Farida Akhter
Shortage of doctors and nurses: Dismal picture of the rural healthcare in Bangladesh
In the rural Bangladesh, people go to “Sorkari Haspatal” (the government health facility) because they know that the ‘Daktar shaheb’ (doctor) is qualified. In times of sickness, they prefer government hospital over a private one, because it is “free” or much less costly than the private treatment. Most importantly, they trust the doctors. They feel it is their right to receive services from a government hospital. For a village patient, the nearest sophisticated health centre is called Upazilla Health Centre, established for a population of 200,000 to 350,000. The services are available are for treatment of common diseases, emergency services and injuries. But the question is, are the doctors available?
Bangladesh is suffering from severe shortage of doctors, nurses and midwives along with a mismanagement of related technicians to facilitate the service delivery. In other words, there is severe shortage of health workforce. WHO Report 2006 defines health workers to be “all people engaged in actions whose primary intent is to enhance health”. It has placed Bangladesh in one of the 58 countries identified with having severe shortage of doctors, nurses and midwives. According to a study, it was found that Bangladesh has the lowest number in the sub-continent; 7.7 doctors/nurses, dentists per 10,000 population compared to 12.5 for Pakistan, 14.6 for India, 21.9 for Sri Lanka, and WHO estimate of 23.0 required to fulfil MDG targets. 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. There is also a gross imbalance in the doctor-technologist ratio as well, the ideal being five technologists for one doctor. According to the WHO estimate, Bangladesh has a staggering shortage of 60,000+ doctors, 2,80,000 nurses and 4,83,000 technologists. [http://syedmasudahmed.blogspot.com/2012/06/bangladesh-faces-severe-shortage-of.html] 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 has centrally controlled health care facilities through the Ministry of Health and Family Welfare under decentralised administrative system. Upazilla or the sub district is the lowest tier of the administration. The health facility called Upazilla health complex has the potentiality, but not the capacity to address the needs of the population for ensuring their health needs. For example, Upazilla Health complex of Delduar in Tangail district, (which is within 100 km from Dhaka) there are 17 approved posts of doctors and 12 approved posts of nurses. This is a 31 bed hospital, with three Union Sub-centres, Delduar Upazila has 3 Union Sub-Centres, 6 Union Health and Family Welfare Centres, 26 Community Clinics and 1 Chest Disease Clinic (TB clinic). CHCP and Health Assistants are providing services at community clinic. During 2012, 62361 patients visited the hospital (mostly women 58%, children 17%), for indoor services it is mostly women. Out of 2751 patients, 1519 (55%) were women. Common diseases such as diarrhoea (23%) are the highest reason for admission, but assault (14%) follows as the next important reason. Doctor sanction post is 17 and filled-up post is 17, class II sanction post is 11 and filled-up post is 11, class III sanction post is 69 and filled-up post is 67, class IV sanction post is 23 and filled-up post is 18 in delduar UHC.
In contrast, Kutubdia upazilla health complex with 50 beds has 27 posts for doctors out of which only 5 are available. The vacancy rate is 81%. Only one nurse out of 12 nursing posts is available. The hospital has treated around 45,689 patients during 2012 through UHC, UH&FWC and community clinic. The upazila health complex consults around 2090 patients every month. “The patient load is high is this hospital & the human source is low. Sometimes it becomes difficult to manage all patients” according to Ministry of Health and Family Welfare Health Bulletin 2012.
Although Upazilla health centres are the ‘nearest’ health facility for the rural people, for a patient in the village within the Upazilla, it can be as far as 5 to 14 km but it can also be as close as within 1 km distance and therefore has great demand. People are very clever. They do not remain confined within their administrative area and go to the nearest adjacent upazilla or district hospital according to their need. The services are available wherever they go, if the doctors are present.
The establishment of Upazilla Health centres (UHC) has been a good development under the decentralisation of administration policy of the government which started in 1983 & healthcare as part of the social sectors became a part of this system. That means, at the lowest administrative level, the health infrastructure and manpower are there to provide services. If we look at the history of the health care system in this region, there was no scope health service delivery at the rural areas. According to the Report of Health Care System Improvement Committee (1987-88) during the 17th century when East India Company governed this region, health facilities were available only to urban elites in the form of small hospitals. The Thana Health Complex (THC) scheme was approved in 1967. This facility is for a population of 200,000 with services in medicine, surgery, gynae and dentistry and indoor facilities with 31 to 50 bed capacity. After decentralisation, the Thana health Complexes were turned into Upazila Health Complexes with Union Health and Family Welfare Centers, for 20,000 population each providing only outpatient services.
The health complex has three functional elements, (i) a 31-bed hospital including six beds for maternal and child health; (ii) an out-patient department for ambulatory medical care, and (iii) a domiciliary health care wing staffed with field personnel. This complex serves as the first referral level for primary health care. On an average, each Upazilla has 10 unions, with about 20,000 people in each. Union family welfare centers or health sub-centers provide some ambulatory care and serve as the first institutional base for the health and family planning workers responsible for domiciliary care. The domiciliary health and family service is comprised of counselling on family planning services, preventive and promotive health care, and treatment of minor ailments. These domiciliary workers are assisted by health volunteers and trained traditional birth attendants.
But when the question of availability of required health workforces, particularly of doctors arises, the system has been facing tremendous fails. Interestingly, the healthcare system has been under media scrutiny in recent days. A few examples of newspapers reporting will give a good picture of the existing situation. [The information are taken from the Bengali newspapers]
“Gopalpur upazilla hospital is in severe crisis” (Daily Ittefaq, 25 October 2012)
For 350,000 population the only health facility Gopalpur Upazilla Health complex, (under Tangail district) was upgraded to 50 bed hospital from 31 bed. But during a period of nine months 4 Upazilla Health Administration were transferred and for four months, the post is vacant. For a long time, the posts of 9 doctors have remained vacant. Only 8 doctors are managing the patients. The post of anaesthesiologist is vacant so no EOC service can be provided if caesarean section is needed for child delivery. Therefore the Operation Theatre remains locked. In the absence of an administrator the doctors do not come before 10 or 11 am, and they leave the hospital at 1 pm for lunch and do not return. The Dentist comes only once or twice a month from Dhaka. After 5 pm, the Emergency service also closes down. The Medical Assistant and the office peons attend the emergency patients after 5 pm.
The Medical representatives of the Pharmaceutical companies visit the hospitals regularly and sit in the offices of the Medical officers. The Medical officers even attend “conference” called by Medical Representatives in the Hall room of the hospital while the patients are waiting for their services.
It may be mentioned that Gopalpur Upazilla is not considered to be a “remote” area; it is only 140 km from Dhaka which is a reasonable distance to be near to the capital city.
One doctor for 300,000 people! [Daily Samakal, 19 January, 2012]
In Sribordi Upazilla hospital only one doctor is managing the hospital that is supposed to provide services for 300,000 population. Out of 9 doctors sanctioned for the hospital only one doctor is found on duty. He is also on leave for a month, a “guest” doctor is providing the services. A female doctor joined the hospital and next day went on leave for three days, but did not return to work. While people still wait for the doctor’s services. Everyday about 350 – 400 patients are receiving services from one doctor and his assistant. The patients in the indoor wards are attended once a day by one doctor and do not get any service afterwards.
Inactive health services at Khaliajuri [Samakal, 9 January, 2012]
Lack of doctors, nurses and other assistants at the hospital has crippled down the health care for people in Haordip Khaliajuri. Khaliajuri is a remote and neglected area. The Upazilla Health Centre had 9 sanctioned doctors but only 1 doctor was available. Over 100,000 people are dependent on this hospital for treatment. The subcentres under the UHC are also without any doctors. There are only 2 nurses and 2 Medical officers, against 9 nursing and 7 medical assistant posts. The dentist is on deputation in a different place, there is no laboratory technician, so pathology section remains closed.
The hospital is supposed to deal with referred patients, but instead it refers patients to other hospitals. It is mostly used for providing “Medical Certificates” required by people for jobs and other purposes. So it is called “Certificate” giving hospital.
On the other hand, when the doctors are available they do not get the required medical and surgical requisites. In Noagaon Rani Shankoil Upzilla Health complex, the anaesthesia doctor is present but there is no Operation Theatre and the required number of nurses. The surgeon is also available at this hospital, but they cannot perform any surgery. [Jugantor, 31 December, 2012] In Kachua UHC in Chandpur district, the operation theatre is in place, but the post of Surgeon is vacant. There is no Technician for operating X-Ray machine, ECG machine is out of order. The Dental and Medical officer is on deputation. The Gynae consultant has been vacant for long time. [ Daily Ittefaq, 8 August, 2012]
Although poor women are the main users of the UHCs, the absence of gynea doctors deprives the patients. Women in need of reproductive health care have to go to the private clinics and spend thousands of Taka. On the other in another hospital in Sripur [ Ittafeq 16 July, 2012] the gynea doctor is available but has no equipment in the Operation theatre to perform her job.
A glimpse of health workforce: Doctors & Nurses
| Categories of Health Workforce | Total |
| DOCTORS | |
| Total Registered Graduate Doctors | 53063 |
| Percentage of doctors working under Ministry of Health and Family Welfare | 35% |
| Percentage of doctors working under private sector | 58% |
| Percentage of doctors working under different Ministries | 3% |
| Public Medical Colleges | 18 |
| Private Medical Colleges | 45 |
| Sanctioned posts under Directorate General of Health Services (Class I) | 20,704 |
| Existing posts Class I | 15666 |
| Male | 12384 |
| Female | 3282 |
| Vacant | 5038 (24.33%) |
| NURSES | |
| Registered Diploma Nurses (4 years course) | 26899 (28793 BMDC 2011) |
| Nurses currently available | 15,023 (56%) |
| Public Nursing Institutions/colleges | 51 |
| Private Nursing Colleges | 33 |
| Annual enrolment in nursing institutes(Public & private) | 3670 |
| Annual turnout of the nursing institutes | 2700 (73%) |
| anctioned Nurses (Class I) under Directorate of Nursing Services | 166 |
| Post Filled up | 2 |
| Post Vacant | 164 (98.80%) |
| Sanctioned Nurses (Class II) under Directorate of Nursing Services | 485 |
| Post Filled up | 142 |
| Post Vacant | 343 (70.42%) |
| Sanctioned Nurses (ClassII I) under Directorate of Nursing Services | 17322 |
| Post Filled up | 15158 |
| Post Vacant | 2164 (12.49%) |
| Sanctioned Nurses (Class IV) under Directorate of Nursing Services | 869 |
| Post Filled up | 628 |
| Post Vacant | 241(27.73%) |
Source: Human Resource Development Unit; HRD Data Sheet – 2011, Ministry of Health and Family Welfare, GOB
The system of allocation for Medical and Surgical Requisite (MSR) is done on the basis of the number of the beds available in a health care facility without taking into account of the out-patients load. Hence, all the UHCs having 31 beds get the same MSR allocation, even though they may differ in bed utilization rate as well as in the number of out-patients. The allocation for UHCs with 31 beds gets Tk. 3,25,500 per year. This means per (indoor) patient per day MSR allocation is Tk. 29. It rises to Tk. 38 if utilization of bed is in the order of 75 per cent. The actual per patient allocation is meagre by any standard. There is a genuine shortage of supply over and above the problems of pilferage, leakage, and misuse of the medical and surgical requisites at the local as well as higher level. Moreover the supply of medicine available in UHC can meet only one-third of the demand for it.
Delivery of effective and adequate health care services in Bangladesh is handicapped both by severe shortage of resources and the shortages of qualified doctors and nurses. Yet, the common rural patients depend on these Daktar shahebs for treatment.