Health workforce in Bangladesh: Who constitutes the healthcare system?

11 July 2008

Health care workers form the backbone of functioning health systems. They are the midwife who helps deliver your baby, the lab technician who processes your HIV test, the doctor who stitches you up after a traffic accident. In 2006 the World Health Organisation estimated that there was a global shortfall of 4.3 million trained health workers.

To those concerned with improving development outcomes this should act as a startling wake up call. How on earth will we meet Millennium Development Goals 4, 5 and 6 – on child and maternal health and communicable disease – without adequate human resources for health?

Bangladesh Health Watch

This is a question that has been taken up by this year’s Bangladesh Health Watch report which poses the question 'Health workforce in Bangladesh: Who constitutes the healthcare system?'. Bangladesh Health Watch is a civil society network that regularly and systematically assess Bangladesh’s health performance. The research that they conduct is a way to involve citizens in health policy and practice.

Rather than focussing on a narrow range of health care providers the report includes traditional, and semi or unqualified health care providers in its assessment of who is providing frontline support to communities. The rationale for this is that, in common with many developing countries, Bangladesh has inadequate numbers of health staff trained in public health and they are not distributed in the right geographical areas. As a result, for example, only 18% of births have skilled attendance. In fact, 95% of the health workforce are non state providers who are largely unrecognised by state regulation and policy.

Non-state health care providers

Over 80% of Bangladeshi’s turn to non-state providers as a first port of call when they fall ill. These health care providers include traditional healers, traditional birth attendants, village doctors, drug stores and NGO trained community health workers. Bangladesh Health Watch have discovered that there are only 5 physicians and 2 nurses per 10,000 of the population as opposed to 12 village doctors and 11 drug sellers. Community members often value informal providers as they only charge for the drugs, not the consultation. They also offer flexible payment schemes.

The report looks at the strengths and weaknesses of providers and offers suggestions for where improvements can be made. It is not uncritical of the quality of health service that is often supplied by informal providers but it argues that this is a reason that they should be trained and managed effectively. They conclude that the quality of care - across the board in the public and private sectors - needs improvement. Currently, unqualified providers give drugs and advice but rarely rely on laboratory testing or refer appropriately to the formal sector. This leads to problems related to the inefficient and improper prescribing of drugs which can lead to continuing ill health and impoverishment. 

One of the Future Health Systems partners Dr Abbas Bhuiya of ICDDRB was a member of the Working Group that helped put the report together. Future Health Systems is a research consortium that addresses fundamental questions about the design of health systems and works closely with people who are leading the transformation of health systems in their own countries. The aim of the research that the Bangladesh team are undertaking is develop a package of interventions to engage with the informal health care providers. They are working to improve the quality of services and establish accountability to improve the health of the villagers, especially the poor.

Please see the Future Health Systems website to read more about this research and other work with health providers in the private and informal sector.