Are we heading towards a crisis, or are we already in a crisis? Is hospital health care in Bangladesh heading for a freefall towards an irreversible crisis situation after achieving such incredible success which the prime minister and the health ministers in recent years have applauded both nationally and internationally?
Are our health policy-makers aware of the possibility of a crisis happening in our health care in the changed environment of newly threatening killer diseases?
Unfortunately, in the absence of easy availability and accessibility of proper data and information, there appears to be a situation where everyone seems to have decided to bury their heads in the sand and pretend that health-care in Bangladesh is enjoying sustained improvement and we are just about to turn the corner where fully developed and accessible health care is waiting to greet our patients.
The health editor of an English newspaper in Dhaka recently wrote: “Millions of people of the country have no access to minimum secondary and tertiary level medical care because of their limited financial abilities and/or poverty ... and conditions of Upazila Health Complexes established to take health services to the poor rural people are in a pitiable state. Absence of doctors, inadequate supply of medicines and dressings, unsuitable and rusted medical equipment, and unserviceable machines have turned most of them into deserted places.”
He then contradicts himself by saying that “we have a good number, though not enough for a population of 160 million, of experienced and skilled manpower, advanced health service devices, and technologies.” Burying the head in the sand indeed!
A good number of experienced and skilled manpower? According to WHO, we should have 2.3 doctors per 1,000 people. We have 0.4. We need at least six times the number of doctors. The doctor to nurse ratio should be 1:3, so we really should have nearly 1.2 million nurses. The reality is that we have about 30,000.
The main concern in today’s Bangladesh is an absence of a minimum skilled health workforce and no indication for preparation for development of such a workforce in sight. Bangladesh does not have a structured policy for human resource planning in the health sector. The first ever stake-holder dialogue on human resources for health in Bangladesh happened in 2012, but it has remained at the dialogue stage till today.
No doubt there has been sustained improvement in a number of health indicators, including a reduction in under-five mortality, immunisation coverage, maternal mortality, and total fertility. The country has improved women’s education, economic conditions, and life expectancy, surpassing those achieved by our sub-continental neighbours India and Pakistan.
However, simultaneous with the demographic transition, Bangladesh is also undergoing a health transition and manifesting the double burden of disease, with the emergence of non-communicable diseases as the prime killers. The success of her government’s achievement of Millennium Developmental Goals and 20th century revolution in health has led to this demographic transition.
It is rightly advocated that health care is dynamic, requiring adoption of policies suitable for combating new challenges with even the developed economies in the world constantly battling to keep up. Unfortunately, for us, absence of strategic vision appropriate for demographic transition responsible for death and disability has lead to serious stagnation and frank regression in hospital health care.
Strategic workforce planning is essential for quality care delivered to patients by ensuring the adequacy of the health care workforce that has the right capacity and skills, values, and behaviours to meet future patient needs, with competence and motivation being critical to the purpose. Sadly, Bangladesh does not have a structured policy for human resource planning in the health sector.
The Ministry of Health and
Family Welfare published the Bangladesh Health Workforce Strategy in 2008. The goal of the ministry was to implement the HR strategy in collaboration with the private sector, development partners, and other stake-holders that work towards the greater good of Bangladesh, and to review it every five years for necessary updates.
The first stake-holder dialogue on human resources for health (HRH) took place in Bangladesh in 2012 with the objective of starting advocacy on the need for an adequate and skilled health workforce for a well-functioning health system, but it has not been effective yet (WHO, 2014).
Only recently, I wrote that Bangladesh’s health care sector has arrived at a crossroad.The internationally acclaimed phenomenal success in primary health care, resulting in the demographic transition, requires our doctors to be trained after MBBS through structured training programs. I also argued that we cannot afford to be indifferent to the adequate and appropriate training need of our doctors with the excuse that Bangladesh is still a developing country and training doctors like they do in the West is not achievable in Bangladesh.
In fact, as we produce increasing numbers of health professionals, including doctors, nurses, and technicians, we must continue to try to improve their quality through universal, competency-based post-graduate education and training. Human resource development and investment in surgical care, which is going to be the cornerstone of the present health system, would become mandatory. International experts believe that this newly required surgical health care strategy is more affordable and I must agree with them when people of our country are buying the same health care from our neighbouring countries at a staggering cost of over $3 billion every year.
We know from the internationally acclaimed medical journal The Lancet’s initiative on global surgery that there has been serious absence of written information about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for the scale-up of surgical services in developing countries.
To begin to address these crucial gaps, the Lancet Commission on Global Surgery was launched in January, 2014. We are, by now, well aware that the commission brought together an international, multi-disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. The commission’s key findings show that the human and economic consequences of untreated surgical conditions in the developing countries may be catastrophic and for many years have gone unrecognised.
Of over 313 million surgical procedures carried out globally, only 6% happens in the poorer countries, 33 million individuals face catastrophic health expenditure due to payment for surgery, and another additional 48 million for the non-medical costs of accessing surgical care. In 2010, an estimated 16.9 million lives (32.9% of all deaths worldwide) were lost from conditions needing surgical care, well surpassing the number of deaths from HIV/AIDS (1.46 million), tuberculosis (1.20 million), and malaria (1.17 million) combined.
Without urgent and accelerated investment in surgical scale-up, low and middle-income countries will continue to have losses in economic productivity, estimated cumulatively at $123tn between 2015 and 2030. On the basis of the Institute for Health Metrics and Evaluation (IHME), the Lancet Commission estimated that 1.4 million deaths could be prevented annually in the developing world.
Should we not then avail of that opportunity of saving lives and avoid economic calamity through national policy on skilled workforce and affordable physical infrastructure development?