HEALTH CARE CRISIS IN BANGLADESH

Briefing Paper 16

February 2012

Summary
There is a critical deficit of trained and licensed health care providers in Bangladesh.1 Vast majorities of the Bangladeshi population live in rural areas and are acutely dependent on traditional/faith healers, village doctors and drug vendors for primary health care. Subsequently there are high rates of mortality caused by treatable communicable diseases such as diarrhea and tuberculosis, as individuals do not have knowledge of, or access to, effective remedies. This brief reiterates the urgency of the matter and suggests possible policy responses.

Key Points
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Traditional healers, including faith healers, and traditional birth attendants have the least amount of training in allopathic medicine and yet they make up 65% of all health care providers in Bangladesh.2 Most informal health providers have a poor knowledge base due to lack of training and access to evidence based research that can introduce new and more effective remedies.

Introduction Bangladesh suffers a severe shortage of qualified health care providers. Health care provider (HCP) density measured in 2011 found a ratio of five doctors and two nurses per 10 000 people in the population.1 There is no consensus on the optimal number of health workers per population, nevertheless it is understood that the number, and quality, of health workers favorably correlates with better health care in a country.9 Bangladesh is a small country with a very large population, approximately 156 million people living in a 55, 813 sq. mi area. This is half the population of the United States in an area the size of Iowa.8 It is estimated that 80% of the population live in rural areas; as a result, there is an incredible gap in access to quality healthcare as the overwhelming majority of trained Health Care Providers (HCPs) are based in the urban areas.

NGOs can step in and play a crucial role in the training and development of Community Health Workers (CHWs) in Bangladesh, currently CHWs only make up 7% of total HCPs, there is significant potential to expand.2

Findings The starting point of this study was an evaluation of health care provision in Bangladesh. The principal objective of this project was to develop a comprehensive view on health care providers and access to/availability of quality health care in Bangladesh. Data collection was carried out through survey and interviews by trained field enumerators, who were chosen by the research team. Structured questionnaires, developed in Bangla, were administered to villagers. Our results reveal a striking deficit in the number of qualified healthcare professionals. The consequence is an increased reliance on the informal health sector for care, which is a cause for concern. Informal providers currently dominate the health work force in Bangladesh, making up a total 94% of the entire workforce.5 The designation informal denotes health care providers that are not associated with any government monitoring system. Informal HCPs include village doctors, drug vendors, traditional healers, faith healers and a certain number of traditional birth attendants (TBAs), homeopaths and community health workers (CHWs). Not all CHWs, TBAs and homeopaths are based in the informal sector; a few are registered with government regulatory bodies. A few community health workers (CHWs) are affiliated with the public sector, however the vast majority of them work in the NGO sector. CHWs have variable lengths of basic preventative and curative health care training from various NGOs, as well as the government.2 As in the formal sector, the vast majority of CHWs are trained in allopathic medicine, which is evidence-based medicine or conventional medicine, and they make up For various reasons, Bangladesh struggles with retaining trained health professionals in the country. A number of participants voiced in the interviews that the health system is extremely overburdened and compensation is poor for the few that remain. They also sited lack of equipment and inadequate supplies barriers to practicing their vocation.7

Actions to Consider
A proactive way to approach this would be to see about the ways in which the formal and informal health providers can develop collaboration which can facilitate a steady incorporation of informal health care providers into the formal system.

Formal healthcare providers (HCPs), of which include doctors, nurses, paramedics, dentists, etc. represent only 6% of HCPs in Bangladesh. Village doctors and drug vendors each represent 8% of HCPs. Most village doctors have received short training (few weeks/few months) to treat common ailments and disease with allopathic medicine. However they are still classified as unqualified allopathic providers as their trainings are organized by semi-formal unregistered primary institutions which are unregulated and do not have a standard curriculum. Most of the drug vendors have no training in diagnosis or treatment.2

Although a few homeopaths have attained qualifications from private homeopathic colleges or the government, most homeopaths are trained informally. Their knowledge and skills are gained from apprenticeships and/or self-training. 2 This applies to Traditional birth attendants (TBAs) as well; they provide services for only home-based deliveries. Traditional healers, who also attain

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Traditional healers, including faith healers, and traditional birth attendants together comprise of 64% HCPs. Of all informal HCPs in Bangladesh they have the least amount of training in allopathic medicine. Findings reveal a majoring of these providers lack the necessary training and capacity to provide basic curative services prudently.2 With the exception of TBAs and CHWs, a vast majority of informal health care providers are male.

The health crisis in Bangladesh is exacerbated by very limited access to quality health care. This is especially so as the majority of HCPs in the country are wholly unqualified and thus unable to provide effective treatment and curative care for a large number of the population. Studies show widespread misuse of prescription drugs by both patients and informal HCPs. Evidence reveals many cases of patients, under the direction of poorly trained HCPs, consuming exceptionally high doses of antibiotics, or cocktails of drugs with unfortunate results. Informal HCPs, on many occasions knowingly and unknowingly, provide expired drugs to patients because they are more affordable. There have been numerous incidences of traditional/faith healers prescribing the wrong drugs or no allopathic drugs at all for ailments such as fever, diarrhea, etc. The acute shortage of health human resource in Bangladesh retards the efficient function of the health system of the country.5 It is unlikely that this shortage will be met in the near future, however, it is imperative that measures are taken immediatelybyline to ensure long-term improvement in the Bangladeshi Lorem Ipsum health care system.

Breakdown of Health Care Providers in Bangladesh

Traditiona healers, Faith Healers & TBAs Village Doctors/Drug Vendors Community Health Workers Homeopaths Formal Sector

High gender inequalities, especially in the rural areas, means girls and women cannot afford and thus do not have access to adequate sexual and reproductive health care. Several from the WHO showed critical health consequences arise shortage of qualified HCPs. A 2008 (World Health Organization) report that

Pneumonia, diarrhea, neonatal sepsis and birth asphyxia was responsible for 60% of deaths in children under 5. Approximately 39% of children under 5 are stunted (i.e. undersized due to malnourishment). Maternal mortality rate is 348 per 100,000 live births. This is compared to the global average of 210. Communicable diseases, such as Malaria, tuberculosis and diarrhea, accounted for 52% of deaths in the country. According to 2009 data from the WHO, the prevalence of tuberculosis in Bangladesh is more than twice the global average.

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POLICY CONCLUSIONS

It is habitual of formal sector practitioners to dismiss informal health care providers, constantly referring to them as quacks or sham doctors. Considering the enormous dependence on informal health care providers, this is an unproductive stance to take as it can alienate patients. Education and training play a vital role. Training packages aimed at expanding the knowledge and skill base in conventional medicine, and also improving traditional medicine, will ensure that informal health providers are more effective. There is enormous potential for NGOs to play a key role in expanding training and development programs for Community Health Workers.

Advances in mobile technology could be used advantageously allowing traditional healers in rural areas the means of contacting registered doctors/nurses, located primarily in urban areas, for consultation on behalf of the patient, and if necessary referrals.5 Finally wide consultation with actors in both the formal and informal sectors on their needs and constraints will reinforce the shared responsibility to improving health provision in the country. _________________________________
Written by s1144010. Contact: s1144010@sms.ed.ac.uk

Reference:
1. Ahmed SM, Hossain AM, Chowdhury RM, Bhuiya UA. 2011. The health workforce crisis in Bangladesh: shortage, inappropriate skill mix and inequitable distribution. Human Resources for Health 9: 1-7. Ahmed SM, Hossain AM, Chowdhury RM. 2009. Informal sector providers in Bangladesh: how equipped are they to provide rational health care? Health and Policy Planning 24:467-478. Bloom G, Standing H, Lucas H, Bhuiya A, Oladepo O, Peters HD. 2011. Making health markets work better for poor people: the case of informal providers. Health Policy and Planning 26: i45-i52. Hamid SA, Roberts J, Mosley P. 2011. Can Micro Health Insurance Reduce Poverty? Evidence From Bangladesh. The Journal of Risk and Insurance 78: 57-82. Mahmood SS, Iqbal M, Hanifi SMA, Wahed T, Bhuiya A. 2010. Are Village Doctors in Bangladesh a curse or blessing? BioMed Central: International Health & Human Rights 10: 1-10. Rashid FS, Akram O, Standing H. 2011. The sexual and reproductive health care market in Bangladesh: where do poor women go? Reproductive Health Matters. 19: 21-31. 7. 8. Rahman RM. 2006. Human rights, health and the state in Bangladesh United States Department of State. 2010. Background Note: Bangladesh. Online at: http://www.state.gov/r/pa/ei/bgn/3452.htm, accessed 25 February 2012. WHO. 2012. WHO Statistical Information System (WHOSIS): Human Resources for Health. Online at: http://www.who.int/whosis/indicators/2007HumanRes ourcesForHealth/en/, accessed 25 February 2012.

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Photo credits: 1. PResponsibility. Copyright 2009. Amanda Hayes. Online at: http:// amandahayes.wordpress.com/2009/03/02/a-pepsi-a-day-keeps-thedoctor-away/. Qamruz Zaman. Copyright 2008. Online at: http://www.news.xinhuanet.com/english/200804/content_8005020.htm RAHFT. Copyright 2008. Cholera Hospital, Bangladesh. Online at: http://www.rahft.org/what-we-do Superstock. Copyright 2012. Online at: www.superstock.com/stockphotos-images/4102-20749 Khabor. Copyright 2009. Ambulance donated to Bangladesh. Online at: http://www.khabor.com/english/news/KN00604200901.htm Millard Jillian. Copyright 2010. Online at: http://www.mrsshinersglobalstudies8.wikispaces.com/file/detail/heal th%2520care%2520india.jpg

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The University of Edinburgh

Old College South Bridge, Edinburgh, Midlothian EH8 9YL Tel: 0131 650 1000 info@sms.ed.ac.uk

This output is funded by the University of Edinburgh, a research institution which is funded in part by the Scottish government. The views expressed are those of the author and do not necessarily reflect on the University of Edinburgh.