc in Nursing for Diploma nurses, and 3-month Diploma in Specialized Nursing.
Global Employment Opportunity
There is a huge demand for qualified nurses in Middle East, North America, Europe, Japan and Australia. USA alone needs 1.5 million new nurses. If Bangladesh can send only 200,000 nurses to these countries for an average yearly salary of USD 70,000 and if these nurses send 50% of their salary to Bangladesh, it will amount to USD 8.5 billion foreign remittance per year. Bangladesh will move from a low income country to a middle income country almost overnight.
Shadab Mahmud is director of partnerships and fundraising, Good HEAL Trust.