Human Resources For Health: Foundation For Universal Health Coverage And The Post-2015 Development Agenda..
Bangladesh has shown remarkable improvement in certain health and population development indicators. There has been a comprehensive network of government health facilities to provide maternal, neonatal and child health services down to the community level. Despite the sincere efforts of the government, the impact of this comprehensive health service network has been much less than the expected level, largely due to shortage of health workforce, their optimal utilization and inadequate quality services provided by them. The importance of investing in human resources for health has been reiterated globally. There is severe shortage of skilled health workers in the places where they are most needed.
Bangladesh is one of the 57 WHO member countries who have been facing severe crisis in human resource for health (HRH). Like other South-east Asian countries, our problems in HRH include shortage of manpower, skill-mix imbalance, migration of work force, underdeveloped work environment, poor knowledge-base and so on.
The third Global Forum on Human Resources for health convened by the Global Health Workforces Alliance (GHWA) and hosted by the Government of Brazil with support from World Health Organization (WHO) and Pan American Health Organization (PAHO) will take place in November 2013. It is an opportunity for Bangladesh to raise voice for increasing awareness about health workforce issues and elicit new HRH commitments to build the health workforce needed to achieve Universal Health coverage.
The Ministry of Health & Family Welfare (MOHFW) in collaboration with CARE Bangladesh and GlaxoSmithKline (GSK) organized a round table titled “Human Resources for Health: Foundation for Universal Health Coverage and the post-2015 development agenda” on November 3, 2013.
Md. Zillar Rahman, Additional Secretary & Line Director Human Resource Management (HRM), Ministry of Health & Family Welfare presided over the discussion. Two papers were presented on the discussion topic. First one was presented by A.K.M Zafar Ullah Khan, former Secretary MOHFW on behalf of CARE and GSK. This paper was presented before on October 7, 2013 in a workshop presided over by M. M. Neazuddin, Secretary, MOHFW. Based on that presentation and incorporating findings and recommendations of the workshop a keynote paper was prepared. Md. Asadul Islam, Director General, Health Economics unit (HEU), MOHFW presented the keynote paper in the round table on November 3, 2013. A. K. M. Zafarullah Khan moderated the round table discussion.
The keynote paper was presented by Md. Asadul Islam, Director General, Health Economics Unit (HEU), MOHFW
Keynote papers showed the present scenario of health service facilities and health professionals in Bangladesh.
In Bangladesh, health services are provided at three levels: primary health care–from the Upazila level down to the community level, secondary level — district level hospitals and health care and tertiary level — University, Medical Colleges Hospital and Specialized health care. Primary health cares are given at the three levels form three different types of facilities: Community Clinics for a population of six thousand at the community level, Union Health and Family Welfare Centers (UHFWC) for a population of about thirty thousand at the union level, and Upazila Health Complex (UHC) for a population of about 3-4 lacs at the upazila level. At the district level, secondary level district hospitals, with 150 – 250 beds, provide secondary health care services. Medical College Hospitals and Specialized Hospitals and Institutes provide tertiary or specialized health services in urban areas.
The number of qualified doctors including dentists is about 66 thousand that means the ratio stands at 0.44 per thousand populations that is far below WHO standard of 2.3 per thousand populations. We find a reverse trend in Nurse-doctor ratio. At present, there are 30,680 nurses in the country. The number of medical technologist is also scarce. For 150 million populations there exist less than a hundred thousand medical technologists.
The workshop and the round table identified the following major HRH issues and challenges: shortage of HRH, skill-mix imbalance and mal-distribution of HRH, inadequate educational and training facilities, low quality of HRH, inefficient allocation of resources, lack of incentives and proper remuneration, absence of HRH monitoring and information, lack of regulatory arrangement for private provider, migration of Health Workforce, absence of HRH development plan and week governance.
A.K.M. Zafarullah Khan
A.K.M. Zafarullah Khan, Former Secretary, MOHFW & Moderator
In 2009, GSK announced its commitment for the least developed countries. Under this strategy, GSK will reinvest 20% of its profits made in least developed countries into health care infrastructure to strengthen the capacity and capability of community health work forces working in rural and marginalised areas.
Under this initiative, GSK in partnership with CARE Bangladesh developed a project to strengthen the health care system, particularly strengthen the community health workforces to provide health care services in the hard-to- reach areas. GSK- CARE initiative has identified the third Global Forum convened by the Global Health Workforce Alliance as an opportunity for Bangladesh to raise voice for increasing awareness about Health Workforce issues and elicit new HRH commitments to build the health workforce needed to achieve Universal Health Coverage.
Human resource for health is a global problem. Bangladesh like all other developing countries is facing the severe shortage of health workforce. We produce a good number of health resources but cannot retain them because many of them migrate to developed countries. There is also rural-urban mal-distribution. Our rural areas have remained deprived since trained doctors do not want to compromise with the urban living standards and facilities.
Dr. Ubaidur Rob
Dr. Ubaidur Rob, Country Director, Population Council
Since population remains a development concern for Bangladesh, all planning and strategies for development needs to be based on proper knowledge of the demographic scenario and projections about population. By 2025, our population will be around 200 million. So our planning for HRH should be planned according to that number of population. We have to keep in mind that creating additional post or manpower is a time consuming process. As an alternative, we can train our existing FWAs/FWVs in nursing and make use of them for providing primary health care services.
Our projection of HRH is based on need, not population. This is a major predicament. We have to combine both the population and their need. Now, we have a clear projection of our population. So, we can easily formulate a production and supply plan based on that projection. We should also make a plan for rural – urban distribution of HRH. The number of aged people in our country is approximately ten millions. We have to also make plan for special kind of HRH for the growing number of our aged population.
We should also carefully think about the issue how long we will continue the door to door family planning service. We have approximately 50,000 field-based work forces. Soon they will retire. Then if we replenish those posts with new recruitments it will be for 35 years more. Do we really need such huge number of field- based workers for that long period? When our rural level hospitals will be equipped and strengthened enough to provide services to the community population, this huge number of health workers will be redundant.
Dr. S. A. J. Md. Musa
Dr. S. A. J. Md. Musa, Director Primary Health Care & Line Director Maternal, Neonatal, Child & Adolescent Health, DGHS
Globally, countries are trying to solve the crisis of HRH in a time befitting manner. Bangladesh has also taken some good initiatives like task shifting, equal distribution of work force and skill mix up.
We have already a plan of strengthening the Upazilla Health System where there will be adequate HRH and resources. We have a detailed plan about that. Implementation of that plan can be a prominent commitment. The question of switching of field-based manpower should be dealt with proper consideration. In an ICDDR,B study it was found that if need could be generated through intensive work of field workers, people would continue the practice even after the withdrawal of field workers.
The role of private sector is very prominent in our healthcare system. At present, government is formulating a plan for the entire healthcare system including both public and private sector. To be more fruitful, separate plans and strategies necessary for public and private health sector to encourage private sector. Another point is the quality of healthcare services. We have a large number of primary health workers at community level. If we can ensure quality of these health workers, we will be able to provide primary health care services successfully.
I know about a health-training institute that provides only one month training to CSBAs while six months training is mandatory for CSBAs. This is violation of Nursing Council’s guideline, and obviously dangerous. That’s why there is a need for certain regulation arrangement from the government side.
Dr. Jahangir Hossain
Dr. Jahangir Hossain, Program Director-Health, CARE Bangladesh
In Bangladesh, new diseases especially non-communicable diseases like diabetes, high blood pressure are becoming serious concern. We should look into this issue seriously and prepare our HRH projection accordingly.
We can promote public private partnership in production and supply of HRH. Many private organisations have already started doing this. Government should promote these initiatives as well as play an effective stewardship role.
Many NGOs have been producing community health workers in remote areas. Most often these NGO initiatives are taken on project basis and therefore not sustainable.
In order to develop a sustainable solution to address the community level HRH in remote areas, CARE Bangladesh with the financial support from GSK has been implementing a public-private partnership (PPP) initiative. This PPP initiative has produced 150 private CSBAs in remote areas of Sunamganj district where roles of MOHFW, Local Government (LG) bodies, community and NGOs are clearly defined so that these private CSBAs will be continuously supervised, monitored, promoted, and supported by MOHFW, LG and community once NGO supports are withdrawn. Hope, the lessons of this PPP initiative on HRH will enable GoB to address the community level Health Work Force issue in remote underserved community in Bangladesh and elsewhere.
Interestingly the ACCOUNTABILITY piece is missing in the HRH framework towards UHC is availability, accessibility, acceptability and quality (three AAA and one Q) of HRH. I strongly recommend to add one more A, that is accountability. In Bangladesh, we have hospital management committee for ensuring accountability in every hospital but most of them remain dysfunctional. There is no government arrangement to collect their recommendations and take initiatives accordingly. Therefore, members of the hospital management committee do not feel encouraged to attend such meetings.
Government should also encourage people in sharing their views on health services. We can introduce community scorecard where community members and service receivers will give their suggestion to improve the health service.
Mohammad Bellal Hossain
Mohammad Bellal Hossain, Associate Professor & Chairperson, Dept. of Population Science, University of Dhaka
We have been repeatedly suggesting for using vocational and technical institutions to produce HRH. But the proposal gets little focus from the policy makers. We should emphasize on producing nurses. It will reduce pressure on doctors and create skilled HRH who can also earn huge foreign currency for our country.
A.K.M. Zafarullah Khan
We should emphasize more on number of hospital beds than number of hospitals. Only then, we will get the real scenario of HRH need, particularly the requirements of nurses in the country.
There was a government policy that all medical colleges should have nursing institute but now we have so many private medical college most of which are without nursing institutes. Private medical college owners care more about business which may not be met by nursing institutes. Government should revive that policy and all private medicals should have nursing institutes.
Dr. Mohammed Sharif
Dr. Mohammed Sharif, Director (MCH-Services) & Line Director (MCRH)
Our field workers have to carry out CSBS on top of regular field based activities. Their workload is exhaustive. Previously we had one FWA for 600 couple and now it has come down to one FWA for 1800-2000 couples. We should rather increase the number of FWA.
Another forgotten area is urban slum. We have improved services in rural and urban areas. But the service situation in urban slums is terrible. Still we find 8-10 children of a couple. We should give special attention to this matter.
A. K. M. Amir Hossain
A. K. M. Amir Hossain, Director General, DGFP
We have started an intensive program of establishing Union Health Centre in every union. These centers provide 24- hour delivery services. So far, we have established 1100 such centers. To empower the whole program with proper manpower we need more field level workers.
The question of services in slum area is very important. MOHFW does not look after this area. DGFP is also in dark. We should immediately recruit people for introducing services in slum areas.
Dr. Khaled Hassan
Dr. Khaled Hassan, Medical Officer, World Health Organization
There are five ways of projecting HRH need. The easiest way is population and professional ratio. And this method is well accepted globally. So we should also do that. When we are going to make some commitment we should emphasize on smart and achievable targets based on standard projection.
Bangladesh has been scaling up nursing profession. But there is unemployment problem of the nurses and at the same there are shortages of nurses. There is a lack of coordination. Government should look after it.
As a low budget health sector, Bangladesh is promoting different categories of HRH like paramedics, Community Skill Birth Attendant (CSBS), Community Health Workers (CHW), Family Welfare Assistant (FWA) and so on. This is a recommendable initiative. Bangladesh should make the commitment that they will strengthen the low cost initiative more.
Number of hospital does not mean much. We have to count beds and number of professionals to attend those beds. That can give a real picture.
The stronger the regulatory body the more they have power to control. The Bangladesh Medical & Dental Council (BMDC) regulation was updated in 2010. But The Bangladesh Nursing Council (BNC) regulation remains unchanged although several attempts have been taken in the last 10 years. To strengthen regulatory bodies we have to update this regulation. This can be a commitment.
Prof. Dr. Abul Kalam Azad
Prof. Dr. Abul Kalam Azad, Additional Director General (Planning & Development) & Director MIS, DGHS
Each year we are producing 14,255 medical Technologists. Among them 2,684 are from public institutions and 11,391 from private institutions. So, private sector is doing more. The trend will continue to remain so.
Our health sector is not entirely dependent on public sector. A robust private sector is supporting our universal health coverage significantly. But there is an important point to note. Though the public sector has limited number of HRH they are equally distributed. In case of private sector, we only find HRH in their project areas. This is where the government has to take the lead. If we use information system to assess different needs of different geographic locations, we can achieve universal health coverage through rational distribution of our existing HRH.
Universal health coverage does not mean only primary health care. It is assurance of providing every type of health services. In that regard we can also partner with private sector. The government has to ensure that if the private sector takes initiatives then the government will provide them all necessary supports.
Community health care programs should be subsidized by both public and private sectors. In case of doctors, nurses and medical technologists we should promote private sector. If private sector provides standard health care services, government will reimburse them. And if it is ensured by the government the private sector will gear up their standards and spend more. Governments also have to have proper regulatory capacity to monitor private sector’s performance.
Ms. Peggy Thorpe
Ms. Peggy Thorpe, First Secretary (Development) & Team Leader – Health Program, Canadian High Commission
Private organizations are doing a lot in the health sector. They train and produce HRH. But after completion of training who will recruit these HRH. That is an important question. MOHFW should take the lead in creating employment and distribution of these HRH.
M Azizul Huq
M Azizul Huq, Managing Director, GlaxoSmithKline
We are very impressed with the Government’s milestone achievements in the overall improvement of the country’s health sector infrastructure specially in building an efficient health work force. We, from GSK through our Private Public Partnership (PPP) with CARE and the MOHFW, are glad to be a small part of the huge health HR infrastructure that the Government is building. Following our global commitment made by GSK’s global CEO, Andrew Witty, to become a partner in finding solutions to healthcare delivery, we in partnership with CARE and MOHFW are reinvesting 20% of our profits to develop first line healthcare workers with a primary target to improve MNCH services at the hard-to- reach areas of Bangladesh
We are also greatly encouraged to see the support MOHFW is providing to the private sector to implement health initiatives. We hope that in future many other private sector participation will take place and significant number of Private Public Partnership like ours will be formed, which will assist and supplement the Government’s public health initiatives.
Md. Zillar Rahman
Md. Zillar Rahman, Additional Secretary& Line Director HRM Unit, Ministry of Health & Family Welfare (MOHFW)
We have gained a tremendous progress in terms of HRH and we will continue to develop that. We have done a recommendable job in both public and private sector. But we should not be complacent because we have to do more to keep pace with the growing population. That is the challenge.
We have ensured at least some training to our health workers. They can provide Primary Health Care services, a limited curative care and at least recommend the patient to contact with nearby medical professional. This is a huge advancement. We have already discussed about the financing in the presentation. I think our commitment should be gradual increase of fund for HRH. We have introduced incentive from demand side for the poor clients. We can also provide incentive from supply side. This can be a commitment.
We have already introduced participation of community stakeholders. We can make commitment to strengthen it more. We have also started performance management system. We can strengthen it more as a part of strengthening our overall management system. We can implement the accountability framework from updating the job description to ensuring accountability of regulatory bodies. The last point is to strengthen the regulatory bodies.