WHO Report 2006 defines health workers to be “all people engaged in actions whose primary intent is to enhance health”. Health workforce is important because in health systems, they function as gatekeepers and navigators and upon them depend effective or wasteful application of all other resources such as drugs, vaccines and supplies. They are important because it has been found that maternal, infant and child survival is directly proportional to the concentration of qualified health workforce all over the globe.
Bangladesh is one of the 58 countries identified with having severe shortage of doctors, nurses and midwives. According to a recent study, the most common healthcare providers per 10,000 population in the country are: traditional healers (64.2), unqualified allopathic providers (23.9) and CHWs (42.9). It was found that Bangladesh has only 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 fulfill 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!
The large-scale shortage of qualified healthcare providers, coupled with an inappropriate skill-mix (more doctors than nurses and technologists) results in the poor and disadvantaged people seeking healthcare from mostly non-qualified providers in the informal sector. Fortunately, the disease profile in the country does not always warrant provision of services by qualified health professionals only. According to the Bangladesh Bureau of Statistics, the most common illnesses (both sexes) in order of frequency are: fever (55%), pain (10%), diarrhoea (6%) and dysentery (4%). The above pattern of disease burden, at least in the primary care level, can be handled by the paraprofessionals (medical assistants, family welfare visitors (FWVs)), including CHWs, with the establishment of a functional referral system to a higher level of facilities.
The CHWs have been increasing in size since the nineties, with the expansion of the government and NGO health network in the country. They have been found to be cost-effective and useful in situations such as the management of childhood pneumonia, oral rehydration for diarrhoea, screening for difficulty in near vision (presbyopia), and DOTS treatment of tuberculosis in rural Bangladesh. Training may also be provided to improve the competency of the vast army of unqualified providers (especially the village doctors) in rational and harmless healthcare provision. Any concern that upgrading their diagnostic and curative skills may lead to abuse and malpractice may be contained by managerial and regulatory interventions by the public sector.
Reducing poverty through development of a pro-poor health system (mainstreaming large informal sector with supervision and regulation), in a country with large out-of-pocket payments for healthcare, is possible and is urgently needed in Bangladesh.
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