Original article Abstract Survey of the Existing Health Workforce of Ministry of Health, Bangladesh Belayet Hossain M.D. 1, Khaleda Begum M.D. 2 1. Professor, Department of Economics, University of Chittagong, Bangladesh 2. Consultant, HRD Master Plan Project, Dhaka, Bangladesh The objective of this study is to present and analyze different issues relating to the existing work-force in the health services of Bangladesh under the Ministry of Health. There are about 83,000 positions available under the Directorate of Health Services in Bangladesh. About 86% of the total available positions are filled. Positions remain unfilled in all categories. The largest percent of vacant positions are among dentists (62%) and doctors (26%). Most of the doctors (35%) and nurses (30%) in health services are located in four metropolitan districts where only 14.5% of the population live. Dhaka district shows the concentration of doctors and of nurses by more than four times and three times compared to the national average, respectively. Among the professional categories, nurses, dentists, pharmacists and technicians are in lower proportion compared to other categories. There is less than one nurse per doctor in the health services which is far less than the international standard. The other staff (consisting of support staff) accounts for more than 37% of total occupied positions. The proportion of women make up about one-fifth of the health services. Women are represented poorly in management and administration. Key Words : Health workforce, Bangladesh, Distribution, Gender, Skill mix. Introduction Bangladesh is one of the most densely populated countries in the world having a population of 120 million in an area of 144,000 sq. kilometers. Nearly 80 percent of the population live in the rural areas, mostly involved with agricultural occupations. The current per capita income of the country is about US$ 250, one of the lowest in the world. Present literacy rate is about 40% (1). The planned country-wide network of government health facilities includes a health and family welfare centre in each of the 4,300 unions, a health complex in each of the 397 rural than as, one hospital in each of the 64 districts as well as 13 tertiary level medical college hospitals and 8 post-graduate institutes besides other establishments like TB clinic, school health clinic, maternal and child welfare centres, urban dispensaries, etc. Presently, there are about 26,000 beds available in the public hospitals, with another 8,000 beds in the private hospitals. The health status of the population continues to be unsatisfactory as reflected in the major indicators of morbidity, mortality and other epidemiological parameters. About 70% of mothers suffer from nutritional deficiency and anemia. Less than 40% of the population has access to basic health care, and 75% of pregnant women do not receive antenatal care nor assistance from a trained attendant at the time of birth. The main causes of death remain infectious and communicable diseases.
2 Studies show that most of the public sector health facilities, particularly in the rural areas, are not being used properly (2-5). Lack of appropriate human resources development and management are considered major factors determining the inefficient use of the government health facilities (6). The development of human resources has been identified as a strategy to bring improvements in efficiency as well as in quality and quantity of services in the health sector of Bangladesh (7, 8). In order to develop a comprehensive human resources plan, an understanding of the many dimensions of the existing work-force is necessary. The principal objective of this paper is to present and analyze different issues relating to the work-force in the health sector, i.e., the gaps between occupied positions and available positions, the geographical distribution of health personnel, existing comparative picture of skill mix, the gender distribution of health personnel, and the distribution of health personnel by levels of intervention. Methods and data sources This study is based on data collected from all health establishments/offices. To collect personnel data, a proforma was developed and distributed to all health establishments/offices throughout the country. Extensive efforts were made to gather all personnel data from these facilities. The information on sanctioned and occupied positions was collected by designation, by class, by salary grade, by institution, by gender, by location, and by sources of funding. The number of positions (occupied and available) is the unit of analysis. One important limitation of this study is that it is limited only to the personnel under the Ministry of Health. Further studies of health personnel working in other ministries as well as the private sector and NGOs needs to be undertaken. Results and Discussions 1. Number of Positions Available and Occupied Our data-base shows that there are 82,871 positions available, of which 71,441 are occupied (86.2%) (Table 1). 1.1 Occupational Category It is clear in Table 1 that positions are unfilled in all professions, with the largest percentage of 62.0 and 26.4 among dentists and doctors, respectively. Among nurses and medical assistants, 10% or less of positions are unfilled.
3 Table 1 Positions sanctioned and filled, by occupation, 1995 Occupation Sanctioned Positions filled Positions occupied Percent of workforce Percent of position Filled Doctors 9,159 6,751 9.45 73.71 Nurses 7,064 6,457 9.04 91.41 M.A. 2,311 2,085 2.92 90.22 Pub. Health Staff 27,148 23,964 33.54 88.27 Dentists 551 208 0.29 37.75 Technicians 6,098 5,096 7.13 83.57 Pharmacists 155 124 0.17 80.00 Other Staff 30,385 26,756 37.45 88.06 Total 82,871 71,441 100.00 86.21 Source: HRD Data-base, 1995 Doctors account for about 9.5% of the total workforce. More than 26,000 in the category of Other Staff do not actually deliver services. They generally involve cleaning, sweeping and clerical jobs. The ratio of Other Staff to health professionals (including allied staff) is estimated at 0.6 to 1.0, which means that for 10 professional/allied staff, there are 6 other staff. It should be noted that doctors outnumber nurses. 1.2 Vacancies by Level of Care Primary care positions have the most vacancies, with 7,700 vacant positions representing over two-thirds of total vacancies (Table 2). The majority of primary care vacancies occur among class 1 employees, where over 40% of available positions are vacant. Doctors occupy most of the class 1 positions at this level. Large number of vacancies at the primary care level may have important consequences for patterns of care, as the primary level is the first point of contact for most persons, while the tertiary level has bed occupancy rates of over 100%. Table 2 Positions filled and percent filled by civil service class and level of care, 1995 Class Tertiary Secondary Primary Total Sanctioned Filled % filled Sanctioned Filled % filled Sanctioned Filled % filled Sanctioned Filled % filled %Class 1 3,018 2,543 84.26 1,672 1,445 86.4 5,342 3,161 59.17 10,032 7,149 71.3 12.11 2 266 207 77.82 341 250 73.3 2,303 2,076 90.14 2,910 2,533 87.0 3.51 3 5,656 4,720 83.45 4,628 4,280 92.5 37,537 32,933 87.73 47,821 41,933 87.7 57.71 4 8,256 6,900 82.07 4,025 3,818 94.9 9,827 9,108 92.68 22,108 19,703 89.1 26.68 Total 17,196 14,370 82.84 10,666 9,793 91.8 55,009 47,278 85.95 82,871 71,441 86.1 100 % level 20.57 20.11-12.87 13.71-66.38 66.18-100.00 100.00 - - of Care Source : HRD Data-base, 1995 1.3 Distribution by Sector of Activity Approximately 60% of human resources in the health services are engaged exclusively in service delivery (Table 3). Excluding doctors and other staff, the number employed in service delivery approaches or is equal to 100%. Approximately two-thirds of doctors are employed exclusively in service delivery, 21% are in teaching or training
4 positions, and almost 12% are in management positions. It is to be noted that those doctors who are involved in teaching also deliver services directly at the hospital as part of their duties. Table 3 Positions filled by sector of activities, 1995. Service Teaching, Occupation Delivery % Training % Admin. % Other % Total Doctors 4,547 67.35 1,381 20.46 790 11.70 33 0.49 6,751 Nurses 6,297 97.52 61 0.95 99 1.53 00-6,457 Med. Assist. 2,082 99.86 03 0.14 00-00 - 2,085 Public Health 23,964 100.00 00-00 - 00-23,964 Dentists 208 100.00 00-00 - 00-208 Tech. & Pharm 5,129 98.26 02 0.04 71 1.36 18 0.34 5,220 Other Staff 546 2.04 00 0 71 0.27 26,139 97.69 26,756 Total 42,773 59.87 1,447 2.03 1,031 1.44 26,190 36.66 71,441 Source : HRD Data-base, 1995 2. Geographic Distribution Establishments as well as the personnel of certain occupational groups have a tendency to concentrate in urban, particularly the metropolitan, areas. To see the urbanrural differences better, methopolitan districts were separated from the others. The four metropolitan districts in the country: Dhaka, Chittagong, Rajshahi, Khulna, were divided into two, viz. Dhaka districts and other metropolitan districts. Rural districts were further divided by division: Rajshahi, Khulna, Barisal, Dhaka, Sylhet, and Chittagong. Table 4 Distribution of medical and public health personnel by geographical region, 1995 Regions Population Doctors Nurses Medical Public health assistant staff Metropolitan Dhaka 6,145,554 1,564 1,128 33 319 Other Metro 9,849,644 806 791 176 1,540 Sub Total Metropolitan 15,995,198 2,370 1,919 209 1,859 Percent of Total 14.5% 35.1% 29.7% 10.0% 6.5% Rural Districts Rajshahi 24,679,647 1,167 1,299 514 5,378 Khulna 11,000,523 443 512 196 2,607 Barisal 7,672,354 424 513 134 2,010 Dhaka 27,443,049 1,266 1,272 574 6,316 Sylhet 7,052,132 506 341 134 1,719 Chittagong 16,029,574 574 601 319 4,075 Sub-Total-Rural 93,877,279 4,380 4,538 1,871 22,105 Percent of Total 85.5% 64.9% 70.9% 90.0% 93.5% Bangladesh 109,872,477 6,750 6,457 2,080 23,964 Note : Public health staff in this table are defined as sanitary & health inspectors, assistant inspectors and health assistants. Figures in the table are based on occupied positions. Source : HRD Data-base, 1995.
5 2.1 Medical and Public Health Personnel The number of medical professionals by area, of practice is shown in Table 4. Over thirty-five percent of doctors and almost thirty percent of nurses practice in the metropolitan areas where less than 15% of the population live. Medical assistants and public health staff consisting of Sanitary Inspector (S.I.), Health Inspector (H.I.), Asstt. Health Inspector (A.H.I.) and Health Assistant (H.A.) are mainly located in rural areas. Table 5 shows district distribution of the national population/professional average. Dhaka metropolitan area shows a larger concentration of doctors and of nurses by more than four and three times, respectively, when compared to the national average. Table 5 Variation of population per health professional around national average among geographical region, 1995 Area/Metro Doctors Nurses Medical Public health Dentists Technicians Pharmacists assistant staff Metropolitan Dhaka 0.24 0.32 3.52 4.20 0.39 0.42 0.76 Other Metro 0.75 0.73 1.06 1.39 0.96 1.00 5.56 Subtotal Metropolitan 0.41 0.49 1.45 1.88 0.61 0.66 1.81 Rural Districts Rajshahi 1.30 1.12 0.91 1.00 1.51 1.06 0.53 Khulna 1.53 1.26 1.06 0.92 1.07 1.25 0.35 Barisal 1.32 1.07 1.07 0.83 1.81 1.14 0.66 Dhaka 1.33 1.27 0.91 0.95 0.61 1.01 6.19 Sylhet 0.86 1.22 1.00 0.89 0.89 1.07 2.65 Chittagong 1.72 1.57 0.95 0.86 0.98 1.23 3.02 Sub Total Rural 1.32 1.22 0.95 0.93 0.94 1.00 1.00 Bangladesh 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Source : HRD Data-base, 1995. 2.2 Dentists, Technicians & Pharmacists There are very few dentists in the Bangladesh Ministry of Health s Health Services (Table 6). 56.2% of them are concentrated in the metropolitan and rural districts of Dhaka, leaving only 97 dentists to attend to a population of more than 66 million. In the rural districts, population-dentist ratios range from slightly more than one to 500,000, to more than one million, which means that access virtually does not exist. There are 5,096 technicians of different categories and only 124 graduate pharmacists working in the health services (Table 6). These professionals are also located dis-proportionately among metropolitan and non-metropolitan districts as well as among rural divisions. The degree of variation across regions can be seen in Table 5.
6 Table 6 Distribution of dentists, technicians and pharmacists by area of practice, 1995 Dentists Technicians Pharmacists* Area of Practice Number Pop/Dentist Number Pop/ Technician Number Pop/ Pharmacist Metropolitan Dhaka 26 236,367 671 9,159 8 678,187 Other Metro 17 579,391 455 21,647 2 4,924,800 Sub Total Metropolitan 43 371,976 1,126 14,205 10 1,599,500 Percent of Total 20.6% 22.09% 8.06% Rural Districts Rajshahi 27 914,061 1,077 22,915 52 474,607 Khulna 17 647,090 409 26,897 35 314,300 Barisal 7 1,090,000 311 24,668 13 590,153 Dhaka 74 370,852 1,263 21,728 5 5,488,600 Sylhet 13 542,472 306 23,046 3 2,350,666 Chittagong 27 593,688 604 26,536 6 2,671,583 Sub-Total-Rural 165 568,952 3,970 23,646 114 823,482 Percent of Total 79.4% 77.91% 91.94% Bangladesh 208 606,133 5,096 22,560 124 886,064 Figures in the table are based on occupied positions. Source : HRD Data-base, 1995. 2.3 International Comparison of Health Personnel International comparisons are difficult because of definitions and organizational differences in health systems. Comparisons, however, are useful in identifying relative norms. Three indices, i.e., population per physician, per nurse, as well as nurse-physician ratio have been estimated for Bangladesh, India, Sri Lanka and Thailand and they are presented in Table 7. The table shows that the nurse-physician ratio is the worst in Bangladesh when comparing the selected countries. While it is 3.83 in Thailand (in 1995) and 4.39 in Sri Lanka (in 1993); in Bangladesh, it is only 0.43 (in 1994); while India is 1.19 (in 1992). The population-doctor ratio is also the highest in Bangladesh (5,530) among the comparison countries. It is 2,141 in India (in 1992) and 4,745 in Sri Lanka (in 1993). Table 7 Nurse-physician ratio and population per physician and nurse in selected Asian Countries Country Bangladesh, 1994 (9) India, 1992 (9) Sri Lanka, 1993 (9) Thailand, 1995 (10) Population/Physician ratio 5,530 2,141 4,745 4,180 Population/Nurse ratio 13,318 1,897 1,126 1,092 Nurse/Physician ratio 0.43 1.19 4.39 3.83 Note : These estimates are based on the cumulative number of registered doctors and nurses, particularly for Bangladesh. There appears to be a confusion about the number of doctors in the country. It is mistakenly considered that the cumulative number of registered physicians as the number of physicians working in the country. Out of total registered physicians, several thousand live outside the country and a number do not practice at all although they obtained registration from the BMDC.
7 3. Distribution by Gender The distribution by gender of the work-force shows that the total proportion of women accounts for little more than one fifth in Health services (Table 8, 9). The distribution of women by occupational category is biased in favour of nurses. Women are also very poorly represented in other categories (dentists, medical assistants, pharmacists, managers/trainers and doctors). While they occupy 21.8% of the total positions in health services, women occupy only 17.9% of the teaching/training positions and 9.3% of the management ones. For the training, where the importance of role models is well established, this underrepresentation calls for serious attention. Table 8 Distribution workforce by Gender, 1995 Occupation Doctors Nurses M.A. Public Health Dentists Tech. & Pharm Other Staff Occupied Position Women percentage Total Women (in each category) 6,751 1,048 15.53 6,457 5,241 81.17 2,085 209 10.05 23,964 4,021 16.78 208 19 9.13 5,220 238 4.56 26,756 4,796 17.96 Total 71,441 15,572 21.80 Note : The figures in the table are based on occupied positions. Source : HRD Data-base, 1995. Table 9 Distribution of workforce by gender and by sector of activities, 1995 Sector of Activity Men Women Total Women share (%) Service Delivery Teaching/Training Admin/Management Others 32,277 1,188 935 21,466 10,496 259 96 4,724 42,773 1,447 1,031 26,190 24.54 17.90 9.31 18.04 Total 55,866 15,575 71,441 21.80 Note : The figures in the table are based on occupied positions. Source : HRD Data-base, 1995. 4. Issues Raised by the Study From the above discussions, the issues raised relating to the existing workforce situation in Bangladesh are presented below to draw the attention of the policy makers. 4.1 Positions sanctioned and occupied The data show that a sizable number of positions were not occupied for many reasons at the time of the survey. First, this data should be further validated and then explanations have to be sought. It is natural that at any point in time, a certain
8 proportion of positions will not be occupied because the recruitment process is not completed, the person is on deputation, or study-leave, etc. Real vacancies have thus to be identified and explained. Second, the number of unoccupied positions is proportionally greater in primary level services. This is in a context where priority needs are precisely greater at that level. This indicates problems of recruitment or of retention of the workforce at this level, hence their causes will have to be identified. 4.2 Mix of personnel According to international norms, the composition of the workforce in Bangladesh presents serious anomalies. The number of nurses is less than that of doctors whereas it should be double or even triple. Even considering that there are medical assistants in Bangladesh, the proportion of nurses remains low. Actually, if we treat medical assistants as substitutes to doctors, rather than assistants to them, it makes the situation even worse (the denominator of the nurse and doctor ratio is then increased). This means that doctors probably do work which could be delegated to other personnel, thus not using their knowledge and skills in an optimal manner. A significant proportion of doctors occupy management positions and most of them do not have formal management training. Thus, quality of management suffers. On the other hand, many of the doctors who hold management positions have high teaching/clinical skills. Because of their involvement in management, the health service is being deprived of their valuable skills. As to other occupational categories, the number of dentists and pharmacists is very small as is their ratio to doctors. The necessary complementarity between the work of doctors, nurses, dentists and pharmacists cannot exist where numbers of one or two categories are insufficient. One last issue in relation to the mix of personnel concerns that of the proportion of support staff. Raw figures seem to point to an excess of such staff; a closer look at the composition and utilization of this staff is necessary, keeping in mind that there are opportunity costs to employing that type of staff, in terms of diminished capacity to recruit staff who produce health services. 4.3 Geographical distribution Bangladesh is not different from any other country in experiencing imbalances in the geographical distribution of its health work-force. Like elsewhere, the more qualified the personnel, the more they tend to concentrate in urban areas. Here, Dhaka city attracts a disproportionate number of professionals and technicians in health services, as a consequence of the centralization of services, administration and facilities. In FP Services, the situation is better controlled as the attraction of private practice and access to higher level technology and facilities which bring personnel to urban areas, does not exit. 4.4 Gender imbalances It is hardly surprising to find gender imbalances in health services. The impact of the under-representation of women in certain professions and cadres has to be assessed. For example, the absence of women at the decision making level means that it is less likely that decisions and actions concerning women will reflect their views and
9 concerns. It might even lead to some problems specific to women being ignored or given lower priority. At the service delivery level, there might be under-utilization of certain services by women, because they cannot have access to a provider of the same sex. The issue here is whether active measures to change the current situation should be taken and, if so, what would those measures be. Conclusion There are about 83,000 positions available in the health services of Bangladesh of which 71,441 (86%) are occupied. Doctors and nurses represent about 19% of the total health work-force. Of the total health work-force, more than 37% is support staff who help the administration either as office support staff or as menial staff. Positions remain unfilled in all categories of health personnel with the largest percent of vacant positions among dentists (62%) and doctors (26%). Of the total number of doctor positions available at the primary level, about 40% are found vacant. Proportionately more doctors (35%) and nurses (30%) in the health services are located in the four metropolitan districts where only 14.5% of the population live. This implies that a highly unequal distribution of doctors and nurses exits between urban and rural areas. For example, there are about 6,700 people per doctor in the metropolitan districts as opposed to 16,000 for the country as a whole. For the rural districts, it varies from 14,000 to 24,000. The distribution of the health work-force by level of care shows that more than two-thirds of the work-force work at the primary level and about 20% are at the tertiary level. The Ministry of Health has a standard of one health assistant for every 4,000 population in rural areas, one assistant health inspector for every five health assistants and one health inspector for every three assistant health inspectors. The combined ratio of population to these three categories of public health personnel would be approximately 3,200 to one. None of the rural divisions meets this standard. This ratio is estimated at 4,500 for the country (11). There is less than one nurse per doctor in the health services of Bangladesh. This is an indication of inappropriate skill mix in the health services of Bangladesh. Among the work-force in the health services, only about 20% are women. The share of women among the doctors is about 15%. It is only 9% in the management/administration. Less representation of women at the decision making level may imply that decisions and actions concerning women will not reflect their views and concerns. References : 1. Bangladesh Bureau of Statistics. Statistical yearbook of Bangladesh, 1995. Dhaka: Ministry of Planning, 1996. 2. Hossain B, et. al. Human resources development master plan for health and family planning sector of Bangladesh, (3 rd Draft), HRD Master Plan Project. Dhaka: Ministry of Health, June 1996.
3. Oversees Development Assistance (ODA). Report on consultancy to develop a project of strengthening nurse education and services in Bangladesh. Khaka: ODA, Dec. 1991. 4. Bangladesh Rural Advancement Committee (BRAC). A tale of two wings. Dhaka: BRAC, May 1990. 5. Management Development Unit (MDU). Management development initiative in the Ministry of Health and Family Welfare, Vol. 1. Dhaka: Ministry of Health, 1995. 6. Abel Smith B. An introduction to health: policy, planning and financing. London : Longman, 1994. 7. Shipp P, Adams O. Bangladesh Fourth Population and Health project: Human Resources Development Plan: an assignment report, Dhaka : WHO Office, 1992. 8. Begum Khaleda ANM, Anisul A. Guideline for a national health and nutrition policy. Dhaka : Ministry of Health, 1992. 9. World Health Organization. Basic indicators for population and health resources. Geneva : World Health Organization, 1994. 10. Wibulpolprasert S, ed. Health in Thailand 1995-1996. Bangkok: Veteran press, 1997. 11. Das A.M. Reports on training need assessment survey, Health Personnel Training Project. Dhaka: Ministry of Health, 1995. 10