The health system of Bangladesh is characterized by “shortage, inappropriate skill-mix and inequitable distribution” of its health workforce which is essential for improving health outcomes and health status of a country (Ahmed et al. 2011). It is also among the 57 countries with a critical shortage[1] of health workforce (WHO, 2006). The prevailing COVID-19 pandemic situation has exacerbated this already vulnerable situation. Besides doctors and nurses, the country is experiencing critical shortages of medical and nursing aids, medical technologists and technicians, and various categories of health workers who provide physiotherapy, elderly and disability care and palliative care including home-based care.
Thus, this situation is both a crisis and an opportunity for building an “adequate health workforce” as an investment in the health workforce is increasingly being recognized as a generator of employment opportunities, especially for women, and a facilitator for inclusive economic growth (Buchan, Dhillon and Campbell, 2017). A survey was done with the following objectives to explore a) types of health care services in demand in the pandemic situation; b) emerging employment opportunities for providing these services, including home-based services; c) the responsible authority tasked with certifying such cadres and the probability that they would certify the future emerging cadres; d) the availability of trainers for current and probable new courses; e) current entry requirements for the existing courses and probable requirements for the new courses, and finally, f) the health care organizations that are likely to expand their business during and beyond COVID-19 pandemic. To address these objectives, it adopted a cross-sectional design to elicit relevant information and applied a combination of a) rapid review, b) quantitative assessment using a semi-structured questionnaire, and c) qualitative assessment (e.g., key informant interviews (KII)) with the stakeholders) using interview guidelines.
Results
- Institutionally, chemotherapy and
radiotherapy were the most commonly used services by the patients under
palliative care; pain relief medication, physiotherapy, and rehabilitation
were the commonest services sought under the home-based care services. Both
public and private hospitals and some non-govt. organizations (NGOs) offer
palliative care and home-based care.
- According to the Directorate
General of Health Services (DGHS), 9 govt. Medical Assistant
Training School (MATS) with 818 seats and 13 Institution of Health
Technology (IHT) with 2,791 seats are currently available; minimum entry
requirements for MATS and IHT courses is secondary school certificate (SSC)
pass and duration of courses varies between 3-4 years including a one-year
internship. The overall course fees varied for the public
and private institutions.
- Most of the home-based care organizations
are mainly based in Dhaka and mostly located in urban settings. However, a
few NGOs provide homecare services both in urban and peri-urban settings
and some provide services outside of Dhaka like Chittagong, Khulna,
Rangpur, Sylhet, Mymensingh, Rajshahi, and Barishal. These
organizations usually train the nurses, attendants and caregivers.
- Due to high cost of healthcare, the
elderly people were found to prioritize informal providers and alternative
medicines such as homoeopathic, Unani, and ayurvedic treatments over
formal providers/institutions; they faced significant barriers to accessing
home-based care due to financial problems, unavailability of specific
providers, required treatments or medications, and a lack of support for the
caregivers.
- Considering the current COVID-19
situation and thereafter, there will be an increased demand of various
home-based services such as palliative care, non communicable diseases (NCD)
and elderly care, disability care, and mental health counselling. Under
the circumstances, the NGOs and other non-profit service providing
organisations must seize this opportunity to produce the extra health
workers with appropriate training to deliver the above services. All these
services should be provided at an affordable cost so that the poor also
can avail these services in their emergency.
II. Findings from the Quantitative survey
· The quantitative study was conducted
among 131 respondents of six categories (Service user, Service provider,
Trainer, Trainee, Employer and Employee) under three major domains: Service,
Training and Job.
· The majority (80%) of the service users
mentioned that they have visited a health care facility within the last six
months to seek health care; majority sought care from private (40%) or public
(30%) hospitals, the rest from an NGO/dispensary/clinic (30%). Pain management (97%)
was the most common care received, followed by treatment of other
illness/symptom management such
as other physical and psychological symptoms apart from pain like
breathlessness, weakness, anxiety, nausea, constipation etc.) and adherence support i.e., support to interact with patients in clinical,
community and home settings where they provide education, treatment support and adherence counseling(50%).
Regarding the type of additional care/service providers needed, the respondents
mostly mentioned about home-based service providers (20%) followed by services
by the nurse (17%), physiotherapist (7%) and counsellor (7%).
·
According to the service providers in
the health facilities, palliative and disability care (each 55%) were most
commonly available followed by home-based care (29%), chronic disease care
(26%), elderly (23%) and NCD (13%)care. Half of these facilities (52%) had a dedicated
unit to provide these services. Apart
from doctors, other providers were nurse/midwives (52%), technicians(29%),
paramedics (23%), palliative care assistants (13%) and others (physiotherapist,
occupational therapist etc.) (26%). Around 42% of the service providers had
training on palliative care followed by disability care (32%); 7% had training
on lab technology, however, 23% of the reported to have no training at all.
Majority of the respondents (77%) agreed that new type of Paraprofessionals/Paramedics/
Technicians will be needed in the facilities to ensure palliative and such
cares.
·
An equal proportion (33%) of training
institutions were offering medical assistant and health technology courses each
followed by disability care(28%), lab technicians (15%) and home-based nursing
care (15%). The institutions offered different types of training e.g. diploma
in medical faculty (25%), diploma in health technology (20%), basic certificate
course (20%) andBachelor of Science (BSc) in physio/occupational therapy (15%).
For half of these courses, the minimum entry requirement was SSC (53%) to higher
secondary certificate (HSC) (23%). The course fee rangedfrom 50,000-2,00,000
BDT in 23% of the courses and more than 2,00,000 BDT in another 23% of the
courses. Majority of the respondents mentioned that their institutions havean adequate
trainer (65%). To improve the training quality, respondents recommended the revision
of curriculum (25%), expand the duration of courses with a practical class (20%)
and to recruit more trainers (15%).
·
When asked about types of training that
may be needed in the health sector in post-COVID 19 scenarios, respondents
mentioned about training on health technology such as the lab technologists and
technicians collecting samples from the patients (35%); home-based care and
nursing care (18% each) followed by Covid-19 related training (13%),
physiotherapy (10%) and training for community volunteer/caregivers (10% each).
The majority suggested a diploma as a pre-requisite of such training (30%)
while some suggested this to be SSC (18%) and HSC (15%) level education.
·
Nearly half (40%) of the organisations
were providing home-based services for more than five years. All the organisations provided palliative care,
elderly care, chronic illness/NCD care and personal care services. Majority of
the organisations had service coverage within Dhaka (70%) and some (30%) were
providing services both inside and outside Dhaka. Half of the organisations
(56%) received less than 50 clients approximately per month. Nearly half (47%)
of the organisations had an average 10-50 caregivers in total. Nurses and
midwives were the most common categories of caregivers the organisations had
(83%) followed by community care assistants (73%).
·
According to the respondents, the
market of home-based care in Bangladesh is promising(97%). High prevalence of
choric disease/NCD was a major reason (93%), followed by growing elderly
population (90%), favourable business environment (43%) and some also mentioned
about nuclear family structure (13%). According to the respondents, lack of
qualified caregivers were the most limiting factor (83%) followed by lack of
qualified trainers (77%).
Five KIIs were conducted with
authorities from the central level of the organisations to explore three
domains: available training for paraprofessionals/technicians, the regulatory
authority of the existing training, and the scope of endorsing new type of
training /home-based care training. The key authorities were mostly between
30-58 years age and male except for one female respondent. All the respondents’
had a master’s degree and one had an MBBS.
Respondents professional work experience ranged from 4.5 years to 30
years and had at least 3 years to 17 years of experience in their respective
current organizations.
·
Regulatory
bodies: According to respondents, the
certification and accreditation authority varies for different types of
training and courses of paraprofessionals. They mentioned that the State
Medical Faculty (SMF) is the accreditation authority for MATS training and
Medical Technologists courses, Pharmacy Council Bangladesh (PCB) provides
accreditation and certifications to the Pharmacy Technologists and Director
General of Health Services (DGHS) under Ministry of Health and Family Welfare (MoHFW)
is responsible to provide accreditation and certifications of courses/ training
for paramedics likeFamily
Welfare visitors(FWVs), Health Assistants (Has), Family Welfare Assistants (FWAs).
·
Demand and
scope of new training/courses:
The authorities had mixed opinions regarding the need fornew training and
cadres. Some of them expressed that new types of services and training such as
health care technicians who are needed for proper collection of pathological
samples from the suspected patients (e.g., COVID-19)are needed in the health
sector right now and also, in the post-COVID 19 situation.Others have disagreed
and stressed on increasing the existing health workforce. Some of the
respondents have highlighted the need to train the existing paraprofessionals and
technicians on palliative care, home-based care, chronic diseases and
disability care, and sample collection.
·
Feasibility
of endorsing new training and cadres:
The public sector authorities found it difficult to endorse new cadre and
course due to complicated and lengthy administrative procedure which needs
proper planning, technical and financial support shortage of qualified
trainers.
Findings reveal an emerging demand of different types of facility and home-based palliative/rehabilitative/disability/elderly health care services during in COVID-19 crisis which is projected to increase especially in the current and post-pandemic situation. However, the supply side is currently unable to meet the demanddue to lackof institutional readiness for producing the cadres of the varieties discussed, including extra resources. Thus, the challenges and opportunities posed by the COVID-19 situation cannot be overemphasized. Nowit’s the policymakers’ and programme planners’ turn to seize this opportunity and train and produce relevant skilled health workforce in adequate number and of quality by taking appropriate institutional measures.
• Ensure availability of fulltime
qualified service providers for home-based palliative/
rehabilitative/disability/elderly care
• Reduce cost of relevant care in public
and private sectors; also to make such services available at
grassroots/doorsteps of the targeted users at an affordable price
• Establish a dedicated department for
home-based palliative/rehabilitative/disability/elderly care in each health facility
with trained service providers to ensure the quality of services.
• Establish community-based and home-based
palliative/rehabilitative/disability/elderly care service system
• Production of paramedics, medical
technologists and physiotherapists to be increased to meet demand
• Ensure training of tariners (ToT) for
producing qualified trainers, practice-based curriculum and appropriate work
placement opportunities.
• Introduce home-based
palliative/rehabilitative/disability/elderly care in the national curriculum
for allied health care professionals
• Incentives (monetary/non-monetary) and
accreditation by MoHFW/Government of Bangladesh (GoB) to the organizations
providing home-based palliative/rehabilitative/disability/elderly care
• Specific policy to coordinate
public-private partnership towards building a national system for home-based
care palliative/rehabilitative/disability/elderly care
• Active role of
professional associations to enhance the scope of home-based palliative/
rehabilitative/disability/elderly care.
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