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Friday 16 October 2020

Skills demand analysis of institution and home-based supplementary health care services in Bangladesh, 2020

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

 I.   Findings from the Rapid Review

  • 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%).

 III.    Findings from the Qualitative survey

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.

The respondents mentioned that different types of courses are available for various categories of paraprofessionals in Bangladesh such as medical assistants, nurse aids, health technologists, lab technologist and diploma pharmacists etc.

·         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.

 Conclusions

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.

 Recommendations

 Based on the findings, following recommendations are made from different perspectives for consideration by the Institute of Skills Development, SDP, BRAC:

 i)       From the service user’s perspective

        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

 ii)      From the service provider’s perspective

        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

 iii)     From trainer and trainee perspective

        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

 iv)      From job providing organisations’ perspective

        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.

 

Excerpts from a forthcoming report 

[1]<23 health workers (doctors, nurses and midwives combined) per 10,000 population (WHO 2006)

 

 

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