Skills and need for institution and home-based supplementary health care services in post-pandemic Bangladesh

 

The unprecedented pandemic of COVID-19, a classic ‘low probability, high impact’ event, has shaken both developed and developing countries alike with its adverse health and livelihood consequences. The demand for an appropriately trained and motivated health workforce has been phenomenal during this crisis. As such, the global shortage of health workforce has come to the forefront of discussion, including measures to overcome this for the necessary surge in capacity under resource constraints.

Before the pandemic, Bangladesh was among the 57 countries with critical shortages of health workforces. Its health system is characterised by a “shortage, inappropriate skill-mix and inequitable distribution” of the health workforce. The COVID-19 pandemic has exacerbated this already vulnerable situation. Besides doctors and nurses, the country experienced a critical shortage of medical and nursing aids, medical technologists and technicians, and various categories of health workers who provide physiotherapy, elderly care, disability care, and palliative care, including home-based care. This situation can be considered both a crisis and an opportunity, especially for generating employment for women and facilitating inclusive economic growth.

A study was conducted in late 2020 to explore the types of healthcare services in demand during a pandemic situation, emerging opportunities to provide these services at home and institutions, and the training and accreditation of healthcare workers for specific services. Under the ongoing pandemic situation,  telephone-based interviews were conducted to gather relevant data from the respondents The study  adopted a cross-sectional design 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.

The Rapid Review findings revealed that Institutional palliative care services are primarily centred around chemotherapy and radiotherapy, while home-based care commonly includes pain relief, physiotherapy, and rehabilitation services provided by public and private sectors, as well as different NGOs. Most home-care providers are concentrated in urban Dhaka, although some NGOs extend their services to peri-urban and other metropolitan cities, often involving themselves in training nurses and caregivers. High healthcare costs lead many older adults to seek informal or traditional care (e.g., homoeopathy, Unani, and Ayurveda), with access challenges including financial constraints, lack of available services, and limited caregiver support. In the wake of COVID-19, demand is growing for affordable home-based health care services, including palliative care, elderly care, disability support, NCD management, and mental health services, highlighting the need for NGOs and nonprofits to expand training and delivery efforts to reach low-income communities.

A quantitative survey involving 131 respondents—including service users, providers, trainers, trainees, employers, and employees—revealed key insights on healthcare access and service delivery. Eighty per cent of service users visited a healthcare facility in the last six months, primarily for pain (97%) and other illnesses. Fifty per cent also received support from caregivers across clinical, community, and home settings, including education, treatment support, and adherence counselling. They mentioned about additional care needs from providers such as home-based providers (20%), nurses (17%), physiotherapists (7%), and counselors (7%).

Most common services at health facilities included palliative and disability care (55% each), followed by home-based (29%), chronic disease (26%), elderly (23%), and NCD care (13%); 52% of facilities had dedicated units for these services. Services were provided by nurses/ midwives (52%), technicians (29%), paramedics (23%), palliative care assistants (13%), and others (26%). These providers received training on palliative care (42%), disability care (32%), and lab technology (7%), while 23% had no relevant training.

Seventy-seven per cent of the respondents agreed that there’s a need for new types of paraprofessionals /paramedics/technicians. The areas of priority training needs included health technology (35%), home-based care (18%), nursing (18%), COVID-19-specific care (13%), physiotherapy and community care (10% each). Key drivers like high chronic disease/NCD burden (93%), aging population (90%), favorable business environment (43%), and rise of nuclear families (13%) reveal strong potential for home-based care in Bangladesh. However, major constraints were shortage of qualified caregivers (83%) and trainers (77%).

Five central-level stakeholders (age 30–58) participated in the Key Informant Interview (KII) —four males and one female. They reported that multiple training programs exist in Bangladesh for paraprofessionals, including Medical Assistants, Nurse Aides, health and lab technologists, and Diploma Pharmacists. The State Medical Faculty (medical assistants and medical technologists), Pharmacy Council Bangladesh (pharmacy technologists) and DGHS under MoHFW (various categories of CHWs) provide certification for these providers. They opined that instead of developing new cadres, it would be more effective to upgrade existing paraprofessionals with skills in palliative care, chronic disease management, disability care, and home-based services. Barriers identified in endorsing new training programs or cadres in the public sector is seen as difficult due to bureaucratic complexity, need for long-term planning, limited technical and financial resources, and shortage of qualified trainers.

In conclusion, it can be said that there is an emerging demand for different types of facility and home-based palliative/rehabilitative/disability/elderly health care services during COVID-19 crisis, which is projected to increase, especially in the post-pandemic situation. However, the supply side is currently unable to meet the demand due to a lack of 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 overemphasised. Now it’s the policymakers’ and programme planners’ turn to seize this opportunity and train and produce a relevant skilled health workforce in adequate numbers and of quality by taking appropriate institutional measures.

Based on a Report of CoE&UHC/BRAC JPGSPH