Where do the poor go for treatment? Who are the main providers of health care? Studies on health-seeking behaviour of the disadvantaged population in rural areas (demand-side perspective) as well as the recently conducted study on the de-facto composition of the health care providers in Bangladesh (supply-side perspective) give us some clue:
- When people do go to a provider, the first contact is with an informal provider (20-30%)— (drug shops attendants and the Village doctors ).
- Semi-qualified para-professionals (medical assistants, mid-wives) and community health workers (CHWs) are main provider of formal allopathic care in more than 25% of illness episodes.
- Qualified modern providers (physicians, dentists, nurses) constitute only 5% of the entire providers.
What can be done/should be done? These issues (including governance issues) are touched by the Health Policy somewhat, but the solutions are not adequately presented. Here are our suggestions:
- Self-care is regarded by the WHO as ‘a primary public health resource in the health care system’. To use this resource to its full potential, its integration as an essential, informed and efficient component of the primary health care and as a cost-effective complement to the formal healthcare, is long overdue in Bangladesh.
- Given the shortage of supply of qualified health care professionals in Bangladesh, the importance of unqualified/semi-qualified practitioners as major providers of healthcare to the poor should be recognized by the public sector, and their capacity developed in a planned way so as to ensure that the poor and the disadvantaged get an acceptable level of care, at least in the short-term, until supply side constraints can be alleviated. Studies from Vietnam, Laos, and Thailand and Nepal show that education and training efforts are necessary to change practice of irrational and harmful use of drugs by these providers, besides managerial and regulatory interventions.
- The education and training system for producing health manpower should be geared towards producing more technologists and nurses than physicians. In the present system, many of the tasks of the nurses are done by the physicians and many of the tasks of the clerks are done by the nurses. This should be changed (e.g., appointment of ward clerks in in-door health facilities who will maintain the inventory of materials in the wards instead of the nurses) so that the doctors and the nurses can devote most of their time for the care of the patients.
- The education curriculums for physicians and nurses should be reorganized in such a way that the students get acquainted with the health problems and health systems of the country early in their education. The culture of responsiveness and empathy towards patients should be pro-actively nurtured throughout the period of education and in-service training. The internship should be extended for six more months for hands on training in the rural upazila health facilities.
- Creating an enabling environment at the upazila level and mapping a career path is absolutely necessary for retention of doctors and nurses at the rural areas. Performance-based assessment of the health workers should apply reward and punishment for improving the attendance and quality of care provided.